Water precautions and ear surgery: evidence and practice in the UK

BACKGROUND

Patients are traditionally advised to refrain from exposing their ears to water after most otological procedures. However, recent evidence suggests that water does not adversely affect the outcome for children with tympanostomy tubes. The evidence behind the potential harmful effects of water on the outcome of other otological procedures is scarce.

OBJECTIVE

The study was done to determine the current practice of otolaryngology consultants in the UK on the advice given to patients regarding swimming, diving and bathing in soapy water after myringotomy and tympanostomy tube insertion, mastoidectomy and myringoplasty.

METHOD

Questionnaire based survey mailed to 382 members (consultants only) of the British Association of Otolaryngologists--Head & Neck Surgeons in the UK.

RESULTS

A total of 195 responses were received (reply rate 51 per cent). In all, 95.6 per cent of the respondents allowed their patients to swim after insertion of tympanostomy tubes, with 32.9 per cent insisting on the use of earplugs until extrusion of the tympanostomy tubes. However, 61.6 per cent of the respondents restricted diving in these patients. In comparison, the respondents were more conservative with water precautions following myringoplasty and mastoidectomy. More than half the respondents recommended earplugs for bathing after all three operations.

CONCLUSION

This study reveals current national practice among UK otolaryngologists. There is no general consensus in post-operative advice following otolaryngological procedures, indicating a need for national guidelines.

Does the slow compression technique of hyperbaric oxygen therapy decrease the incidence of middle-ear barotrauma?

OBJECTIVE

To note the incidence of middle-ear barotrauma following standard and slow compression during hyperbaric oxygen therapy (HBOT). The standards used were: (1) less than 40 per cent of the cohort should develop barotraumas, and (2) the incidence of barotrauma following the slow technique should be less than that caused by the standard technique.

DESIGN

Prospective clinical audit.

MATERIAL AND METHODS

Forty-two consecutive patients who received either standard compression or slow compression HBOT were included. Pre- and post-treatment otoscopy (graded according to a modified Teed's scale), tympanometry, audiometry and subjective ear complaints were compared between the groups and also compared with the set standard.

RESULTS

Significantly less middle-ear barotrauma was noted when using the slow compression technique compared with the standard compression technique (p < 0.05). The incidence of barotrauma when using standard compression failed to meet the set standard of less than 40 per cent.

CONCLUSION

The slow compression method of HBOT proved to be both safe and superior to the standard compression technique.

Culture, ethnicity, and paranoia

This paper defines concepts of culture, ethnicity, and paranoia. It then explores the relationship between culture and ethnicity and the development of paranoia both in mental health settings and in the wider world. The importance of cultural awareness training while dealing with an ethnic population in any multicultural setting is emphasized. When exploring paranoia, proper exploration of its genesis is essential to distinguish between pathological and nonpathological paranoia.

Endoscopic stapling of pharyngeal pouch

The relatively new technique of endoscopic stapling in the surgical management of pharyngeal pouch has gained widespread popularity over the last few years. The technique seems to be the procedure of choice as it is easier and quicker to perform and has a lower morbidity compared with open techniques. We present here an overview of the current evidence provided by a literature search performed by Ovid MEDLINE on literature published between January 1993 and May 2003 on endoscopic stapling of pharyngeal pouch. Several case series have been reported on various aspects of the surgery. The modifications in technique, peri-operative care, success rate, complications and recurrence are summarized, based on observational analytical case series. There were no randomized controlled trials comparing this approach to any other endoscopic or open surgical techniques for pharyngeal pouch.

Ectopic meningioma: a case report with a literature review

Ectopic (extradural) meningiomas that do not originate from either the optic fascicle or the intracranial meninges are exceedingly rare. A patient with an ectopic meningioma in the external auditory canal and mastoid was treated in our unit. The world literature of the last 20 years was reviewed.

Surgical interventions for pharyngeal pouch

BACKGROUND

A pharyngeal pouch is an out-pouching or pocket that develops from the posterior wall of the pharynx just above the entrance to the oesophagus (gullet). Pouches may give rise to difficulty in swallowing, sensation of a lump in the throat or of food sticking in the throat and may lead to troublesome regurgitation of food. Food may enter the pouch rather than passing down the oesophagus and this and regurgitation may result in weight loss, hoarseness of voice and/or recurrent chest infections. The management of patients with a pharyngeal pouch may be either conservative or surgical. The surgical management can be further divided into two broad categories: endoscopic and open procedures. In the first half of the twentieth century an open surgical approach to the pouch was most frequently used, and remains common in some parts of the world. In recent decades endoscopic procedures (where the approach is made through the mouth) have become popular. The superiority of one approach over another has yet to be clearly demonstrated.

OBJECTIVES

To assess the effectiveness and safety of open and endoscopic surgical procedures for the management of a pharyngeal pouch.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2004, MEDLINE (1966 to 2004) and EMBASE (1974 to 2004). Reference lists of all identified trials and previous reviews were searched for additional trials. Further electronic searches for key authors identified were made. There were no language restrictions. The date of the last search was September 2004.

SELECTION CRITERIA

We sought to identify all randomised controlled trials (RCTs) comparing two or more interventions.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed the eligibility of trials for inclusion in the review, based on pre-determined criteria.

MAIN RESULTS

No trials were identified which fulfilled the criteria.

AUTHORS' CONCLUSIONS

There is no evidence from high quality randomised controlled trials to demonstrate the effectiveness of endoscopic compared with open procedures for pharyngeal pouch. There is no good evidence to establish whether one endoscopic procedure is superior to another.

Calcium binding protein 1 of the protozoan parasite Entamoeba histolytica interacts with actin and is involved in cytoskeleton dynamics

Blocking expression of EhCaBP1, a calmodulin-like, four EF-hand protein from the protozoan parasite Entamoeba histolytica, resulted in inhibition of cellular proliferation. In this paper we report that EhCaBP1 is involved in dynamic changes of the actin cytoskeleton. Both endocytosis and phagocytosis were severely impaired in cells where EhCaBP1 expression was blocked by inducible expression of the antisense RNA. In wild-type cells both actin and EhCaBP1 were found to co-localize in phagocytic cups and in pseudopods. However, in antisense-blocked cells the phagocytic cup formation is affected. Analysis of the staining patterns in the presence and absence of actin dynamics inhibitors, jasplakinolide and cytochalasin D suggested that EhCaBP1 and polymerized F-actin co-localize on membrane protrusions. Direct interaction between soluble EhCaBP1 and F-actin was further demonstrated by a co-sedimentation assay. A variant of EhCaBP1 did not bind F-actin showing the specificity of the interaction between EhCaBP1 and actin. There is no significant change in the kinetics of in vitro polymerization of actin in presence of EhCaBP1, indicating that EhCaBP1 does not affect filament treadmilling. In addition, using atomic force microscopy; it was found that filaments of F-actin, polymerized in presence of EhCaBP1, were thinner. These results indicate that EhCaBP1 may be involved in dynamic membrane restructuring at the time of cell pseudopod formation, phagocytosis and endocytosis in a process mediated by direct binding of EhCaBP1 to actin, affecting the bundling of actin filaments.

A case of recurrent erythema multiforme and its therapeutic complications

INTRODUCTION

We report a patient with recurrent erythema multiforme (recurrent EM) who developed iatrogenic Cushing's syndrome due to prolonged corticosteroid use.

CLINICAL PICTURE

The patient had been treated with multiple courses of oral and intramuscular prednisolone over a 10-year period to suppress his recurrent and episodic symptoms. This resulted in the development of iatrogenic Cushing's syndrome with secondary adrenal suppression and steroid-induced osteoporosis.

TREATMENT

The patient was treated with continuous acyclovir therapy in addition to azathioprine. This combination controlled his disease and enabled us to stop his requirement for high-dose prednisolone.

OUTCOME

The patient responded well to this treatment regimen and has been in remission to date.

CONCLUSION

This represents a severe case of recurrent EM and the side effects associated with years of chronic high-dose steroid usage. We discuss the therapeutic options to aid physicians in treating this disabling condition.

Ménière disease patient information and support: which website?

Management of Ménière's disease remains problematic. Many different therapies are available, with variable success. Ménière's patients frequently research the Internet for information about the disease and to make contact with other patients. Internet websites providing this information have grown in number vastly in the past few years. This paper aims to identify the best websites available for Ménière's patients. Using Internet search engines the top 50 websites were evaluated a Website Global Scoring and Evaluation Proforma. From the above the top ranking 15 websites were identified.

Prescribing trends in a teaching hospital in Nepal

Prescriptions of the patients at the time of admission to the college of Medical Sciences (CMS), Bharatpur,Nepal were collected for a period of 6 months to study the prescribing pattern in a teaching hospital. Theprescriptions were subjected to critical evaluation using WHO basic drug use indicators. The averagenumber of drugs per prescription was 4.34. Percentage of drugs prescribed by generic name and percentageof fixed drug combinations (FDCs) were 22.57 and 17.49 respectively. The percentage of prescriptionscontaining antimicrobials (72.05%) and injections(66.66%) were relatively more in our study. Percentageof drugs prescribed from the WHO essential drug list and the Nepal essential drug list were 41.76% and38.20% respectively. The most commonly used group of drugs were antimicrobials(32.27%) ,followed byanalgesics(11.85%) and drugs for acid-peptic-disorders(10.72%). The present drug utilization study is togive feedbacks to the prescribers, so as to create awareness about the rational use of drugs.

Initial study to assess the effects of topical glyceryl trinitrate for pain after haemorrhoidectomy

BACKGROUND

Postoperative pain remains the most dreaded part of haemorrhoidectomy in the minds of both patients and doctors. It may delay patient discharge, recovery, and return to work. Glyceryl trinitrate has been used successfully in the treatment of anal fissures. We investigated its topical use in the management of pain after haemorrhoidectomy.

METHOD

Twenty patients were entered into a double-blind trial and randomised into two groups. Group A (n = 10) applied glyceryl trinitrate ointment (0.2% twice daily) to the perianal area following surgery, and Group B applied a placebo ointment. They applied the ointment for up to 42 days after surgery, or until they felt it necessary to stop the treatment. Patients scored their daily anal pain using a visual analogue scale. Six weeks after surgery, patients were reviewed by an independent observer.

RESULTS

The total pain score was calculated for each patient. The median score for Group A was 50.65; the median score for Group B was 73.50. There was no significant difference in pain scores between both groups, even when aberrant results were ignored. 20% of patients in each group complained that the ointment caused headache.

CONCLUSION

The results suggest that topical glyceryl trinitrate ointment may not significantly reduce postoperative pain following haemorrhoidectomy. Meta-analysis would provide a more definitive answer.

Study of interspouse communication and adoption of family planning and immunization services in a rural block of Varanasi District

Interspouse communication was studied in some pertinent areas which have an important bearing on day to day transactions. The level of such communication measured on a three-point scale was studied for its role on acceptance of family planning and immunization services. 200 currently married females residing with their husbands in a rural block of Varanasi, in the reproductive age group, with at least one child aged 1-3 years were selected and interviewed. Scores were ascribed for 12 selected items of conversation according to frequency of conversation on a three point scale based on which high, medium and low communicators were delineated. In this study high, medium and low communicators were found to be 14%, 40% and 45% respectively. Topics of importance which never featured in interspouse communication were menstrual problems (44%), when to have first child (82.5%) and birth spacing (48.5%). Interspouse communication was better in upper castes and joint families. Literacy status of both husband and wife and per capita income of the family revealed positive relationship with inter-spouse communication. Adoption and practice of family planning methods as well as full immunization coverage of the child in the family were observed to be higher among high and medium communicators as compared to low degree of communcators (p < 0.001).

Simulation of flux lines with columnar pins: bose glass and entangled liquids

Using path integral Monte Carlo we simulate a 3D system of up to 1000 magnetic flux lines by mapping it onto interacting bosons in (2+1)D. With increasing temperatures we find first order melting from an ordered solid to an entangled liquid signaled by a finite entropy jump and sharp discontinuities of the defect density and the structure factor S(G). For a particular density of strong columnar pins the crystal is transformed into a Bose glass phase with patches of crystalline order disrupted by the trapped vortices at the pinning sites but with no overall positional or orientational order. This glassy phase melts into a defected entangled liquid through a continuous transition.

Quantum-fluctuation-induced spatial stochastic resonance at zero temperature

We consider a model in which the quantum fluctuation can be controlled and show that the system responds to a spatially periodic external field at zero temperature. This signifies the occurrence of spatial stochastic resonance where the fluctuations are purely quantum in nature. Various features of the phenomenon are discussed.

Recovering maxillofacial trauma patients: the hidden problems

This longitudinal study highlights the psychological and functional problems that can result from maxillofacial trauma. This is the first study to report outcome at one year. A total of 147 patients admitted for surgery following facial trauma were recruited over a seven-month period. Three questionnaires were used to record patient-derived levels of dysfunction: the Hospital Anxiety Depression scale, a modified University of Washington Quality of Life questionnaire and five non-validated facial trauma items. At one year 46 patients (31%) responded. Although there were significant improvements in scores from pre-operatively to one year, with all patients being discharged from outpatient follow-up, there was a substantial level of subjective symptomatology. Most notable was the level of anxiety and depression, which were present in 30% of the sample at both time points. Health-care professionals tend to underestimate the long-term effects of maxillofacial trauma. To improve patient care, greater appreciation of these problems is required at the time of initial management.

Selective impairment of protein kinase C isotypes in murine macrophage by Leishmania donovani

Leishmania donovani, an obligate intracellular parasite resides and multiplies within macrophage of the reticuloendothelial system. The intracellular signalling mechanism involved in the impaired oxidative response in leishmaniasis has not yet been clearly established. Generation of superoxide anion (O2-) is supposed to be the first line of host defence during microbial invasion. We found a substantial inhibition of superoxide anion generation in parasitized macrophages, which was just the reverse in case of macrophages challenged with Lipophosphoglycan (LPG) deficient attenuated leishmanial parasite UR-6. The generation of O2- essentially needs the prior activation of protein kinase C (PKC) mediated phosphorylation events. Our study proposed that phosphorylation of 67, 54, 47 and 36 kDa proteins was attenuated during infection. This was supported by PKC activity study, where Ca-dependent PKC activity was inhibited but, Ca-independent PKC activity was enhanced. This result was further confirmed by using isotype specific pseudosubstrate inhibitors of Ca-dependent PKC beta and Ca-independent PKC zeta. Application of beta-pseudosubstrate could not alter the Ca-dependent PKC activity but zeta-pseudosubstrate inhibited the Ca-independent PKC activity in infected macrophages. Our immunoblot analysis with specific antibody against PKC beta and PKC zeta isotypes showed down regulation of PKC beta-II expression with concomitant induction of PKC zeta. Such inhibition of Ca-dependent PKC beta was reversed in macrophages treated with UR-6. Taken together, our observations revealed that infection with L. donovani selectively attenuates both the expression and activity of Ca-dependent PKC beta.

Quantum phase transitions in the Ising model in a spatially modulated field

The phase transitions in the transverse field Ising model in a competing spatially modulated (periodic and oscillatory) longitudinal field are studied numerically. There is a multiphase point in absence of the transverse field where the degeneracy for a longitudinal field of wavelength lambda is [(1+sqrt[5])/2](2N/lambda) for a system with N spins, an exact result obtained from the known result for lambda=2. The phase transitions in the Gamma (transverse field) versus h(0) (amplitude of the longitudinal field) phase diagram are obtained from the vanishing of the mass gap Delta. We find that for all the phase transition points obtained in this way, Delta shows finite size scaling behavior signifying a continuous phase transition everywhere. The values of the critical exponents show that the model belongs to the universality class of the two dimensional Ising model. The longitudinal field is found to have the same scaling behavior as that of the transverse field, which seems to be a unique feature for the competing field. The phase boundaries for two different wavelengths of the modulated field are obtained. Close to the multiphase point at h(c), the phase boundary behaves as (h(c)-h(0))(b), where b is also lambda dependent.

Rapidly progressive necrotizing fasciitis and gangrene due to Clostridium difficile: case report

A case of rapidly progressive necrotizing fascitis and gas gangrene due to Clostridium difficile that responded very well to surgical intervention is described.

A benign parathyroid cyst presenting with hoarse voice

Parathyroid tumours and cysts are rare and, when presenting as neck masses, can be clinically misdiagnosed as thyroid lesions. Symptoms may be caused by compression of the surrounding structures or hormonal overactivity. This paper describes a patient with recurrent hoarseness owing to the pressure effects of a parathyroid cyst on the recurrent laryngeal nerve.

Pharmacology of rosemary (Rosmarinus officinalis Linn.) and its therapeutic potentials

The use of plants is as old as the mankind. Natural products are cheap and claimed to be safe. They are also suitable raw material for production of new synthetic agents. Rosemary (Rosmarinus officinalis Linn.) is a common household plant grown in many parts of the world. It is used for flavouring food, a beverage drink, as well as in cosmetics; in folk.medicine it is used as an antispasmodic in renal colic and dysmenorrhoea, in relieving respiratory disorders and to stimulate growth of hair. Extract of rosemary relaxes smooth muscles of trachea and intestine, and has choleretic, hepatoprotective and antitumerogenic activity. The most important constituents of rosemary are caffeic acid and its derivatives such as rosmarinic acid. These compounds have antioxidant effect. The phenolic compound, rosmarinic acid, obtains one of its phenolic rings from phenylalanine via caffeic acid and the other from tyrosine via dihydroxyphenyl-lactic acid. Relatively large-scale production of rosmarinic acid can be obtained from the cell culture of Coleus blumei Benth when supplied exogenously with phenylalanine and tyrosine. Rosmarinic acid is well absorbed from gastrointestinal tract and from the skin. It increases the production of prostaglandin E2 and reduces the production of leukotriene B4 in human polymorphonuclear leucocytes, and inhibits the complement system. It is concluded that rosemary and its constituents especially caffeic acid derivatives such as rosmarinic acid have a therapeutic potential in treatment or prevention of bronchial asthma, spasmogenic disorders, peptic ulcer, inflammatory diseases, hepatotoxicity, atherosclerosis, ischaemic heart disease, cataract, cancer and poor sperm motility.

Immunoprophylaxis and immunotherapy against experimental visceral leishmaniasis

The ability of the Leishmanial parasite, UR6 (MHOM/IN/1978/UR6) to act as a immunoprophylactic and immunotherapeutic agent against experimental visceral leishmaniasis in a hamster model was tested. The Leishmanial parasite, UR6, lacked LPG but possessed abundant message for kinetoplastid membrane protein-11 (KMP-11), and failed to induce visceral infection when given through the intracardiac route, unlike the virulent Leishmania donovani, AG83 (MHOM/IN/1983/AG83), the causative agent of Kala-azar. Priming of macrophage with UR6 in vitro, induced superoxide (O2-) generation whereas a similar experiment with virulent AG83 inhibited O2- generation. This observation prompted us to test the efficacy of UR6 as a immunoprophylactic and immunotherapeutic agent. It was observed that priming of hamsters with either live or sonicated UR6 in the absence of any adjuvant provided strong protection against subsequent virulent challenge. The UR6 mediated protection was also observed in hamsters having established infection. Furthermore, UR6 primed infected hamsters displayed a greatly extended life span as compared to infected hamsters. To our knowledge, this is the first report concerning the use of an atypical Leishmanial parasite, UR6 in immunoprophylaxis and immunotherapy in the absence of any adjuvant.

Using focus groups to evaluate an education program

Two evaluation studies were carried out in 1995 and 1997. The first evaluation assessed tile effectiveness of the Psychiatric Nurse Practitioner's education program and its impact on mental health and psychiatry in Belize. The second study was done to determine if the mental health services were sustained in the country. Interviews and focus groups were used for data collection. In this paper the focus is on the findings from the focus groups. The findings show that the PNP's role performance was adequate, they have made an impact on the mental health services and the services are sustained.

Reduced expression of lipophosphoglycan (LPG) and kinetoplastid membrane protein (KMP)-11 in Leishmania donovani promastigotes in axenic culture

The expression of surface lipophosphoglycan (LPG) and the lipophosphoglycan-associated kinetoplastid membrane protein (KMP)-11 was studied in the strain AG83 of Leishmania donovani in axenic culture. The expression of LPG and KMP-11 decreased along with parasite virulence as a function of the time of the subculture.

Epilepsies among twins born in families of Indian probands with epilepsy

Twins have a high frequency of adverse perinatal events and have been reported to have an increased risk of seizures. Contrary to popular belief, a recent study reported that twins do not have an increased risk of seizures. We studied the relationship of twinning and epilepsy in India. The frequency of twinning in families of probands with epilepsy was compared with the frequency of twinning among hospital births in the same region of India. We also compared consecutively ascertained probands with epilepsy for their twin status and the occurrence of epilepsies in their twin and non-twin relatives. The frequency of twin births in families of 524 probands with epilepsy was comparable to the twin births among consecutive deliveries over a 3-year period in another government hospital in the same catchment area (1:99 vs. 1:75). Every 1 in 58 of probands with epilepsy was a twin while a twin was born in these families every 1 in 71 live births. The frequency of epilepsy in non-proband twin relatives was 1.5% compared with 2% among non-proband, non-twin relatives. This data suggests that twin birth is not a major risk factor for seizures even in families of Indian probands with epilepsy. Family data such as ours can be used to study the contribution by genetic factors in the pathogenesis of complex genetic diseases such as human epilepsies.

Depression rating scales can be related to each other by simple equations

We present evidence that scores on the Montgomery, Hamilton and Beck depression scales are strongly intercorrelated and can be equated to each other. These scales were administered on 107 occasions to patients with major depression. The correlations between scores on each scale were much higher than has been previously reported and, furthermore, the relationships were always well described by a linear function. The close correlations could not be explained by rater biases. We were able to provide validation data for two of the rating scales, demonstrating that our simple models generalize well to a novel dataset. The knowledge that there is a robust relationship between the three scales has practical value for both clinicians and researchers.

SKP1 connects cell cycle regulators to the ubiquitin proteolysis machinery through a novel motif, the F-box

We have identified the yeast and human homologs of the SKP1 gene as a suppressor of cdc4 mutants and as a cyclin F-binding protein. Skp1p indirectly binds cyclin A/Cdk2 through Skp2p, and directly binds Skp2p, cyclin F, and Cdc4p through a novel structural motif called the F-box. SKP1 is required for ubiquitin-mediated proteolysis of Cin2p, Clb5p, and the Cdk inhibitor Sic1p, and provides a link between these molecules and the proteolysis machinery. A large number of proteins contain the F-box motif and are thereby implicated in the ubiquitin pathway. Different skp1 mutants arrest cells in either G1 or G2, suggesting a connection between regulation of proteolysis in different stages of the cycle.