Detection of middle-ear fluid in children with spectral gradient acoustic reflectometry: a screening tool for nurses?

OBJECTIVE: To evaluate the validity of spectral gradient acoustic reflectometry (SG-AR) in the hands of nurses in screening children for middle-ear fluid (MEF). DESIGN: Prospective, blinded study. SETTING: A satellite study within the Finnish Otitis Media Vaccine Trial in primary care in 1995-99. PATIENTS: Some 739 ear examinations among a cohort of 271 children under the age of 2 years during different healthcare contacts (acute sick visits, check-up visits after otitis media, and scheduled healthy control visits at 24 months of age). MAIN OUTCOME MEASURES: Specificity, sensitivity and positive and negative predictive values of SG-AR performed by nurses in detecting MEF using pneumatic otoscopy by trained physicians as a reference. RESULTS: SG-AR was successful in 585 (79%) ears. None of the cut-off points assessed resulted in both excellent sensitivity and specificity. Nevertheless, at the sick visits, positive predictive values at 50 and 60 degrees were as high as 94% and 89%, respectively. However, negative predictive value for the cut-off point of 100 degrees was considerably lower, at 75%. At the non-acute visits, negative predictive values were excellent. CONCLUSION: SG-AR is a useful device for nurses in screening MEF among children. It detects ears with both very high and very low probability of MEF and is especially effective in detecting MEF during sick visits and in ruling out MEF among non-acute patients. We recommend the use of the SG-AR cut-off point of 60 degrees as a sign of MEF when screening sick children, and the cut-off point of 100 degrees as a sign of a healthy ear among non-symptomatic patients.     

Does daily vitamin D 800 IU and calcium 1000 mg supplementation decrease the risk of falling in ambulatory women aged 65–71 years? A 3-year randomized population-based trial (OSTPRE-FPS)

Objective

The hypothesis was that the calcium and vitamin D supplementation prevents falls at the population level.Study design: The OSTPRE-FPS was a randomized population-based open-trial with 3-year follow-up. The supplementation group (n = 1566) received daily cholecalciferol 800 IU + calcium carbonate 1000 mg, while the control group (n = 1573) received no supplementation or placebo. A randomly selected subsample of 593 subjects underwent a detailed measurement program including serum 25(OH)D measurements.

Main outcome measure

The occurrence of falls was the primary outcome of the study. The participants in the subsample were telephoned at 4 months intervals and the rest of the trial population was interviewed by phone once a year.

Results

In the entire trial population (ETP), there were 812 women with 1832 falls in the intervention group and 833 women with 1944 falls in the control group (risk ratio was 0.98, 95% CI 0.92–1.05, P = 0.160). The supplementation was not associated with single or multiple falls in the ETP. However, in the subsample, multiple fall incidence decreased by 30% (odds ratio (OR) 0.70, 95% CI 0.50–0.97, P = 0.034) in the supplementation group. Further, the supplementation decreased the incidence of multiple falls requiring medical attention (OR 0.72, 95% CI 0.53–0.97, P = 0.031) in the ETP. The mean compliance in the entire trial population was 78% and in the subsample 79%.

Discussion

Overall, the primary analysis showed no association between calcium and vitamin D supplementation and risk of falls. However, the results of a post hoc analysis suggested that there was a decreased risk of multiple falls requiring medical attention: this finding requires confirmation.     

Oculomotor findings mimicking a cerebellar disorder and postural control in severe Meniere's disease

Objective

We explored whether vestibular derangement in patients with severe Meniere's disease is related to gaze and fixation difficulties and could explain complains of visual blurring and visual neglect.

Methods

Twenty-six patients with severe Meniere's disease treated with intratympanically applied gentamicin of the affected ear were examined. Saccades (with pseudo-random timing, size and side of the step) and pursuit eye movements (PEMs; pseudo-random target trajectory made of a combination of two sinusoidal waves of different frequencies) and posturography were tested in patients. For normative data of voluntary eye movements, 45 control subjects were tested, and for posturography 29 control subjects. Severity of symptoms in Meniere patients was assessed according to the total handicap score of AAO-HNSF (1985).

Results

Saccadic eye movements and postural stability were severely deteriorated in Meniere patients, and these disturbances correlated significantly with each other. Most of PEM parameters were significantly worse in Meniere patients than in control subjects. Prolongation of saccadic latency and reduced gains due to saccadization in PEMs were characteristic features for Meniere's patients. Severity of symptoms in Meniere patients correlated with prolongation of latency in saccades and with poorer gains in PEMs. Postural instability measured with posturography correlated with saccadic latency and PEMs.

Conclusion

In severe Meniere's disease, programming of oculomotor and postural responses show the same pattern of disturbance, an increased delay of processing and inaccuracy in the motor output. A fluctuant vestibular lesion with advanced severity can cause disorders of voluntary eye movements that are reflected with clinical complaints of difficulties in reading and visual scanning of surrounding.     

Consumer acoustic reflectometry by parents in detecting middle-ear fluid among children undergoing tympanostomy

Objective

This study aimed at evaluating the diagnostic accuracy of a consumer model acoustic reflectometer in the hands of parents in the detection of middle-ear fluid among children.

Design

Prospective diagnostic study according to STARD guidelines. Acoustic reflectometry recorded by the parents was compared with otomicroscopic myringotomy with suction in general anaesthesia, performed immediately afterwards.

Setting

Secondary care (Kanta-Häme Central Hospital, Finland).

Patients

Pre-school (<7 years) children undergoing otomicroscopic myringotomy due to recurrent acute otitis media or suspicion of glue ear.

Main outcome measures

Sensitivity, specificity, and positive and negative predictive values of acoustic reflectometry.

Results

Consumer model acoustic reflectometry performed by parents reached sensitivity of 94% (95% confidence interval 88–100%) and negative predictive value of 92% (83–100%) with result 1 (green colour) on a scale of 1–5. On the other hand, the method was not very specific and positive predictive value was poor.

Conclusions

The negative screening result was very reliable. Thus, home screening of otitis among otitis-prone children and home follow-up of resolution of middle-ear fluid afterwards deserves to be studied in the home setting in the future.     

Strain-Dependent Modulation of Ultrasound Speed in Articular Cartilage Under Dynamic Compression

Mechanical properties of articular cartilage may be determined by means of mechano-acoustic indentation, a clinically feasible technique for cartilage diagnostics. Unfortunately, ultrasound speed varies in articular cartilage during mechanical compression. This can cause significant errors to the measured mechanical parameters. In this study, the strain-dependent variation in ultrasound speed was investigated during dynamic compression. In addition, we estimated errors that were induced by the variation in ultrasound speed on the mechano-acoustically measured elastic properties of the tissue. Further, we validated a computational method to correct these errors. Bovine patellar cartilage samples (n = 7) were tested under unconfined compression. Strain-dependence of ultrasound speed was determined under different compressive strains using an identical strain-rate. In addition, the modulation of ultrasound speed was simulated using the transient compositional and structural changes derived from fibril-reinforced poroviscoelastic (FRPVE) model. Experimentally, instantaneous compressive strain modulated the ultrasound speed (p < 0.05) significantly. The decrease of ultrasound speed was found to change nonlinearly as a function of strain. Immediately after the ramp loading ultrasound speed was found to be changed –0.94%, –1.49%, –1.84%, –1.87%, –1.89% and –2.15% at the strains of 2.4%, 4.9%, 7.3%, 9.7%, 12.1% and 14.4%, respectively. The numerical simulation revealed that the compression-related decrease in ultrasound speed induces significant errors in the mechano-acoustically determined strain (39.7%) and dynamic modulus (72.1%) at small strains, e.g., at 2.4%. However, at higher strains, e.g., at 14.4%, the errors were smaller, i.e., 12.6% for strain and 14.5% for modulus. After the proposed computational correction, errors related to ultrasound speed were decreased. By using the correction, with e.g., 2.4% strain, errors in strain and modulus were decreased from 39.7% to 7.2% and from 72.1% to 35.3%, respectively. The FRPVE model, addressing the changes in fibril orientation and void ratio during compression, showed discrepancy of less than 1% between the predicted and measured ultrasound speed during the ramp compression. (E-mail: juha.toyras@kuh.fi)     

Divergent Effects of Losartan and Metoprolol on Cardiac Remodeling,C‐kit+ Cells,Proliferation and Apoptosis in the Left Ventricle after Myocardial Infarction

There is strong evidence for the use of angiotensin converting enzyme inhibitors and beta‐blockers to reduce morbidity and mortality in patients with myocardial infarction (MI), whereas the effect of angiotensin receptor blockers is less clear. We evaluated the effects of an angiotensin receptor blocker losartan and a beta‐blocker metoprolol on left ventricular (LV) remodeling, c‐kit⁺ cells, proliferation, fibrosis, apoptosis, and angiogenesis using a model of coronary ligation in rats. Metoprolol treatment for 2 weeks improved LV systolic function. In contrast, losartan triggered deleterious structural remodeling and functional deterioration of LV systolic function, ejection fraction being 41% and fractional shortening 47% lower in losartan group than in controls 2 weeks after MI. The number of c‐kit⁺ cells as well as expression of Ki‐67 was increased by metoprolol. Losartan‐induced thinning of the anterior wall and ventricular dilation were associated with increased apoptosis and fibrosis, while losartan had no effect on the expression of c‐kit or Ki‐67. Metoprolol or losartan had no effect on microvessel density. These results demonstrate that beta‐blocker treatment attenuated adverse remodeling via c‐kit⁺ cells and proliferation, whereas angiotensin receptor blocker‐induced worsening of LV systolic function was associated with increased apoptosis and fibrosis in the peri‐infarct region.     

Fractal scaling properties of heart rate dynamics and myocardial efficiency in dilated cardiomyopathy

Introduction  

Since altered heart rate (HR) fluctuations provide prognostic information in heart failure, we examined the associations between HR dynamics, myocardial efficiency and perfusion, among patients with dilated cardiomyopathy.     

Microbial genome count in cerebrospinal fluid compared with clinical characteristics in pneumococcal and Haemophilus influenzae type b meningitis in children

Cerebrospinal fluid genome counts were determined by quantitative real-time polymerase chain reaction from 121 children: 36 with Streptococcus pneumoniae and 85 with Haemophilus influenzae meningitis. To examine the interactions of genome count and to determine its prognostic importance, we projected the results against findings on admission and different outcomes. The genome count varied vastly in both meningitides ranging from 0 to 9,250,000/microL. The genome quantity was weakly associated with only some of the patient findings on admission. High counts predicted neurologic (odds ratio [OR]=1.36; 95% confidence interval [CI], 1.09-1.69; P=0.006 for 1 log increase) but not audiologic sequelae. They also predicted death in S .pneumoniae (OR=2.05; 95% CI, 1.08-3.87; P=0.03) but not in H. influenzae meningitis.