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Objective/hypothesis: The prevalence and causes of pediatric hearing loss (HL) in the developing world are largely unknown. Infectious sequelae, ototoxic medications, and genetic causes may play a larger role in developing countries. In addition, the significance of GJB2 mutation gene in poorly developed areas remains unclear. The intent of this study is to investigate the prevalence and etiology of HL in children living in a remote, impoverished region of northern Nicaragua.Study Design: Cross-sectional study.Methods: Clinical data from two sources were analyzed: data from screening examinations performed in rural schools in the Department of Jinotega, Nicaragua (group A) and pediatric HL patients seen at the Otolaryngology and Audiology Clinic in Jinotega, Nicaragua (group B). Patients with congenital HL were offered a genetic test for GJB2 mutations. Comparisons were made using parametric (analysis of variance) and nonparametric (Kruskal-Wallis) tests.Results: School-based screening examinations (group A) revealed a high prevalence of significant HL (>30 dB) of 18%. The majority of these children had normal otoscopic examinations (58%). A family history of HL was seen in 24% of children who failed screening exams. Positive family history was more common in patients with HL (P < .01) and in specific schools (P < .05). Clinic-based evaluations (group B) reveal a population with predominantly severe-profound HL. Physical dysmorphism was common, yet identifiable syndromic HL was rare. Although familial HL was common (33%), there were no pathologic GJB2 mutations. Other common risk factors in this population were maternal infection during pregnancy, neonatal distress, low birth weight or prematurity, and gentamicin exposure.Conclusions: HL in this rural, third world environment is more prevalent, and the etiologies responsible in this study group are different from those encountered in industrialized nations. Poor perinatal health care, infectious causes, gentamicin exposure, and hereditary HL are potentially preventable causes that play a major role in this population. [ABSTRACT FROM AUTHOR]

1. The metabolism of proguanil to the active metabolite cycloguanil has been evaluated in 135 British Troops and 26 Kenyan schoolchildren. 2. Large inter-subject variability was observed in both plasma and urinary concentrations of proguanil and cycloguanil after standard doses of drug. 3. Based on the ratio of proguanil to cycloguanil (P/C) in urine the British troops formed a non-normal distribution. 90% of the population formed a discrete distribution with P/C ranging from 0.5 to 9.0 while the remaining 10% were scattered throughout the distribution to an extreme value of 39. A similar pattern of variability was observed using P/C from a 6 h plasma sample. 4. This variability was due to differences in the ability of individuals to metabolise proguanil to cycloguanil. 5. Thirteen schoolchildren who had experienced malaria during prophylaxis with proguanil and thirteen matched controls each received proguanil (100 mg). We could not discriminate between the two groups based on P/C ratio in either a 6 h plasma or 0-6 h urine sample. [ABSTRACT FROM AUTHOR]

Most cases of sudden sensorineural hearing loss (SHL) remain idiopathic, and the majority are unilateral. From 1989 to 1993, 823 patients with sudden SHL were evaluated. Of these, 14 (1.7%) had sudden bilateral SHL. We reviewed the charts of these 14 patients to compare sudden bilateral SHL with sudden unilateral SHL. Usually, bilateral SHL was asymmetric. Most bilateral cases received combined steroid and vasodilator treatment, while unilateral cases were more likely to receive only one of these treatments. By audiological criteria, 67% of bilateral SHL cases improved, while the improvement rate in unilateral SHL was 52%; however, this difference was not statistically significant. In bilateral SHL patients showing improvement, both ears responded. Bilateral SHL patients were older at the onset of hearing loss, had a higher incidence of vascular disease, and were more likely to have positive antinuclear antibody titer. Recognition of similarities and differences between sudden unilateral and bilateral SHL can help in counseling patients. [ABSTRACT FROM AUTHOR]

Abstract Background Problem alcohol use is common among illicit drug users and is associated with adverse health outcomes. It is also an important factor in poor prognosis among drug users with hepatitis C virus (HCV) as it impacts progression to hepatic cirrhosis or opiate overdose in opioid users. The aim of this systematic review was to assess the effects of psychosocial interventions for problem alcohol use in adult illicit drug users with concurrent problem alcohol use (principally, problem drug users of opiates and stimulants). Methods We searched the following databases (November 2011): Cochrane Library, PUBMED, EMBASE, CINAHL, PsycINFO and reference list of articles. We also searched conference proceedings and online registers of clinical trials. Two reviewers independently assessed risk of bias and extracted data from included randomized controlled trials. Results Four studies (594 participants) were included in this review. Half of the trials were rated as having a high or unclear risk of bias. The four studies considered six different psychosocial interventions grouped into four comparisons: 1) cognitive-behavioral coping skills training versus 12-step facilitation (N = 41), 2) brief intervention versus treatment as usual (N = 110), 3) hepatitis health promotion versus motivational interviewing (N = 256), and 4) brief motivational intervention versus assessment-only group (N = 187). Differences between studies precluded any pooling of data. Findings are described for each trial individually. Most findings were not statistically significant except for comparison 2: decreased alcohol use at three months (risk ratio (RR) 0.32; 95% confidence interval (CI) 0.19 to 0.54) and nine months (RR 0.16; 95% CI 0.08 to 0.33) in the treatment-as-usual group and comparison 4: reduced alcohol use in the brief motivational intervention (RR 1.67; 95% CI 1.08 to 2.60). Conclusions No conclusion can be made because of the paucity of the data and the low quality of the retrieved studies.

Abstract Background People with Multiple Sclerosis have a life long need for physiotherapy and exercise interventions due to the progressive nature of the disease and their greater risk of the complications of inactivity. The Multiple Sclerosis Society of Ireland run physiotherapy, yoga and exercise classes for their members, however there is little evidence to suggest which form of physical activity optimises outcome for people with the many and varied impairments associated with MS. Methods and design This is a multi-centre, single blind, block randomised, controlled trial. Participants will be recruited via the ten regional offices of MS Ireland. Telephone screening will establish eligibility and stratification according to the mobility section of the Guys Neurological Disability Scale. Once a block of people of the same strand in the same geographical region have given consent, participants will be randomised. Strand A will concern individuals with MS who walk independently or use one stick to walk outside. Participants will be randomised to yoga, physiotherapy led exercise class, fitness instructor led exercise class or to a control group who don't change their exercise habits. Strand B will concern individuals with MS who walk with bilateral support or a rollator, they may use a wheelchair for longer distance outdoors. Participants will be randomised to 1:1 Physiotherapist led intervention, group intervention led by Physiotherapist, group yoga intervention or a control group who don't change their exercise habits. Participants will be assessed by physiotherapist who is blind to the group allocation at week 1, week 12 (following 10 weeks intervention or control), and at 12 week follow up. The primary outcome measure for both strands is the Multiple Sclerosis Impact Scale. Secondary outcomes are Modified Fatigue Impact Scale, 6 Minute Walk test, and muscle strength measured with hand held dynamometry. Strand B will also use Berg Balance Test and the Modified Ashworth Scale. Confounding variables such as sensation, coordination, proprioception, range of motion and other impairments will be recorded at initial assessment. Discussion Data analysis will analyse change in each group, and the differences between groups. Sub group analysis may be performed if sufficient numbers are recruited. Trial registration ISRCTN77610415

Abstract Introduction Human Immunodeficiency Virus (HIV) has an estimated prevalence of 0.9% in India (5.2 million). Anti-retroviral drugs (ARV) are the treatments of choice and non-adherence is an important factor in treatment failure and development of resistance, as well as being a powerful predictor of survival. This study assesses adherence to ARV in HIV positive patients in Bangalore, India, a country where only 10% of those who need therapy are receiving it. Methods A cross-sectional anonymous questionnaire survey of 60 HIV antibody positive patients was carried out with patients attending HIV outpatient services at two centres: The Chest and Maternity Centre, Rajajinagar, and Wockhardt Hospital and Heart Institute, Bangalore. Consent was obtained. Translation was done by a translator and doctors where required. Data was analysed using SPSS statistical analysis. Results A response rate of 88% (53/60) was achieved. The mean patient age was 39.98 years, with 50% aged 30–40, and 73.6% of participants being male. Mean family size was 4.8 (1–13). 21% lived less than 50 kms and 21% greater than 400 kms from clinic. 60% reported they were fully adherent. Adherence was statistically significantly linked to regular follow-up attendance (70.5%, p = 0.002). No other results were statistically significant but trends were found. "100% adherence" trends were seen in older patients, male gender, those from larger families, those who had a previous AIDS defining illness, those taking fewer tablets, and without food restrictions. Commonest side-effects causing non-adherence were metabolic reasons (66%) and GI symptoms (50%). No trends were seen for education level, family income, distance travelled to clinic, time since diagnosis, or time on ART. Conclusion Regular attendance for follow up was statistically significant for 100% lifetime adherence. Positive trends were seen in those in larger families, older, those who had AIDS defining illness, simple regimes, and without side-effects. Education, income, distance travelled and length of time diagnosed or treated had no effect on adherence.

Objective: To describe a treatment strategy for paradoxical vocal-cord dysfunction (PVCD) as it applies to an athletic population.Background: Paradoxical vocal-cord dysfunction has been identified as a cause of dyspnea and stridor in athletes. The basic element of PVCD is an inappropriate closure of the vocal cords during respiration, resulting in airway obstruction. This condition is familiar to speech-language pathologists and otolaryngologists yet remains poorly understood in the sports medicine community. Treatment strategies are even less understood. A therapeutic exercise program designed to promote diaphragmatic breathing may allow an athlete to gain control during episodes of dyspnea. Elimination of contributing or concomitant conditions is critical to resolution of the condition.Description: The treatment of PVCD requires an understanding of the pathoanatomy of the condition. The focus of the exercise program is on relaxation of the larynx and conscious activation of the diaphragm and abdominal muscles during respiration. The athlete must have a sense of laryngeal control while performing the exercises. In addition, the patient and practitioner must realize the amount of neuromuscular reeducation required to change breathing patterns.Clinical Advantages: This therapy may allow the athlete to gain control over episodic dyspnea, participate in athletic activities with fewer complications, and, perhaps, reduce or eliminate medications prescribed to treat suspected bronchospasm. [ABSTRACT FROM AUTHOR]

Objectives: A wide variety of intraoperative tests are available in cochlear implantation. However, no consensus exists on which tests constitute the minimum necessary battery. We assembled an international panel of clinical experts to develop, refine, and vote upon a set of core consensus statements., Design: A literature review was used to identify intraoperative tests currently used in the field and draft a set of provisional statements. For statement evaluation and refinement, we used a modified Delphi consensus panel structure. Multiple interactive rounds of voting, evaluation, and feedback were conducted to achieve convergence., Results: Twenty-nine provisional statements were included in the original draft. In the first voting round, consensus was reached on 15 statements. Of the 14 statements that did not reach consensus, 12 were revised based on feedback provided by the expert practitioners, and 2 were eliminated. In the second voting round, 10 of the 12 revised statements reached a consensus. The two statements which did not achieve consensus were further revised and subjected to a third voting round. However, both statements failed to achieve consensus in the third round. In addition, during the final revision, one more statement was decided to be deleted due to overlap with another modified statement., Conclusions: A final core set of 24 consensus statements was generated, covering wide areas of intraoperative testing during CI surgery. These statements may provide utility as evidence-based guidelines to improve quality and achieve uniformity of surgical practice., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Ear & Hearing is published on behalf of the American Auditory Society, by Wolters Kluwer Health, Inc.)

Purpose: In cochlear implantation (CI) surgery, there are a wide variety of intraoperative tests available. However, no clear guide exists on which tests must be performed as the minimum intraoperative testing battery. Toward this end, we studied the usage patterns, recommendations, and attitudes of practitioners toward intraoperative testing., Methods: This study is a multicentric international survey of tertiary referral CI centers. A survey was developed and administered to a group of CI practitioners (n = 34) including otologists, audiologists and biomedical engineers. Thirty six participants were invited to participate in this study based on a their scientific outputs to the literature on the intraoperative testing in CI field and based on their high load of CI surgeries. Thirty four, from 15 countries have accepted the invitation to participate. The participants were asked to indicate the usage trends, perceived value, influence on decision making and duration of each intraoperative test. They were also asked to indicate which tests they believe should be included in a minimum test battery for routine cases., Results: Thirty-two (94%) experts provided responses. The most frequently recommended tests for a minimum battery were facial nerve monitoring, electrode impedance measurements, and measurements of electrically evoked compound action potentials (ECAPs). The perceived value and influence on surgical decision-making also varied, with high-resolution CT being rated the highest on both measures., Conclusion: Facial nerve monitoring, electrode impedance measurements, and ECAP measurements are currently the core tests of the intraoperative test battery for CI surgery., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Hispanic/Latino adults are less likely than non-Hispanic White adults to seek treatment for hearing disability. While differential socioeconomic factors may contribute to this finding, differences in phonology and syntax in the Spanish, versus English, language may also influence patient perception of hearing disability. The objective of this study is to investigate the association between primary language spoken and participant perception of hearing disability., Design: This study represents a cross-sectional cohort study using National Health and Nutrition Examination Study cycles 2015-2016 and 2017-2020 data. Multivariable logistic regressions estimated the association between respondent-selected interview language, which was used as a proxy for primary spoken language, and participant perception of hearing disability. Models were adjusted for age, gender, highest degree of education, pure-tone average, and self-reported general health. Participants included 4687 individuals from the United States population who elected to speak English (n = 4083) or Spanish (n = 604) during the interview. Perception of hearing disability was assessed by (1) frequency of reported difficulty in following a conversation in noise, (2) frequency with which hearing caused respondents to experience frustration when talking with members of their family or friends, and (3) participants' subjective overall assessment of their hearing., Results: Speaking Spanish, versus English, as a primary language was associated with a 42% lower odds of reporting difficulty hearing and understanding in background noise (odds ratio [OR]: 0.58, 95% confidence interval [CI]: 0.48 to 0.70). Spanish speakers had 28% lower odds of reporting feeling frustrated when talking to family members or friends due to hearing (OR: 0.72, 95% CI: 0.59 to 0.88) as compared with the English-speaking cohort. Speaking Spanish additionally conferred 31% lower odds of describing their own general hearing as "a little trouble to deaf" than participants speaking English (OR: 0.69, 95% CI: 0.53 to 0.90). These observed associations were independent of age, gender, highest degree of education, better pure-tone average? and self-reported general health., Conclusions: Primary Spanish speakers may be less likely than English speakers to report hearing-related disability, an effect which may be independent of ethnicity. Patient perception of hearing-related disability is an important component of the assessment of and counseling for hearing-related disability and discussion of the need for amplification or other hearing intervention., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Lateral skull base defects (LSBD) pose a diagnostic challenge; however, early recognition and treatment are important to avoid sequelae. This study examines the impact of health care disparities associated with time to diagnosis and treatment for patients with LSBD., Study Design, Setting, Patients, Intervention, Outcome Measures: Multi-institutional retrospective cohort study at four U.S. tertiary centers from 2000 to 2022. Adult patients with a primary diagnosis of CSF leak or encephalocele were included. Multivariate regressions used to analyze how age, sex, race/ethnicity, insurance, language, zip code, distance to medical center, referral patterns, diagnostic workup, and clinical course affected time to diagnosis and treatment., Results: In 127 patients with LSBD, mean time to treatment of CSF leak or encephalocele was 13.9 months. On average, patients waited 10.6 months from initial assessment to diagnosis and saw 2 providers prior to diagnosis. Approximately 91% (115) of patients had a CT scan, and 75% (95) had an MRI. Imaging did not influence time to treatment. Older age, public insurance, and number of providers seen were associated with delays. Non-English speakers (5% of 127) encountered treatment delays, although this was not statistically significant. Fifty-eight (46%) people had private insurance. The average traveled distance for care was 62.6 miles. Clinical presentation, race, zip code, imaging, myringotomy, beta-2 transferrin, and ED workup were not found to be associated with delays to care., Conclusion: There are significant delays in diagnosis and management of LSBD. Referral patterns did influence care. Health care disparities did not impact care; however, disparities and language barriers need to be studied further to determine contributions to delays in care., (Copyright © 2024, Otology & Neurotology, Inc.)

Objective: To determine the utility of computed tomography (CT) and magnetic resonance imaging (MRI) in cochlear implant candidates., Study Design: Retrospective case review., Setting: Tertiary referral hospital., Patients: A total of 207 cochlear implanted patients with CT and/or MRI., Interventions: N/A., Main Outcome Measures: Age versus abnormal radiologic findings, imaging abnormality versus postoperative outcomes, postoperative outcomes versus electrode design, Cambridge Cochlear Implant Protocol (CCIP) status for imaging abnormalities, sensitivity and specificity of CT and MRI for round-window/cochlear occlusion, and MRI for incomplete partitions., Results: A total of 207 patients with CT, MRI, or both were reviewed retrospectively. Less than half (15.5%) of CT scans had findings that might affect surgical intervention compared with 5.9% of MRI. No significant difference was found between children and adults for relevant imaging abnormalities (grade 4 or higher) with either CT (p = 0.931) or MRI (p = 0.606). CCIP status correlated with cochlear abnormalities (p = 0.040); however, only 46.2% of radiographic abnormalities on CT would be identified by these criteria. For detecting cochlear occlusion requiring surgical intervention, the sensitivity and specificity for CT were 40% (4 of 10; 95% confidence interval [CI], 12.16-73.76) and 95.73% (95% CI, 91.40-98.27), respectively. For MRI, the sensitivity and specificity were 33.33% (1 of 3; 95% CI, 0.84-90.57) and 96.97% (63 of 65; 95% CI, 89.32-99.63), respectively. There was no difference for postoperative AzBio scores for higher-grade imaging abnormalities (p = 0.6012) or for electrode designs (p = 0.3699)., Conclusions: Significant radiographic abnormalities were relatively uncommon in cochlear implant patients on either CT or MRI at our single-center institution. If present, abnormal imaging findings rarely translated to management changes. CCIP status does not reliably predict which patients are likely to have abnormalities. Both MRI and CT have low sensitivity for round-window or cochlear occlusion, but detection likely leads to changes in surgical management., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2024, Otology & Neurotology, Inc.)

Porcine reproductive and respiratory syndrome virus (PRRSV) remains a leading cause of economic loss in pig farming worldwide. Existing commercial vaccines, all based on modified live or inactivated PRRSV, fail to provide effective immunity against the highly diverse circulating strains of both PRRSV-1 and PRRSV-2. Therefore, there is an urgent need to develop more effective and broadly active PRRSV vaccines. In the absence of neutralizing antibodies, T cells are thought to play a central role in controlling PRRSV infection. Herpesvirus-based vectors are novel vaccine platforms capable of inducing high levels of T cells against encoded heterologous antigens. Therefore, the aim of this study was to assess the immunogenicity and efficacy of an attenuated herpesvirus-based vector (bovine herpesvirus-4; BoHV-4) expressing a fusion protein comprising two well-characterized PRRSV-1 T-cell antigens (M and NSP5). Prime-boost immunization of pigs with BoHV-4 expressing the M and NSP5 fusion protein (vector designated BoHV-4-M-NSP5) induced strong IFN-γ responses, as assessed by ELISpot assays of peripheral blood mononuclear cells (PBMC) stimulated with a pool of peptides representing PRRSV-1 M and NSP5. The responses were closely mirrored by spontaneous IFN-γ release from unstimulated cells, albeit at lower levels. A lower frequency of M and NSP5 specific IFN-γ responding cells was induced following a single dose of BoHV-4-M-NSP5 vector. Restimulation using M and NSP5 peptides from PRRSV-2 demonstrated a high level of cross-reactivity. Vaccination with BoHV-4-M-NSP5 did not affect viral loads in either the blood or lungs following challenge with the two heterologous PRRSV-1 strains. However, the BoHV-4-M-NSP5 prime-boost vaccination showed a marked trend toward reduced lung pathology following PRRSV-1 challenge. The limited effect of T cells on PRRSV-1 viral load was further examined by analyzing local and circulating T-cell responses using intracellular cytokine staining and proliferation assays. The results from this study suggest that vaccine-primed T-cell responses may have helped in the control of PRRSV-1 associated tissue damage, but had a minimal, if any, effect on controlling PRRSV-1 viral loads. Together, these results indicate that future efforts to develop effective PRRSV vaccines should focus on achieving a balanced T-cell and antibody response., Competing Interests: Authors BS-B, MH, HB, and VF are employed by the company ECO Animal Health, London, UK. Authors JR, YW, SH, TM, JS, and MJ in part are employed by the company The Vaccine Group, Plymouth, UK. Author MF was employed by BioVacc Consulting Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors declare that project was funded by ECO Animal Health. The authors declare that this study received funding from ECO Animal Health, who contributed to the design and coordination of the study., (Copyright © 2023 de Brito, Holtham, Roser, Saunders, Wezel, Henderson, Mauch, Sanz-Bernardo, Frossard, Bernard, Lean, Nunez, Gubbins, Suárez, Davison, Francis, Huether, Benchaoui, Salt, Fowler, Jarvis and Graham.)

Studies have demonstrated the importance of the gut microbiota during pregnancy, and there is emerging literature on the postpartum maternal gut microbiota. The primary objective of this paper was to synthesize the literature on the postpartum gut microbiome composition and diversity measured in stool samples from healthy mothers of predominantly term infants. The secondary objectives were (1) to identify biological and environmental factors that influence postpartum maternal gut microbiota and (2) to assess health conditions and clinical intermediate measures associated with postpartum gut microbiota changes in all mothers. Electronic searches were conducted November 9, 2020 and updated July 25, 2021 without publication time limits on PubMed, Embase, CINHAL, Scopus, Cochrane Library, BioArchives, and OpenGrey.eu. Primary research on maternal gut microbiota in the postpartum (up to one year after childbirth) were eligible. Postpartum gut microbiota comparisons to pregnancy or non-pregnancy gut microbiota were of interest, therefore, studies examining these in addition to the postpartum were included. Studies were excluded if they were only conducted in animals, infants, pregnancy, or microbiome of other body locations (e.g., vaginal). Data extraction of microbial composition and diversity were completed and synthesized narratively. Studies were assessed for risk of bias. A total of 2512 articles were screened after deduplication and 27 were included in this review. Of the 27 included studies, 22 addressed the primary objective. Firmicutes was the predominant phylum in the early (<6 weeks) and late postpartum (6 weeks to 1 year). In early postpartum, Bacteroides was the predominant genus. Findings from longitudinal assessments of alpha and beta diversity from the early to the late postpartum varied. Nineteen of the 27 studies assessed biological and environmental factors influencing the postpartum gut microbial profile changes. Timing of delivery, probiotic supplementation, triclosan exposure, and certain diets influenced the postpartum gut microbiota. Regarding health conditions and intermediate clinical measures assessed in 8 studies; inflammatory bowel disease, postpartum depression, early-onset preeclampsia, gestational diabetes, excessive gestational weight gain, and anthropometric measures such as body mass index and waist-to-hip ratio were related to gut microbiota changes. There is limited data on the maternal postpartum gut microbiota and how it influences maternal health. We need to understand the postpartum maternal gut microbiome, establish how it differs from non-pregnancy and pregnancy states, and determine biological and environmental influencers. Future research of the gut microbiome's significance for the birthing parent in the postpartum could lead to a new understanding of how to improve maternal short and long-term health., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: The tick-borne bunyavirus, Crimean-Congo Haemorrhagic Fever virus (CCHFV), can cause severe febrile illness in humans and has a wide geographic range that continues to expand due to tick migration. Currently, there are no licensed vaccines against CCHFV for widespread usage., Methods: In this study, we describe the preclinical assessment of a chimpanzee adenoviral vectored vaccine (ChAdOx2 CCHF) which encodes the glycoprotein precursor (GPC) from CCHFV., Findings: We demonstrate here that vaccination with ChAdOx2 CCHF induces both a humoral and cellular immune response in mice and 100% protection in a lethal CCHF challenge model. Delivery of the adenoviral vaccine in a heterologous vaccine regimen with a Modified Vaccinia Ankara vaccine (MVA CCHF) induces the highest levels of CCHFV-specific cell-mediated and antibody responses in mice. Histopathological examination and viral load analysis of the tissues of ChAdOx2 CCHF immunised mice reveals an absence of both microscopic changes and viral antigen associated with CCHF infection, further demonstrating protection against disease., Interpretation: There is the continued need for an effective vaccine against CCHFV to protect humans from lethal haemorrhagic disease. Our findings support further development of the ChAd platform expressing the CCHFV GPC to seek an effective vaccine against CCHFV., Funding: This research was supported by funding from the Biotechnology and Biological Sciences Research Council (UKRI-BBSRC) [BB/R019991/1 and BB/T008784/1]., Competing Interests: Declaration of interests SCG is co-founder and board member of Vaccitech and named as an inventor on a patent covering use of ChAdOx2-vectored vaccines. TL was consultant to Vaccitech. The remaining authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: Automated threshold audiometry (ATA) could increase access to paediatric hearing assessment in low- and middle-income countries, but few studies have evaluated test-retest repeatability of ATA in children. This study aims to analyse test-retest repeatability of ATA and to identify factors that affect the reliability of this method., Design: ATA was performed twice in a cohort of Nicaraguan schoolchildren. During testing, the proportion of responses occurring in the absence of a stimulus was measured by calculating a stimulus response false positive rate (SRFP). Absolute test-retest repeatability was determined between the two trials, as well as the impact of age, gender, ambient noise, head circumference, and SRFP on these results., Study Sample: 807 children were randomly selected from 35 schools in northern Nicaragua., Results: Across all frequencies, the absolute value of the difference between measurements was 5.5 ± 7.8 dB. 89.6% of test-retest differences were within 10 dB. Intra-class correlation coefficients between the two measurements showed that lower SRFP was associated with improved repeatability. No effect of age, gender, or ambient noise was found., Conclusions: ATA produced moderate test-retest repeatability in Nicaraguan schoolchildren. Participant testing behaviours, such as delayed or otherwise inappropriate response patterns, significantly impacts the repeatability of these measurements.

Hypothesis: Commercially available povidone-iodine solution can eliminate biofilms and persister cells rapidly in in vivo achievable concentrations without inducing ototoxicity., Background: Chronic suppurative otitis media (CSOM) is a substantial global problem. Current treatment options often induce a temporary remission without leading to a permanent cessation of symptoms secondary to the treatments' inability to eliminate persister cells. Povidone-iodine has been shown to be able to clear biofilm and planktonic cells in in vitro assays, but there are reports of ototoxic effects limiting its clinical utility., Methods: Bacterial and biofilm growth with quantification by spectrophotomer, murine auditory brainstem response (ABR), and distortion product otoacoustic emissions, immunohistochemistry, in vivo povidone-iodine treatment of murine CSOM, persister cell assay., Results: Commercially available 10% povidone-iodine solution is able to completely eradicate multiple clinical strains of Pseudomonas aeruginosa and Staphylococcus aureus in vitro with 10 minutes of exposure. Mice that have received a transtympanic injection of 1% povidone-iodine solution did not have significantly different auditory brainstem response or distortion product otoacoustic emission results compared with the control. Mice that received a povidone-iodine scrub or 10% povidone-iodine solution had significantly worsened hearing (25- and 13-dB increase in threshold, respectively; p < 0.05). In vivo CSOM infection recurred in all mice after the completion of treatment with 10% povidone-iodine solution, and there was no improvement in the bacterial load after treatment, indicating in vivo failure of therapy., Conclusion: Povidone-iodine solution is effective at eliminating biofilm and persister cells in vitro at in vivo achievable concentrations but fails in vivo most likely because of kinetics of distribution in vivo. Even if drug distribution could be improved, the therapeutic window is likely to be too small given that the diluted solution does not have ototoxic potential, whereas while the scrub variant, which contains detergents, and the undiluted solution are ototoxic after a single treatment., Competing Interests: Conflicts of interest: P.L.S.M., L.A.B., and A.X. are inventors on patents for treatments for chronic suppurative otitis media currently owned by Stanford University., (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: To investigate the utility and effectiveness of a noise-attenuating, tablet-based mobile health system combined with asynchronous telehealth evaluations for screening rural Nicaraguan schoolchildren for hearing loss., Study Design: Prospective population-based survey., Setting: Rural Nicaraguan communities., Patients: There were 3,398 school children 7 to 9 years of age., Interventions: Diagnostic automated and manual audiometry, detailed asynchronous telehealth evaluations., Main Outcome Measures: Referral rates, ambient noise levels, and audiometric results as well as hearing loss prevalence, types, and risk factors., Results: Despite high ambient noise levels during screening (46.7 dBA), no effect of noise on referral rates on automated audiometry or confirmatory manual audiometry in those who failed automated testing was seen. The overall audiometric referral rate was 2.6%. Idiopathic sensorineural hearing loss (SNHL) and cerumen impaction were the most common types of hearing loss in this population with an estimated prevalence of hearing loss (all types) of 18.3 per 1,000 children. SNHL was associated with both drug exposure during pregnancy (p = 0.04) and pesticide exposure in the home (p = 0.03)., Conclusion: Hearing screening using a tablet-based, noise-attenuating wireless headset audiometer is feasible and effective in rural low-resource environments with moderately elevated ambient noise levels. The referral rate with noise-attenuating headsets was much lower than that previous reports on this population. In addition, manual audiometry resulted in much lower referral rates than automated audiometry. The confirmed hearing loss rate in this study is comparable to reports from other low-income countries that use some form of noise attenuation during screening. Pesticide exposure and drug exposure during pregnancy are potential causes of SNHL in this population., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2022, Otology & Neurotology, Inc.)

Background: We aimed to investigate the effectiveness of using minimally trained community health workers (CHW) to screen schoolchildren in rural Nicaragua for hearing loss using a tablet-based audiometric system integrated with asynchronous telehealth evaluations and mobile health (mHealth) appointment reminders., Methods: A population-based survey was conducted using community health workers (CHWs) to perform tablet-based audiometry, asynchronous telehealth evaluations, and mHealth reminders to screen 3398 school children (7-9 years of age) in 92 rural Nicaraguan communities. The accuracy of screening, test duration, testing efficiency, telehealth data validity, and compliance with recommended clinic visits were analyzed., Results: Minimally trained CHWs successfully screened children within remote rural schools with automated audiometry (test duration = 5.8 minutes) followed by manual audiometry if needed (test duration = 4.3 minutes) with an estimated manual audiometry validity of 98.5% based on a review of convergence patterns. For children who were referred based on audiometry, the otoscopy and tympanometry obtained during telehealth evaluations were high quality (as reviewed by 3 experts) in 44.6% and 80.1% of ears, respectively. A combination of automated short message service (SMS) text messages and voice reminders resulted in a follow-up compliance of 75.2%. No families responded to SMS messages alone., Conclusions: Tablet-based hearing screening administered by minimally trained CHWs is feasible and effective in low- and middle-income countries. Manual audiometry was as efficient as automated audiometry in this setting. The physical exam tasks of otoscopy and tympanometry require additional training. Mobile phone messages improve compliance for confirmatory audiometry, but the utility of SMS messaging alone is unclear in this population., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interest., (Copyright © 2022 by the Journal of Global Health. All rights reserved.)

Background: Aminoglycosides are widely used, broad-spectrum antibiotics with significant potential for ototoxicity. Global efforts to prevent ototoxicity must account for aminoglycoside overuse and non-prescription use., Objectives: The goals of this study were to a) estimate the prevalence of aminoglycoside overuse by synthesizing evidence on self-medication, over the counter (OTC) availability, and household antibiotic storage for later use, and to report the specific aminoglycosides used and the predictors of overuse, and b) leverage this information to comment on potential risk of ototoxicity., Methods: Two systematic search strings were conducted to extract peer-reviewed articles published from 2005 to 2020. The first focused on overuse of aminoglycoside antibiotics. The second focused on potentially ototoxic effects of aminoglycosides related to drug overuse., Results: A total of 26 articles were included (first search string: n = 21; second search string: n = 5). The prevalence of aminoglycoside self-medication was high and household storage and OTC availability of aminoglycosides was common. Gentamicin was the most commonly overused aminoglycoside. No studies provided information on antibiotic dosing or resultant toxicities, including ototoxicity., Conclusions: The limited available evidence indicates that antibiotic overuse (self-medication, home storage, and non-prescription availability) is relatively common, especially in low resource settings, and that aminoglycoside antibiotics comprise a variable, but concerning, proportion of non-prescribed antibiotics. Additional evidence is needed to evaluate the relationship between these dispensing patterns and ototoxicity., (Copyright © 2021. Published by Elsevier Inc.)

Background: There is no published decision model for informing hearing health care resource allocation across the lifespan in low- and middle-income countries. We sought to validate the Decision model of the Burden of Hearing loss Across the Lifespan International (DeciBHAL-I) in Chile, India, and Nigeria., Methods: DeciBHAL-I simulates bilateral sensorineural hearing loss (SNHL) and conductive hearing loss (CHL) acquisition, SNHL progression, and hearing loss treatment. To inform model inputs, we identified setting-specific estimates including SNHL prevalence from the Global Burden of Disease (GBD) studies, acute otitis media (AOM) incidence and prevalence of otitis-media related CHL from a systematic review, and setting-specific pediatric and adult hearing aid use prevalence. We considered a coefficient of variance root mean square error (CV-RMSE) of ≤15% to indicate good model fit., Findings: The model-estimated prevalence of bilateral SNHL closely matched GBD estimates, (CV-RMSEs: 3.2-7.4%). Age-specific AOM incidences from DeciBHAL-I also achieved good fit (CV-RMSEs=5.0-7.5%). Model-projected chronic suppurative otitis media prevalence (1.5% in Chile, 4.9% in India, and 3.4% in Nigeria) was consistent with setting-specific estimates, and the incidence of otitis media-related CHL was calibrated to attain adequate model fit. DeciBHAL-projected adult hearing aid use in Chile (3.2-19.7% ages 65-85 years) was within the 95% confidence intervals of published estimates. Adult hearing aid prevalence from the model in India was 1.4-2.3%, and 1.1-1.3% in Nigeria, consistent with literature-based and expert estimates., Interpretation: DeciBHAL-I reasonably simulates hearing loss natural history, detection, and treatment in Chile, India, and Nigeria. Future cost-effectiveness analyses might use DeciBHAL-I to inform global hearing health policy., Funding: National Institutes of Health (3UL1-TR002553-03S3 and F30 DC019846)., Competing Interests: The authors have no conflicts of interest to declare., (© 2022 The Authors.)

Background: Falls are the leading cause of fatal and nonfatal injuries among adults over 65 years old. The increase in fall mortality rates is likely multifactorial. With a lack of key drivers identified to explain rising rates of death from falls, accurate predictive modelling can be challenging, hindering evidence-based health resource and policy efforts. The objective of this work is to examine the predictive power of geographic utilization and longitudinal trends in mortality from unintentional falls amongst different demographic and geographic strata., Methods: This is a nationwide, retrospective cohort study using the United States Centers for Disease Control (CDC) Web-based Injury Statistics Query and Reporting System (WISQARS) database. The exposure was death from an unintentional fall as determined by the CDC. Outcomes included aggregate and trend crude and age-adjusted death rates. Health care utilization, reimbursement, and cost metrics were also compared., Results: Over 2001 to 2018, 465,486 total deaths due to unintentional falls were recorded with crude and age-adjusted rates of 8.42 and 7.76 per 100,000 population respectively. Comparing age-adjusted rates, males had a significantly higher age-adjusted death rate (9.89 vs. 6.17; p <  0.00001), but both male and female annual age-adjusted mortality rates are expected to rise (Male: + 0.25 rate/year, R 2 = 0.98; Female: + 0.22 rate/year, R 2 = 0.99). There were significant increases in death rates commensurate with increasing age, with the adults aged 85 years or older having the highest aggregate (201.1 per 100,000) and trending death rates (+ 8.75 deaths per 100,000/year, R 2 = 0.99). Machine learning algorithms using health care utilization data were accurate in predicting geographic age-adjusted death rates., Conclusions: Machine learning models have high accuracy in predicting geographic age-adjusted mortality rates from health care utilization data. In the United States from 2001 through 2018, adults aged 85+ years carried the highest death rate from unintentional falls and this rate is forecasted to accelerate., (© 2022. The Author(s).)

Background: Hearing loss affects over 50% of people in the US across their lifespan and there is a lack of decision modeling frameworks to inform optimal hearing healthcare delivery. Our objective was to develop and validate a microsimulation model of hearing loss across the lifespan in the US., Methods: We collaborated with the Lancet Commission on Hearing Loss to outline model structure, identify input data sources, and calibrate/validate DeciBHAL-US (Decision model of the Burden of Hearing loss Across the Lifespan). We populated the model with literature-based estimates and validated the conceptual model with key informants. We validated key model endpoints to the published literature, including: 1) natural history of sensorineural hearing loss (SNHL), 2) natural history of conductive hearing loss (CHL), and 3) the hearing loss cascade of care. We reported the coefficient of variance root mean square error (CV-RMSE), considering values ≤15% to indicate adequate fit., Findings: For SNHL prevalence, the CV-RMSE for model projected male and female age-specific prevalence compared to sex-adjusted National Health and Nutrition Examination Survey (NHANES) data was 4.9 and 5.7%, respectively. Incorporating literature-based age-related decline in SNHL, we validated mean four-frequency average hearing loss in the better ear (dB) among all persons to longitudinal data (CV-RMSE=11.3%). We validated the age-stratified prevalence of CHL to adjusted NHANES data (CV-RMSE=10.9%). We incorporated age- and severity-stratified time to first hearing aid (HA) use data and HA discontinuation data (adjusted for time-period of use) and validated to NHANES estimates on the prevalence of adult HA use (CV-RMSE=10.3%)., Interpretation: Our results indicate adequate model fit to internal and external validation data. Future incorporation of cost and severity-stratified utility data will allow for cost-effectiveness analysis of US hearing healthcare interventions across the lifespan. Further research might expand the modeling framework to international settings., Funding: This study was funded by the National Institute on Deafness and Other Communication Disorders and the National Institute on Aging (3UL1-TR002553-03S3 and F30 DC019846)., Competing Interests: JRD reports grants from the National Institutes of Health, participation on the National Institute on Deafness and Other Communication Disorders Data Safety Monitoring Board (DSMB) and the National Institute on Aging ACHIEVE (Aging and Cognitive Health Evaluation in Elders) DSMB, and participation on the Board of Directors of the Hearing Health Foundation and on the Executive Council of the Acoustical Society of America. All other authors declare no competing interests., (© 2021 Published by Elsevier Ltd.)

Objectives: To characterize the quality and enjoyment of sound by cochlear implant (CI) recipients and identify predictors of these outcomes after cochlear implantation., Study Design: Cross-sectional study., Setting: A tertiary care hospital., Methods: Surveys based on the Hearing Implant Sound Quality Index were sent to all patients who received a CI at a tertiary care hospital from 2000 to 2019. Survey questions prompted CI recipients to characterize enjoyment and quality of voices, music, and various sounds., Results: Of the 339 surveys, 60 (17.7%) were returned with complete data. CI recipients had a mean ± SD age of 62.5 ± 17.4 years with a mean 8.0 ± 6.1 years since CI surgery. Older current age and age at implantation significantly predicted lower current sound quality ( P < .05) and sound enjoyment ( P < .05), as well as worsening of sound quality ( P < .05) and sound enjoyment ( P < .05) over time. Greater length of implantation was associated with higher reported quality and enjoyment ( r = 0.4, P < .001; r = 0.4, P < .05), as well as improvement of sound quality ( r = 0.3, P < .05) but not sound enjoyment over time., Conclusion: Recipients who had CIs for a longer period had improved quality of sound perception, suggesting a degree of adaptation. However, CI recipients with implantation at an older age reported poorer sound quality and enjoyment as well as worsening sound quality and enjoyment over time, indicating that age-related changes influence outcomes of cochlear implantation., (© The Authors 2021.)

Objective: To identify preoperative patient and surgical parameters that predict operative time variability within tympanoplasty current procedural terminology (CPT) codes., Study Design: Retrospective., Setting: Tertiary referral center., Patients: One hundred twenty eight patients who underwent tympanoplasty (CPT code 69631) or tympanoplasty with ossicular chain reconstruction (69633) by a single surgeon over 3 years., Interventions: Procedures were preoperatively assigned a complexity modifier: Level 1 (small or posterior perforation able to be repaired via transcanal approach), Level 2 (large perforation or other factor requiring postauricular approach), or Level 3 (cholesteatoma or severe infection)., Main Outcome Measures: Total in-room time (nonoperative time plus actual operative time)., Results: Consideration of preoperative parameters including surgical complexity, surgical facility, use of facial nerve monitoring, laser usage, resident involvement, revision surgery, and underlying patient characteristics (American Society of Anesthesiologists [ASA] score, body mass index [BMI]) accounted for up to 69% of surgical time variance. Across both CPT codes, surgical complexity levels accurately stratified operative times (p < 0.05). Total time was longer (by 30.0 min for 69631, 55.4 min for 69633) in Level 3 procedures compared with Level 2, while Level 1 cases were shorter (27.6, 33.9 min). Resident involvement added 25 and 32 minutes to total time (p < 0.02). Nonoperative preparation times were longer (22.1, 15.4 min) in the main hospital compared with ambulatory surgical center (p < 0.001)., Conclusions: There is significant surgical time variability within tympanoplasty CPT codes, which can be accurately predicted by the preoperative assignment of complexity level modifiers and consideration of patient and surgical factors. Application of complexity modifiers can enable more efficient surgical scheduling., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021, Otology & Neurotology, Inc.)

Breast stroma plays a significant role in breast cancer risk and progression yet remains poorly understood. In breast stroma, collagen is the most abundantly expressed protein and its increased deposition and alignment contributes to progression and poor prognosis. Collagen post-translation modifications such as hydroxylated-proline (HYP) control deposition and stromal organization. The clinical relevance of collagen HYP site modifications in cancer processes remains undefined due to technical issues accessing collagen from formalin-fixed, paraffin-embedded (FFPE) tissues. We previously developed a targeted approach for investigating collagen and other extracellular matrix proteins from FFPE tissue. Here, we hypothesized that immunohistochemistry staining for fibroblastic markers would not interfere with targeted detection of collagen stroma peptides and could reveal peptide regulation influenced by specific cell types. Our initial work demonstrated that stromal peptide peak intensities when using MALD-IMS following IHC staining (αSMA, FAP, P4HA3 and PTEN) were comparable to serial sections of nonstained tissue. Analysis of histology-directed IMS using PTEN on breast tissues and TMAs revealed heterogeneous PTEN staining patterns and suggestive roles in stromal protein regulation. This study sets the foundation for investigations of target cell types and their unique contribution to collagen regulation within extracellular matrix niches.

Hypothesis: Ciprofloxacin-resistant pathogens are inhibited by high concentrations of ciprofloxacin found in commercially-available ototopical solutions., Background: Ciprofloxacin-resistant pathogens in otitis media are currently treated with ototopical ciprofloxacin suspensions. This is done irrespective of laboratory-reported ciprofloxacin susceptibility, under the assumption that the high concentration of ciprofloxacin applied topically is sufficient to overcome antimicrobial resistance., Methods: We evaluated 34 ciprofloxacin-resistant isolates consisting of Staphylococcus aureus, Pseudomonas aeruginosa, Corynebacterium spp., and Turicella otitidis. Ciprofloxacin minimum inhibitory concentration (MIC) assays and clinical ototopical solution minimum bactericidal concentration (CMBC) assays were performed., Results: Amongst the ciprofloxacin-resistant isolates, ciprofloxacin MICs ranged from 8 to 256 mcg/ml (mean: 87.1 mcg/ml) and CMBCs ranged from 23.4 to 1500 mcg/ml (mean: 237.0 mcg/ml). There were no significant differences with respect to MIC in comparing P. aeruginosa versus Corynebacterium spp. (mean: 53.3 versus 55.2, p = 0.86), S. aureus versus P. aeruginosa (mean: 128.0 versus 53.3, p = 0.34), and S. aureus versus Corynebacterium spp. (mean: 128.0 versus 55.2, p = 0.09). The correlation between ciprofloxacin MIC and CMBC was poor (Pearson's r = -0.08, p = 0.75)., Conclusions: Ciprofloxacin-resistant pathogens commonly recovered from otitis media exhibit highly variable ciprofloxacin MIC and CMBC levels. Ciprofloxacin was able to inhibit growth in all isolates tested at MIC levels less than or equal to 256 mcg/ml; however, CMBC's up to 1500 mcg/ml were observed within that same group. The clinical relevance of these in vitro MICs is unclear due in part to higher bactericidal concentrations (CMBC) in several strains. Our results suggest that treatment failures may be due to a combination of factors rather than high-level resistance alone., Competing Interests: The authors have no conflicts of interest or funding sources to disclose., (Copyright © 2021, Otology & Neurotology, Inc.)

Objective: To demonstrate the feasibility of a novel procedure whereby a suture is placed transorally in the tensor veli palatini muscle to tighten it, thereby dilating the cartilaginous portion of the eustachian tube (ET)., Study Design: The study design was a prospective cadaveric experiment to examine the feasibility of a novel treatment for ET dysfunction., Setting: Academic medical center in a research-oriented operating room with intraoperative computed tomography (CT) capabilities., Methods: Seven fresh-frozen cadaver heads were obtained, each of which was thawed for 36 hours prior to use. The preprocedural volumes of the cartilaginous ET were measured by filling the ET with an iodine-containing radiocontrast agent via the nasopharynx and then obtaining CT images. Submucosal flaps in the soft palate were raised, and sutures were placed in the tensor veli palatini bilaterally to increase tension. After completion of the procedure, contrast placement and CT imaging were repeated. Three-dimensional models of the ETs were created, and the volumes were measured and compared., Results: Of the 14 ETs evaluated, 13 showed an increase in postprocedure volume. On average, postprocedure volumes showed a 57% increase from preprocedure volumes (mean relative change, 57.1%; P = .013)., Conclusion: Placement of a tension-holding suture in the tensor veli palatini muscle can reliably dilate the cartilaginous portion of the ET. Such a procedure may be useful in the treatment of ET dysfunction.

Objective: To analyze surgical outcomes of a novel alloplastic reconstruction technique for partial external auditory canal (EAC) defects in tympanomastoidectomy., Methods: Retrospective study of 51 patients with cholesteatoma who underwent repair of partial EAC defects during tympanomastoidectomy at a tertiary referral center over 8 years. Nineteen patients were treated with a novel alloplastic graft technique using hydroxyapatite cement and bone pâté for EAC repair. Thirty-two patients treated with traditional cartilage repair of the EAC served as a control group. The primary outcomes measured were postoperative cholesteatoma recurrence rates, infection rates, and mean air-bone gap (ABG)., Results: Twenty of the 51 cases (39.2%) were revision surgeries for cholesteatoma recidivism, with a greater proportion of revision surgeries in the alloplastic group (57.9% vs 28.1%, P = .04). There was no significant difference in postoperative cholesteatoma recurrence ( P = 1.00) or infection rates ( P = .64) between the two techniques, with the alloplastic group experiencing slightly lower rates of recurrence (36.8%) and infection (5.3%) than cartilage repair (37.5% recurrence, 12.5% infection). Mean postoperative ABGs were comparable between the alloplastic (21.5 dB) and cartilage group (26.0 dB, P = .10)., Conclusions: Composite alloplastic and bone pâté reconstruction is an effective technique to repair partial EAC defects in tympanomastoidectomy, with comparable postoperative hearing outcomes and no increased risk of cholesteatoma recurrence or infection compared to traditional cartilage repair. Recidivism rates were relatively high in both groups, likely due to the high rate of revision surgeries and aggressive nature of cholesteatoma within the cohort., Level of Evidence: Level 3B., Competing Interests: The authors declare no sources of funding or conflicts of interest for this study., (© 2020 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC. on behalf of The Triological Society.)

Objective: To determine the cost-effectiveness of cochlear implantation (CI) with mainstream education and deaf education with sign language for treatment of children with profound sensorineural hearing loss in low- and lower-middle income countries in Asia., Study Design: Cost-effectiveness analysis., Setting: Bangladesh, Cambodia, India, Indonesia, Nepal, Pakistan, Philippines, and Sri Lanka participated in the study., Subjects and Methods: Costs were obtained from experts in each country with known costs and published data, with estimation when necessary. A disability-adjusted life-years model was applied with 3% discounting and 10-year length of analysis. A sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and probability of device failure. Cost-effectiveness was determined with the World Health Organization standard of cost-effectiveness ratio per gross domestic product (CER/GDP) per capita <3., Results: Deaf education was cost-effective in all countries except Nepal (CER/GDP, 3.59). CI was cost-effective in all countries except Nepal (CER/GDP, 6.38) and Pakistan (CER/GDP, 3.14)-the latter of which reached borderline cost-effectiveness in the sensitivity analysis (minimum, maximum: 2.94, 3.39)., Conclusion: Deaf education and CI are largely cost-effective in participating Asian countries. Variation in CI maintenance and education-related costs may contribute to the range of cost-effectiveness ratios observed in this study.

Objective: To compare outcomes for patients undergoing a transmastoid approach versus a middle fossa craniotomy approach with plugging and/or resurfacing for repair of superior semicircular canal dehiscence. Outcome measures include symptom resolution, hearing, operative time, hospital stay, complications, and revision rates., Study Design: Multicenter retrospective comparative cohort study., Settings: Three tertiary neurotology centers., Subjects and Methods: All adult patients undergoing repair for superior canal dehiscence between 2006 and 2017 at 3 neurotology centers were included. Demographics and otologic history collected by chart review. Imaging, audiometric data, and vestibular evoked myogenic potential measurements were also collected for analysis., Results: A total of 68 patients (74 ears) were included in the study. Twenty-one patients underwent middle fossa craniotomy repair (mean age, 47.9 years), and 47 underwent transmastoid repair (mean age, 48.0 years). There were no significant differences in age or sex distribution between the groups. The transmastoid group experienced a significantly shorter duration of hospitalization and lower recurrence rate as compared with the middle fossa craniotomy group (3.8% vs 33%). Both groups experienced improvement in noise-induced vertigo, autophony, pulsatile tinnitus, and nonspecific vertigo. There was no significant difference among symptom resolution between groups. Additionally, there was no significant difference in audiometric outcomes between the groups., Conclusion: Both the transmastoid approach and the middle fossa craniotomy approach for repair of superior canal dehiscence offer symptom resolution with minimal risk. The transmastoid approach was associated with shorter hospital stays and lower recurrence rate as compared with the middle fossa craniotomy approach.

Objective: Ciprofloxacin resistance has been reported in 4.5% of patients with otorrhea and is increasing in prevalence. Due to ototoxicity, only fluoroquinolones are Food and Drug Administration approved for topical therapy in the middle ear. Furthermore, there is an assumption that antibiotic resistance is less relevant to topical therapy due to in vivo concentrations much higher than the minimum inhibitory concentration used to determine resistance. This study investigates ciprofloxacin-resistant infections and seeks to develop a better understanding of treatment options and outcomes., Study Design: Retrospective review of 141 ciprofloxacin-resistant otologic infections., Setting: Tertiary-care hospital., Patients: Patients with culture-proven ciprofloxacin-resistant infections from 2008 to 2017., Intervention(s): Antibiotic treatment with ciprofloxacin topical drops, ciprofloxacin plus oral antibiotics, and nonciprofloxacin therapy., Main Outcome Measure(s): Bacteriology for ciprofloxacin-resistant infections and treatment effectiveness of various therapies., Results: Methicillin-resistant Staphylococcus aureus (33%), Corynebacterium striatum (19%), and non-Methicillin-resistant Staphylococcus aureus (11%) are the most frequent causes of ciprofloxacin-resistant infections. Topical ciprofloxacin monotherapy was successful in 2.7% of infections compared with a 64.7% success rate with the addition of an oral antibiotic (p < 0.001). Nonciprofloxacin drops are more effective with a 70% cure rate compared with the 2.7% of the ciprofloxacin drops p < 0.001. There was no difference in treatment efficacy when comparing nonciprofloxacin topical therapy (70% cure) to nonciprofloxacin topical therapy plus oral antibiotic (83% cure, p = 0.17)., Conclusions: Using ciprofloxacin drops to treat ciprofloxacin-resistant bacteria is ineffective and patients do significantly better with alternative therapy. This finding supports the conclusion that high concentrations achieved in topical applications are not sufficient to overcome antibiotic resistance.

The Global Burden of Disease (GBD) project provides longitudinal analysis of the global burden of otolaryngologic diseases by measuring the all-cause mortality, years of life lost, the years of life lived with disability, and disability-adjusted life years. Hearing loss burden is assessed overall and as sequelae of other diseases, such as otitis media or meningitis. Using these measures, we can appreciate the high prevalence and disability related to hearing loss globally. Other otolaryngologic diseases that contribute to the GBD include otitis media, cleft lip and palate, head and neck cancer, facial trauma, and oral disorders., (Copyright © 2018 Elsevier Inc. All rights reserved.)