***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES Using a microscope to achieve a view of the canal during dewaxing is the most commonly performed method of dewaxing in secondary care , but an endoscope can also be used . We set out to compare endoscopic and microscopic dewaxing . DESIGN R and omised clinical trial . SETTING Otolaryngology Outpatient Department . PARTICIPANTS One hundred participants selected sequentially from patients requiring dewaxing of their ears to allow examination of the tympanic membrane . Patients with external or middle ear pathology were excluded . METHODS Patients were r and omly assigned to have dewaxing performed using microinstruments aided by vision with a microscope or an endoscope . All participants who were entered the study completed the study . MAIN OUTCOME MEASURES Levels of pain and discomfort experienced by the participants were assessed by a visual analogue scale ( VAS ) . Difficulty of performing the dewaxing indicated by the endoscopist using a VAS . The length of time taken to perform the dewaxing was also recorded . RESULTS Endoscopic dewaxing was less uncomfortable than microscopic dewaxing for patients ( VAS median values 5 and 25 respectively ; P < 0.002 ) as well as less painful ( VAS median values 3.5 and 10 respectively ; P < 0.075 ) . Endoscopic dewaxing was easier to perform than microscopic dewaxing ( VAS median values for difficulty were 9 and 20 respectively ; P < 0.005 ) and took less time ( mean time for endoscopic dewaxing was 1.8 min versus 3.3 min for microscopic dewaxing ( P < 0.001 ) . Ninety-one per cent of ears could be dewaxed with a Jobson-Horne probe or wax hook . CONCLUSIONS The cost of an operating microscope suitable for use with dewaxing is approximately 10 times that of a suitable endoscope , dewaxing is a cheaper alternative to microscopic dewaxing that has benefits for the patient and clinician OBJECTIVE To assess the protein and simple sugar content of earwax in pursuit of better ceruminolytic agents . STUDY DESIGN Collected earwax specimens were tested in several media for dissolution before being analyzed for amino acid and carbohydrate content . PATIENTS The sample s were obtained from eight r and om patients requiring ear plug removal . RESULTS The amino acid composition differs considerably from hair and stratum corneum of glabrous skin . Sugar analysis revealed high levels of galactosamine and galactose . CONCLUSIONS This analysis of proteins and carbohydrates further characterizes earwax . Future ceruminolytic agents must dissolve lipid , keratin , and a monolayer of lipid covalently bound to the epidermal cells , which encourages cellular aggregation BACKGROUND Earwax is a common problem in general practice . The incidence of complaints owing to earwax in general practice in the Netherl and s is 39.3 per 1000 patients . AIM To determine the feasibility of a strategy using water as a quick dispersant for persistent earwax , compared with the usual strategy using oil as a dispersant for three days in a general practice setting . DESIGN OF STUDY Practice based , prospect i ve controlled intervention study . SETTING Forty-two patients ( 59 ears ) in four general practice s in the Netherl and s. METHOD Patients with persistent earwax were r and omised into an intervention group and a control group . For patients in the intervention group , water drops at body temperature were dropped into the impacted ear and the auditory meatus was blocked with a wet wad of cotton . After the patient had waited for 15 minutes in the waiting room a series of attempts at syringing was completed . Patients in the control group received the usual strategy and were instructed to soften the earwax with oil each night before sleeping and to block the auditory meatus with a wad of cotton , for three days . They were asked to come back after three days for the second attempt of syringing . For both strategies the mean number of syringing attempts ( and 95 % confidence interval ) was calculated and compared by testing the difference between the means using a t-test for independent sample s. All ears in which the wax was still persistent after another five syringing attempts were given the value of 6 in the calculations . RESULTS The mean number of syringing attempts needed per patient in the intervention group was 3.0 ( 95 % CI = 2.4 to 3.6 ) and for the control group , the mean was 2.4 ( 95 % CI = 1.7 to 3.1 ) . The difference between means ( 0.6 , 95 % CI = 0.3 to 1.5 ) was not statistically significant ( P = 0.18 ) . CONCLUSION A patient with persistent earwax can stay in the waiting room following the initial series of five attempts at syringing , with water instilled in the ear canal . After 15 minutes , the earwax is removed as easily as in the usual strategy using oil instilled for three days . The strategy using water as a dispersant for persistent earwax is quick and more convenient for the patient BACKGROUND Dispute exists over the best treatment for softening occlusive earwax .  Some require the patient to go away for days before returning for syringing . Some syringe immediately with no preparation . METHODS An open , nonblinded , r and omised controlled trial was conducted in one rural general practice . Effects of instillation of water into the ear canal for 15 minutes before syringing were compared to effects of syringing immediately . RESULTS Thirty-nine ears ( of 26 patients ) were r and omised .  Ear wax was removed entirely by syringing in all ears . Prior instillation of water required a mean 7.5 ( + /- 7.3 ) attempts at syringing versus a mean 25.4 ( + /- 39.4 ) attempts for ears that were syringed immediately ( p=0.043 ) . DISCUSSION Prior installation of water before syringing seems to be an effective and simple method of reducing the number of attempts required to clear the ear of occlusive wax OBJECTIVES Ongoing developments in design have improved the outlook for  left-ventricular assist device ( LVAD ) implantation as a therapy in end-stage heart failure . Nevertheless , early cost-effectiveness assessment s , based on first-generation devices , have not been encouraging . Against this background , we set out ( i ) to examine the survival benefit that LVADs would need to generate before they could be deemed cost-effective ; ( ii ) to provide insight into the likelihood that this benefit will be achieved ; and ( iii ) from the perspective of a healthcare provider , to assess the value of discovering the actual size of this benefit by means of a Bayesian value of information analysis . METHODS Cost-effectiveness assessment s are made from the perspective of the healthcare provider , using current UK norms for the value of a quality -adjusted life-year ( QALY ) . The treatment model is grounded in published analyses of the R and omized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure ( REMATCH ) trial of first-generation LVADs , translated into a UK cost setting . The prospect s for patient survival with second-generation devices is assessed using Bayesian prior distributions , elicited from a group of leading clinicians in the field . RESULTS Using established thresholds , cost-effectiveness probabilities under these priors are found to be low ( approximately .2 percent ) for devices costing as much as 60,000 pounds . Sensitivity of the conclusions to both device cost and QALY valuation is examined . CONCLUSIONS In the event that the price of the device in use would reduce to 40,000 pounds , the value of the survival information can readily justify investment in further trials Thirty-six patients with symptoms of impacted ear wax were recruited to an open , r and omized , parallel group study of ' Audax ' ear drops and ' Earex ' ear drops .  Patients had had their symptoms for several weeks and they were assessed on entry for the degree of impaction in each ear . After using the drops , morning and evening for 4 days , they were assessed on the fifth day for degree of impaction , ease of syringing , side-effects or discomfort , and the investigator 's and patient 's own global impression of efficacy of the ear drops . A trend was seen showing less impaction post-treatment in the ' Audax ' group than in the ' Earex ' group although the difference did not reach statistical significance . A significant difference was seen in favour of ' Audax ' for the frequency and ease of syringing ( p < 0.005 ) . No patients in the ' Audax ' group reported any side-effect or discomfort although 1 patient using ' Earex ' reported slight irritation whilst another found the smell unacceptable . The results of the investigators ' and patients ' own global impression of efficacy were significantly in favour of ' Audax ' ear drops ( p < 0.01 ) BACKGROUND Cerumen obstructing visualization of the tympanic membrane in children is a common and frustrating problem . Docusate sodium , triethanolamine polypeptide , and saline were compared to determine their effectiveness in relieving cerumen obstruction in children . METHODS A r and omized , controlled , double-blind trial was performed on pediatric patients aged 6 months through 5 years with cerumen obstruction . The enrolling physician determined whether the cerumen completely or partially obstructed visualization of the tympanic membrane . One milliliter of docusate sodium , triethanolamine polypeptide , or normal saline as control was placed into the patient 's ear canal . If the tympanic membrane was not completely visualized after 15 minutes , the ear was irrigated with 50 mL of tepid water . Irrigation was repeated a second time if needed . The main outcome was the proportion of tympanic membranes that were completely visualized after cerumeno-eblytic agents or control saline , alone or with irrigation if needed . RESULTS Of 92 patients enrolled , 34 received docusate sodium ; 30 , triethanolamine polypeptide ; and 28 , saline .  Mean + /- SD patient age was 34.7 + /- 18.1 months , and 50 ( 54 % ) of the patients were girls . Groups were similar in age , race , sex , ear enrolled , wax consistency , and degree of obstruction . There was no significant difference in the proportion of tympanic membranes completely visualized after treatment with docusate ( 18/34 ; 53 % ) , triethanolamine polypeptide ( 13/30 ; 43 % ) , or saline ( 19/28 ; 68 % ) ( P = .17 ) . CONCLUSION Application of docusate sodium or triethanolamine polypeptide did not significantly improve the proportion of tympanic membranes that were completely visualized vs application of the saline control STUDY OBJECTIVE To test the hypothesis that  ear irrigation with warmed normal saline solution is more comfortable and results in fewer side effects than irrigation with room temperature saline solution in normal volunteers . METHODS The study was a r and omized , single-blind , crossover trial in which each subject received 30 mL warmed normal saline solution in 1 ear and 30 mL room temperature saline solution in the opposite ear . The solutions ( warmed versus room temperature ) and the order of irrigation ( right versus left ear ) were separately r and omized . Investigators obtaining scores were blinded to solution temperature . Subjects rated the discomfort of irrigation , using separate visual analog scales , from 0 ( no pain ) to 100 mm ( worst pain ever ) . RESULTS Forty volunteers were enrolled in the study . The mean difference in visual analog scale scores favoring warmed over room temperature saline solution was 26 mm ( 95 % confidence interval [ CI ] , 19 to 33 mm ; P < .0001 ) . Twenty percent more patients reported dizziness with room temperature irrigation ( 95 % CI , 6 % to 34 % ) . There was no gender effect or order effect for the 2 solutions . CONCLUSION Warmed normal saline solution was both clinical ly and statistically more comfortable than room temperature saline solution as an ear irrigant in normal volunteers . Significantly less dizziness was reported with the warmed solution The purpose s of this study were to estimate the prevalence of impacted cerumen in a population of hospitalized elderly patients , and to evaluate the effect of cerumen removal in reversing hearing impairment . The design was a pre-test/post-test static-group comparison . Over a 1-year period , a r and om sample ( n = 226 ) was drawn every third day from daily admission lists of English-speaking patients aged 65 or older , admitted to non-intensive care units of one hospital . On either the second or third day of hospital stay , subjects were given a hearing test using an AudioScope and then their ear canals were examined for impacted cerumen . Ear canal irrigations were performed on those subjects with impacted cerumen . All subjects received a second hearing test . Results indicate that impacted cerumen is a common condition in the hospitalized elderly . Thirty-five per cent of the sample had impacted cerumen , 19.9 % bilaterally and 15.0 % unilaterally . Furthermore , removal of cerumen significantly improved hearing ability . Improved hearing scores were obtained in 75.0 % of the ears after the impacted cerumen was removed , with subjects hearing from one to three more tones per ear on the second hearing test . An analysis of variance for repeated measures on hearing was computed to test for the effect of removing cerumen from individuals who had neither , one or both ears occluded . A significant interaction ( F = 146.83 , d.f . = 2/223 , P less than 0.0001 ) between hearing tests and cerumen removal was found indicating that those with no occlusion had no change in hearing whereas both occluded groups increased with the greatest change for the bilateral group . 
    Output:
    
Although softeners are effective , which specific softeners are most effective remains uncertain .
Evidence on the effectiveness of methods of irrigation or mechanical removal was equivocal .