Comparative Analysis of 30-Day Readmission, Reoperation, and Morbidity between Posterior Cervical Decompression and Fusion Performed in Inpatient and Outpatient Settings

STUDY DESIGN

A retrospective cohort study.

PURPOSE

To compare 30-day readmission, reoperation, and morbidity for patients undergoing posterior cervical decompression and fusion (PCDF) in inpatient vs. outpatient settings.

OVERVIEW OF LITERATURE

PCDF has recently been increasingly performed in outpatient settings, often utilizing minimally invasive techniques. However, literature evaluating short-term outcomes for PCDF is scarce. Moreover, no currently large-scale database studies have compared short-term outcomes between PCDF performed in the inpatient and outpatient settings.

METHODS

Patients who underwent PCDF from 2005 to 2018 were identified using the National Surgical Quality Improvement Program database. Regression analysis was utilized to compare primary outcomes between surgical settings and evaluate for predictors thereof.

RESULTS

We identified 8,912 patients. Unadjusted analysis revealed that outpatients had lower readmission (4.7% vs. 8.8%, p =0.020), reoperation (1.7% vs. 3.8%, p =0.038), and morbidity (4.5% vs. 11.2%, p <0.001) rates. After adjusting for baseline differences, readmission, reoperation, and morbidity no longer statistically differed between surgical settings. Outpatients had lower operative time (126 minutes vs. 179 minutes) and levels fused (1.8 vs. 2.2) (p <0.001). Multivariate analysis revealed that age (p =0.008; odds ratio [OR], 1.012), weight loss (p =0.045; OR, 2.444), and increased creatinine (p <0.001; OR, 2.233) independently predicted readmission. The American Society of Anesthesiologists (ASA) classification of ≥3 predicted reoperation (p =0.028; OR, 1.406). Rehabilitation discharge (p <0.001; OR, 1.412), ASA-class of ≥3 (p =0.008; OR, 1.296), decreased hematocrit (p <0.001; OR, 1.700), and operative time (p <0.001; OR, 1.005) predicted morbidity.

CONCLUSIONS

The 30-day outcomes were statistically similar between surgical settings, indicating that PCDF can be safely performed as an outpatient procedure. Surrogates for poor health predicted negative outcomes. These results are particularly important as we continue to shift spinal surgery to outpatient centers. This importance has been highlighted by the need to unburden inpatient sites, particularly during public health emergencies, such as the coronavirus disease 2019 pandemic.

Liposomal bupivacaine does not decrease postoperative opioid use or length of hospital stay in patients undergoing anterior cervical discectomy and fusion

BACKGROUND

Despite its widespread use, definitive data demonstrating the efficacy of liposomal bupivacaine (LB) is limited especially in patients undergoing anterior cervical discectomy and fusion (ACDF). Therefore, this investigation examined whether ACDF patients who received intra-operative LB (LB cohort) exhibited decreased post-operative opioid use and lengths of hospital stay (LOS) compared to ACDF patients who did not receive intra-operative LB (controls).

METHODS

Eighty-two patients who underwent primary ACDF by a single surgeon from 2016 to 2019 were identified from an institutional database. Fifty-nine patients received intra-operative LB while twenty-three did not. Patient characteristics, medical comorbidities, complications, post-operative opioid consumption, and LOS data were collected.

RESULTS

The LB cohort did not require fewer opioids on post-operative day (POD) 0, POD1, POD2, or throughout the hospital course after normalizing by LOS (total per LOS). The number of cervical vertebrae involved in surgery, but not LB use, predicted opioid consumption on POD0, POD1, and total per LOS. For every vertebral level involved, 242 additional morphine milligram equivalents (MME) were consumed on POD0, 266 additional MME were utilized on POD1, and 130 additional MME were consumed in total per LOS.

CONCLUSIONS

ACDF patients who received intra-operative LB did not require fewer post-operative opioids or exhibit a decreased LOS compared to controls. Patients whose procedures involved a greater number of cervical vertebrae were associated with greater opioid consumption on POD0, POD1, and total per LOS. ACDF patients, especially those who had a high number of vertebrae involved, may require alternative analgesia to LB.

Discharge to Rehabilitation Predicts Increased Morbidity in Patients Undergoing Posterior Cervical Decompression and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim was to compare 30-day readmission and postdischarge morbidity for posterior cervical decompression and fusion (PCDF) in patients who were discharged to home versus rehabilitation.

SUMMARY OF BACKGROUND DATA

An increasing number of patients are being discharged to postacute inpatient care facilities following spine surgery. However, little research has been performed to evaluate the effect of this trend on short-term outcomes.

MATERIALS AND METHODS

Patients who underwent PCDF from 2011 to 2018 were identified using the National Surgical Quality Improvements Program (NSQIP)-database. Regression was utilized to compare primary outcomes between home and rehabilitation groups and to control for predictors of outcomes.

RESULTS

We identified 8912 patients. Unadjusted analysis revealed that rehabilitation-discharge patients had greater readmission (10.4% vs. 8.0%, P=0.002) and postdischarge morbidity (7.1% vs. 4.0%, P<0.001) rates. After controlling for patient-related factors, rehabilitation-discharge independently predicted postdischarge morbidity (P<0.001, odds ratio=2.232). Readmission no longer differed between groups (P=0.071, odds ratio=1.311). Rates of discharge to rehabilitation increased from 23.5% in 2011 to 25.3% in 2018, while postdischarge morbidity rates remained stagnant.Patients discharged to rehabilitation were older (66.9 vs. 59.4 y); more likely to be African American (21.4% vs. 13.8%) and have diabetes (27.1% vs. 17.5%), steroid use (6.4% vs. 4.7%, P=0.002), and American Society of Anaesthesiologists (ASA)-class ≥3 (80.2% vs. 57.7%); less likely to be male (53.9% vs. 57.4%, P=0.004) and smokers (20.3% vs. 26.6%); and had greater operative time (198 vs. 170 min) and length of hospital stay (5.9 vs. 3.3 d) (P<0.001).

CONCLUSIONS

Despite controlling for significant factors, discharge to rehabilitation independently predicted a 2.2 times increased odds of postdischarge morbidity. Rates of discharge to rehabilitation increased overtime without an appreciable decrease in postdischarge morbidity, suggesting that greater resources are being utilized in the postacute care period without an obvious justification. Therefore, home-discharge should be prioritized after hospitalization for PCDF when feasible. These findings are notable in light of reform efforts aimed at reducing costs while improving quality of care.

Impact of Discharge to Rehabilitation on Postdischarge Morbidity Following Multilevel Posterior Lumbar Fusion

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to compare 30-day postdischarge morbidity for 3-or-more level (multilevel) posterior lumbar fusion in patients who were discharged to home versus rehabilitation.

SUMMARY OF BACKGROUND DATA

Spine surgery has been increasingly performed in the elderly population, with many of these patients being discharged to rehabilitation and skilled nursing facilities. However, research evaluating the safety of nonhome discharge following spine surgery is limited.

MATERIALS AND METHODS

Patients who underwent multilevel posterior lumbar fusion from 2005 to 2018 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Regression was utilized to compare primary outcomes between discharge disposition and to evaluate for predictors thereof.

RESULTS

We identified 5276 patients. Unadjusted analysis revealed that patients who were discharged to rehabilitation had greater postdischarge morbidity (5.6% vs. 2.6%). After adjusting for baseline differences, discharge to rehabilitation no longer predicted postdischarge morbidity [odds ratio (OR)=1.409, confidence interval: 0.918-2.161, P=0.117]. Multivariate analysis also revealed that age (P=0.026, OR=1.023), disseminated cancer (P=0.037, OR=6.699), and readmission (P<0.001, OR=28.889) independently predicted postdischarge morbidity.

CONCLUSIONS

Thirty days morbidity was statistically similar between patients who were discharged to home and rehabilitation. With appropriate patient selection, discharge to rehabilitation can potentially minimize 30-day postdischarge morbidity for more medically frail patients undergoing multilevel posterior lumbar fusion. These results are particularly important given an aging population, with a great portion of elderly patients who may benefit from postacute care facility discharge following spine surgery.

Current Concepts of Cervical Disc Arthroplasty

BACKGROUND

Radiculopathy and myelopathy resulting from degenerative disc disease are currently treated with anterior cervical discectomy and fusion (ACDF), but there is a high incidence of adjacent segment disease after treatment.

METHODS

With recent advances in cervical disc arthroplasty (CDA), we performed a review of published articles, examining the latest clinical data on the efficacy, safety, and complications of the current cervical disc devices on the market. We focused on the long-term follow up data of single-level, multi-level, and hybrid CDA as compared to ACDF, paying close attention to the newest cervical disc devices. A search was performed utilizing PubMed, Google Scholar, and Clinical Key to identify articles on 1-level, 2-level, and hybrid approaches to CDA. The articles were reviewed by two authors for relevance and power with higher emphasis placed on FDA IDE trials.

RESULTS

The results conclude that CDA has an equivalent or improved clinical outcome when compared with ACDF with improved patient reported neck disability indexes and VAS neck pain scale. CDA also has lower rates of dysphagia, adjacent segment disease, and lower rates of reoperation when compared to ACDF. The data suggest there is no increased rate of reoperation in patients treated with multilevel CDA when compared to ACDF. In addition, the data from the limited clinical trials suggest that hybrid CDA and ACDF is safe and decreases risk of ASD.

CONCLUSION

CDA has been shown to be effective and safe with low complication rates. However, the data are of low quality, and more hybrid studies must be performed in the future to confirm these findings.

CLINICAL RELEVANCE

The reduction in overall postsurgical complications including ASD and in the need for additional surgery in the CDA group.

LEVEL OF EVIDENCE

3.

Comparative Analysis of 30-Day Readmission, Reoperation, and Morbidity Between Lumbar Disc Arthroplasty Performed in the Inpatient and Outpatient Settings Utilizing the ACS-NSQIP Dataset

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Spine surgery has been increasingly performed in the outpatient setting, providing greater control over cost, efficiency, and resource utilization. However, research evaluating the safety of this trend is limited. The objective of this study is to compare 30-day readmission, reoperation, and morbidity for patients undergoing lumbar disc arthroplasty (LDA) in the inpatient versus outpatient settings.

METHODS

Patients who underwent LDA from 2005 to 2018 were identified using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database. Regression was utilized to compare readmission, reoperation, and morbidity between surgical settings, and to evaluate for predictors thereof.

RESULTS

We identified 751 patients. There were no significant differences between inpatient and outpatient LDA in rates of readmission, reoperation, or morbidity on univariate or multivariate analyses. There were also no significant differences in rates of specific complications. Inpatient operative time (138 ± 75 minutes) was significantly (P < .001) longer than outpatient operative time (106 ± 43 minutes). In multivariate analysis, diabetes (P < .001, OR = 7.365), baseline dyspnea (P = .039, OR = 6.447), and increased platelet count (P = .048, OR = 1.007) predicted readmission. Diabetes (P = .016, OR = 6.533) and baseline dyspnea (P = .046, OR = 13.814) predicted reoperation. Baseline dyspnea (P = .021, OR = 8.188) and ASA (American Society of Anesthesiologists) class ≥3 (P = .014, OR = 3.515) predicted morbidity. Decreased hematocrit (P = .008) and increased operative time (P = .003) were associated with morbidity in univariate analysis, but not in multivariate analysis.

CONCLUSIONS

Readmission, reoperation, and morbidity were statistically similar between surgical setting, indicating that LDA can be safely performed in the outpatient setting. Higher ASA class and specific comorbidities predicted poorer 30-day outcomes. These findings can guide choice of surgical setting given specific patient factors.

Impact of sleep deprivation on anaesthesia residents' non-technical skills: a pilot simulation-based prospective randomized trial

Background

Sleep deprivation is common in anaesthesia residents, but its impact on performance remains uncertain. Non-technical skills (team working, situation awareness, decision making, and task management) are key components of quality of care in anaesthesia, particularly in crisis situations occurring in the operating room. The impact of sleep deprivation on non-technical skills is unknown. We tested the hypothesis that in anaesthesia residents sleep deprivation is associated with impaired non-technical skills.

Methods

Twenty anaesthesia residents were randomly allocated to undergo a simulation session after a night shift [sleep-deprived (SLD) group, n =10] or after a night of rest [rested (R) group, n =10] from January to March 2015. The simulated scenario was a situation of crisis management in the operating room. The primary end point was a composite score of anaesthetists' non-technical skills (ANTS) assessed by two blinded evaluators.

Results

Non-technical skills were significantly impaired in the SLD group [ANTS score 12.2 (interquartile range 10.5-13)] compared with the R group [14.5 (14-15), P <0.02]. This difference was mainly accounted for by a difference in the team working item. On the day of simulation, the SLD group showed increased sleepiness and decreased confidence in anaesthesia skills.

Conclusions

In this randomized pilot trial, sleep deprivation was associated with impaired non-technical skills of anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario.

Trial registration

NCT02622217.

Anti-inflammatory effect of vagus nerve stimulation in a rat model of inflammatory bowel disease

Vagus nerve stimulation of afferents is used as an adjunctive treatment for drug-resistant epilepsy and depression. In addition, anti-inflammatory properties of vagus nerve stimulation have been reported in various experimental models of inflammation but not in colitis. These effects are thought to be mediated via peripheral release of acetylcholine from the vagus and subsequent activation of macrophages. Our aim was to evaluate in rats the anti-inflammatory effects of chronic vagus nerve stimulation on colonic inflammation. Colitis was induced by intracolonic instillation of trinitrobenzene sulfonic acid. Vagus nerve stimulation (left cervical) was performed in freely moving animals 3 h per day for five consecutive days. Assessment of colonic inflammation was obtained using physiological (e.g. body weight, temperature and locomotor activity) parameters, macroscopical (area of lesions), histological, and biological parameters (e.g. myeloperoxidase activity, cytokine and cytokine-related mRNAs), both at the level of the damaged colon and the colon immediately above. A global multivariate index of colitis was then generated for a better characterization of colonic inflammation. Vagus nerve stimulation reduced the degree of body weight loss and inflammatory markers as observed above the lesion by histological score and myeloperoxidase quantification. This anti-inflammatory effect was also demonstrated by the improvement of the multivariate index of colitis. These data argue for an anti-inflammatory role of vagus nerve stimulation chronically performed in freely moving rats with colitis and provide potential therapeutic applications for patients with inflammatory bowel diseases.

A rare case of nasal cysticercosis mimicking a nasal dermoid

Cysticercosis, caused by infestation with the pork tapeworm Taenia solium, is known to commonly involve the brain, muscles and subcutaneous tissue. Diagnosing cysticercosis can be difficult as its clinical presentation is usually non-specific. When involving subcutaneous tissue, it can present as firm, non-tender, solitary or multiple nodules. We report a case of subcutaneous cysticercosis at the nasion mimicking a nasal dermoid.

Septate fungal invasion in masked mastoiditis: a diagnostic dilemma

Invasive fungal mastoiditis is a rare entity, seen almost entirely in immunocompromized patients. It has been reported primarily in patients with leukaemia and more recently with acquired immunodeficiency syndrome. A literature search revealed only a few reports in diabetic patients, in whom the invasive fungus was identified as mucormycosis in all cases. We report the first case in the English literature of invasive septate fungal mastoiditis in a diabetic patient with intact tympanic membranes.

Cyanoacrylate in myringoplasty - an office based procedure

Graft failure continues to be a problem for surgery of the perforated eardrum. We present our experience of six cases managed using commercially available superglue (cyanoacrylate) for myringoplasty. This method is simple, office based, less time consuming and cost effective. An insulin syringe was used to deliver the glue after a temporalis fascia graft was tucked under the edges of the perforation.

Clinicopathological and mycological spectrum of allergic fungal sinusitis in South India

In the present study, we describe characteristic clinicopathological and radiological features as well as fungal culture results in a series of 24 patients with allergic fungal sinusitis (AFS). Nasal obstruction and discharge with nasal polyposis was the commonest (95.8%) clinical presentation. Allergic mucin was uniformly present in all patients. Aspergillus species were the commonest fungal isolates (95.8%). One case of mixed Aspergillus and Curvularia sinusitis as well as one case of Drechslera sinusitis were also identified. Typical computerized tomography scan features of hyperdense areas interspersed with soft tissue densities in the affected sinuses were seen in all patients. Application of appropriate diagnostic criteria is essential to establish the diagnosis of AFS and distinguish it from invasive fungal sinus infections.

Malignant otitis externa in an infant with selective IgA deficiency: a case report

The occurrence of malignant otitis externa (MOE) in infancy is rare. We report a case of MOE in a neonate who was later identified to have selective IgA deficiency. She was successfully treated with oral ciprofloxacin, but developed external auditory canal stenosis, a deformed pinna, persistent facial nerve palsy, temporal bone erosion and hearing loss. No cases of MOE in selective IgA deficiency have been reported in literature. This is also the first report on the use of ciprofloxacin in infants with MOE.

Somatic embryogenesis from leaf derived callus of Tylophora indica (Burm. f.) Merrill

Mature leaf explant derived callus of Tylophora indica (Burm. f.) Merrill yielded somatic embryos on MS medium supplied with BA(1-2 mg/L) or kinetin(1-5 mg/L) or kinetin/BA (1-2 mg/L) used along with IAA(0.1-1 mg/L). Maximum somatic embryos (30) could be recovered from 100 mg of embryogenic callus within 60 days at an optimum concentration of 2 mg/L of BA which was also best suited for providing the maximum conversion rate (90%) of embryoids to plantlets. Kinetin (1-5 mg/L), used as the sole growth hormone, induced the development of embryoids showing either shoot or root primordia in 30% of the cultures. However, embryoids with shoot primordia developed roots upon transfer to medium containing IAA(0.1 mg/L) and kinetin(2 mg/L). Embryoids from all cultures germinated in the initiation medium and were transplanted to sterile vermiculite for hardening. After two weeks of hardening, the plantlets were transferred to the green house where they grew and established well showing a high rate of survival (90%).

Alkathine shell, an innovative way of neck flexion after tracheoplasty

Tracheal resection and end-to-end anastomosis is the treatment of choice for mature, isolated, segmental tracheal stenosis and tracheomalacia. Postoperatively, it is important to avoid tension at the anastomotic site. This is usually done by keeping the head in flexion, by a skin suture from chin to chest in the midline. Movement in the post-operative period often results in cutting through of this suture and also formation of scar tissue at the suture site, particularly in those prone to keloid formation. We report seven cases with tracheal stenosis who had primary repair and were managed postoperatively without the midline chin to chest suture, but with an alkathine shell, to maintain the neck in flexion for ten days postoperatively. This had good results with minimal complications.

Throat swab in the chronic tonsillitis: how reliable and valid is it?

INTRODUCTION

The diagnostic test of swabbing the surface of the tonsil as a culture specimen for the determination of the organism responsible for the tonsil infection is still in practice, despite controversy. To date there has been no reports of establishing the reliability and validity of this common diagnostic test by appropriate statistical test of Likelihood ratios taking into consideration the specificity and sensitivity.

AIMS

To assess the reliability and validity of throat swab in the diagnosis of bacterial microflora in chronic tonsillitis.

PATIENTS AND METHODS

A prospective study of 40 patients clinically diagnosed to have chronic tonsillitis undergoing tonsillectomy was undertaken. The reliability of the throat surface swab was then assessed and validated with the reference (gold) standard of tonsil core culture.

RESULTS

The likelihood ratio of this diagnostic test being positive (LR +ve) was 0.84 to similar and 1.3 to general organism pathogen.

CONCLUSION

Routine culture of the throat by surface swab in the accurate diagnosis of bacterial flora in chronic tonsillitis is neither reliable nor valid. The clinical implications of this investigation which is still very popular is discussed.

Hearing status of French youth aged from 18 to 24 years in 1997: a cross-sectional epidemiological study in the selection centres of the army in Vincennes and Lyon

BACKGROUND

It is currently thought that young adults are at increasing risk of exposure to deleterious sources of noise. To test this possibility we have assessed hearing status of young French men aged between 18 and 24 years in 1997 and study risk factors of deafness in a cross-sectional epidemiological study at selection centres for aptitudes to National Service.

METHODS

During the time of the study, 1208 subjects were examined. For each subject, data of an interview, an otoscopy and audiograms were collected. We compared hearing thresholds between subjects with different noise exposures and we determined risk factors of deafness in this population.

RESULTS

The prevalence of hearing loss was 9% at medium frequencies (0.5-2 kHz) and 15% at high frequencies (4-8 kHz).We found that 60% of the subjects were regularly exposed to at least one source of loud noise. Acoustic trauma (6%) mostly explained hearing losses. Repeated episodes of otitis media in childhood (17%) also emerged as an important risk factor apparently due to increased sensitivity to noise. In subjects with antecedent of otitis media, hearing impairments were significant in personal stereo users (>1 hour per day) (p<0.001), in those who went to discos and rock concerts (>2 times per month) (p=0.01) and in those who worked in noisy places (p=0.01). In contrast, in subjects without antecedent of otitis, we found no difference in hearing thresholds between noise exposed and non noise exposed subjects.

CONCLUSIONS

Loud sound exposure is a true risk factor of early deafness in subjects that had had repeated episodes of otitis media in childhood. This study stresses the need for both prevention policies and information of health professionals and practitioners.

Successful management of benign paroxysmal positional vertigo with the epley manoeuvre

Benign paroxysmal positional vertigo is a recurrent, disabling disorder characterized by transient vertigo induced by changes in head position. Several non-surgical and surgical treatment procedures have been recommended as definitive treatment in this condition. Recent reports indicate a favourable response to a variety of non-invasive, easy to perform liberatory manoeuvres, often with a single treatment session. We report our experience with the Epley manoeuvre in which we obtained a 90% overall success rate which is comparable with results of similar recent studies.

A comparative study of external and endoscopic endonasal dacryocystorhinostomy - a preliminary report

This prospective study was done ta compare the results of external and endonasal dacryocys-torhinostomy (DCR). 6 patients were studied under each group. Success rate for external DCR was 93.3% and endonasal was DCR 100%. The technique, merits and disadvantages of both the procedures are discussed as well as the advantages of endonasal DCR highlighted.

Nasal mucosa and skin of smear-positive leprosy patients after 24 months of fixed duration MDT: histopathological and microbiological study

The skin and nasal mucosa of 10 lepromatous leprosy patients who had completed 24 doses of fixed duration multidrug therapy (MDT) but who continued to be skin-smear positive for acid-fast bacilli (AFB) were examined histopathologically. The nasal mucosa showed granuloma fractions that exceeded those seen in the skin specimens, signifying that activity in this region subsides much more gradually than the activity in the skin. Mouse foot pad studies done using T900r mice with an inoculum from the nasal mucosa biopsy specimens of these patients did not demonstrate any growth of Mycobacterium leprae, indicating that these bacilli were not viable. A skin specimen from one patient grew significant amounts of bacteria in the T900r mouse foot pad. These results show that 2 years of treatment with MDT would prevent dissemination of M. leprae from the nasal mucosa and, therefore, should preclude further transmission of the disease. It also indicates that viable bacteria might persist in the skin of patients, especially those with an initial bacterial index of > or = 4+ who have completed 24 doses of regular MDT. Therefore, a more cautious approach to administering only 12 doses of MDT to highly positive multibacillary patients is suggested.

Otogenic intracranial abscess: concurrent craniotomy and mastoidectomy--changing trends in a developing country

OBJECTIVES

To evaluate (1) the clinical profile, treatment, and outcome of adult and pediatric patients presenting with intracranial abscess of otogenic origin and (2) the advantages of concurrent craniotomy and mastoidectomy.

DESIGN

A prospective case series.

SETTING

An academic tertiary referral center in India.

PATIENTS

Thirty-six patients clinically diagnosed as having intracranial abscess that was secondary to suppurative otitis media and confirmed by computed tomographic scanning.

INTERVENTION

Concurrent craniotomy and mastoidectomy.

RESULTS

Children were more commonly affected than adults, and there was a male preponderance. All patients had cholesteatoma at surgery, although one third of the children had only granulation tissue on otoscopy. More than two thirds of the patients in both the groups presented with more than one intracranial complication and definitive surgical intervention was done later than 24 hours. Meningitis was the most frequent intracranial complication, followed by cerebellar abscess. There was no significant intraoperative or postoperative morbidity, mortality, recurrence of intracranial complications, or residual neurological deficits. Three children (14%) showed evidence of recidivism cholesteatoma requiring revision surgery.

CONCLUSIONS

In suppurative otitis media with intracranial complications, it is accepted practice to treat the neurosurgical complication first, followed by mastoidectomy at a later date after the patient has been stabilized. Craniotomy with concurrent mastoidectomy is not only safe, but it also removes the source of infection at the same time the complications are being treated, thus avoiding reinfection while the patient is awaiting the ear surgery. In addition, the treatment is completed with a single, shorter hospital stay, which is more economical for the patient.

Histological studies in primary neuritic leprosy: changes in the nasal mucosa

The nasal mucosae of 39 cases of primary neuritic leprosy (PNL) registered at Karigiri were studied histologically to determine nasal mucosal involvement in PNL and its relevance to the pathogenesis of the disease. Specific changes of leprosy were seen in 20 (51%) biopsies, ranging from macrophage granulomas with acid fast bacilli, to epithelioid granulomas and nerve inflammation. The remaining biopsies revealed chronic inflammatory changes of the mucosa or mild non-specific nerve changes. These findings show that there are widespread effects of the disease even in PNL patients in whom the disease is believed to be confined to the peripheral nerves. The findings also show that early leprosy involvement can be found in the nasal mucosa even before lesions become apparent in the skin or other parts of the body. The nasal mucosa could be one of the sites for the primary lesion in leprosy. Clinical and histological examination of the nasal mucosa may be useful and important in the early diagnosis of leprosy and especially in contacts.

Bilateral simultaneous hearing preservation mastoidectomy in otogenic meningitis

Bilateral simultaneous hearing conservation mastoidectomy has not been previously documented. We present our experience with this procedure. Three patients with pyogenic meningitis secondary to bilateral unsafe ears had hearing preservation surgeries of both ears in a single sitting. Although ear surgery carries risk of inner ear damage, in our series there was no deterioration of inner ear function in the 6 ears operated on. The air conduction threshold improved in 3 (50%) of the ears. When meningitis results from bilateral otogenic foci as in our series, simultaneous mastoidectomy in both ears may be the preferred method of treatment to eradicate the source of infection.

Intrinsic differences in hearing performances between ears revealed by the asymmetrical shooting posture in the army

Left ear noise-induced hearing losses are dominant in the army. The common explanation is the asymmetrical effect of the shooting posture. However, firm evidence to support this possibility is still lacking. In the French army shooters, eye preference rather than hand preference for shooting determines the side of shooting and hence the ear more exposed to noise. To test whether left-right asymmetry of hearing thresholds really relates to the shooting posture, we analyzed audiograms from 644 officers of the infantry and artillery branches. The interaural differences reached 7 dB for right-eyed subjects, and less, about 5 dB, for left-eyed subjects at 6-7 kHz, both with disadvantage for the left ear. In contrast, hearing thresholds of both groups in the low frequency range were significantly better for left ears. Our results suggest each ear has different intrinsic characteristics. The right cochlea might be a less sensitive but more robust sensor than the left cochlea, which might be a finer sensor but more sensitive to noise.

Light and electron microscopic findings in rhinosporidiosis after dapsone therapy

Morphological findings in serial nasal mucosal biopsies from three cases of rhinosporidiosis on dapsone therapy were compared with biopsies from 33 patients taken before dapsone or surgical treatment was initiated. All biopsies were examined by light microscopy and five by electron microscopy. Counts of histologically intact and degenerated organisms showed a decreasing proportion of intact forms with treatment.

Autograft ossicle selection in cholesteatomatous ear disease: histopathological considerations

In order to determine whether selection of autograft ossicles in cholesteatomatous ear disease should be based upon their appearance under the surgical operating microscope, we studied the histopathological features of 113 such ossicles. We attempted to correlate the extent of erosion of the ossicle, as noted under the surgical operating microscope, with their histopathological appearance. There were 60 mallei and 53 includes. Seventy-nine ossicles were eroded and 34 were intact. The commonest abnormality noted was erosion of the long process of the incus (75 per cent). Both intact and eroded ossicles had similar histological features. There was no evidence of intra-ossicular cholesteatoma. The results suggest that the extent of erosion of these ossicles as seen under the surgical operating microscope should in no way prejudice their use as autografts when required.

Recurrent laryngeal lipoma

A rare case of laryngeal lipoma is reported with review of literature. We describe our technique of intra laryngeal excision of this tumour by microlaryngeal dissection.

Ludwig's angina

A 13 year review of patients diagnosed to have Ludwig's angina admitted to the Christian Medical College and Hospital, Vellore, India, between March 1982 and April 1995 is presented. The patients were either admitted to the ENT or paediatric surgical units. There were 41 patients, 24% being children and 76% adults. The clinical profile and outcome of these two groups were compared. In the paediatric group, none had dental caries while in the adult group, 52% had associated dental caries. In children, 70% were controlled with conservative medical management unlike the adults of whom 81% needed incision and drainage. Tracheostomy was necessary in 10% of the children and in 52% of the adults. The mortality was 10% in both groups.

Hearing impairment and otitis media in a rural primary school in south India

In order to determine the prevalence of hearing impairment and otitis media in rural primary school children, a pilot study of 284 children aged 6-10 years was performed. These children were screened by otoscopy, pure tone audiometry and tympanometry. The overall prevalence of otological abnormalities (excluding wax) was 21.5%. Hearing impairment was detected in 34 children (11.9%). Conductive hearing impairment was predominant (10.9%). Otitis media was diagnosed in 17.6% of children. While 91.2% of children with hearing impairment had associated middle ear disease, only 53.4% of those with middle ear disease were detected as have hearing impairment. The importance of including tympanometry as part of the screening protocol is highlighted.

VISAUDIO: a Windows software application for Bekesy audiogram analysis and hearing research

A Windows software system has been designed to facilitate hearing research programs and decision aid for epidemiological surveys in a military context. VISAUDIO provides graphical displays of audiograms with the results of various processing (smoothing, pathological patterns detection and classification), audiograms with pathological patterns like scotoms and recruitments are described (number, impaired frequencies, severity of loss for scotoms). Classical French ORL indexes are calculated (Index 42 which is the French legal index in occupational medicine, PAM or Lafon's index, IPA from the French norm NF S31-013 and IRB, a new occupational medicine index). An audiometric pattern classification is done for each audiogram using discriminant factorial analysis. The program allows audiogram comparisons on the same screen. The processing and analysis results can also be copied to any Windows software package via a PC clipboard. This prototype software is to be tested in a quasi real-time audiological information system comprising audiogram acquisition, processing, analysis and storage in a database. VISAUDIO software functions are illustrated with examples of screen displays.

Use of digoxigenin-labeled RNA probe to test hepatitis A virus antiviral drugs

A nucleic acid hybridization assay was used to evaluate inhibitory activity of antiviral compounds against hepatitis A virus (HAV) in cell culture and compared to radioimmunoassay by analysis of variance procedure. The 5' genomic end of the HM-175 strain was used as digoxigenin-labeled RNA probe. Dot-blot examination showed a reduction of detectable HAV RNA in infected cells when treated with amphotericin B. An antiviral dose-effect was shown by statistical analysis of densitometric measures of hybridization signals. Comparison between molecular hybridization assay and radioimmunoassay by analysis of variance procedure showed the equivalence of both methods. Data previously obtained on selected drugs by antigen and infectious titres determinations were confirmed by hybridization assay and make possible digoxigenin-labeled RNA probe use to measure an antiviral dose-effect for screening of hepatitis A antiviral compounds.

A three-dimensional representation of an athletic female knee joint using magnetic resonance imaging

Intense interest in knee joint mechanics has resulted in the development of numerous models to predict forces acting at the knee. However, few models have accounted for the unique geometric characteristics of the knee joint's articular surfaces when predicting the mechanical response of the joint. The purpose of this study was to stimulate accurately the complex geometric characteristics of the tibiofemoral joint for input into a finite element model representing the knee joint of athletic females. The right knee of an athletic female with no history of knee joint trauma was imaged using a 0.5 T magnetic resonance imaging (MRI) unit. Twelve cross-sectional slices of the knee were scanned in each of three orthogonal planes (coronal, sagittal and axial) at slice intervals of 6 mm, 7 m, and 8 mm respectively. A scan plan (two coronal images and an axial image) was also generated to enable calculation of the orthogonal scans with respect to one another. Select anatomical reference points representing cancellous and compact bone, major ligament attachment areas, and articular cartilage of the distal femur and proximal tibia were digitized from the processed shadowgraphs. The processed digitized data were input into a computer graphics program which was the pre- and post-processing software for the finite element analysis package. Contours of the cancellous and compact bone of the tibial and femoral condyles were generated using beta and cubic spline curves. Bezier quadratic and cubic polynomials were used to reconstruct the tibial and femoral shafts.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical therapy of rhinosporidiosis with dapsone

Clinical, histopathological and ultrastructural studies in three cases of rhinosporidiosis show complete remission of infection within one year of therapy with dapsone. Light and electron microscope studies confirmed arrest of the maturation of the spores and accentuated granulomatous response with fibrosis following dapsone therapy.

[Detection of hepatitis A virus by riboprobe labeled with digoxigenin: comparison of methods]

A riboprobe (RNA probe), corresponding to the 5' end of the HM175 hepatitis A virus (HAV) genome, was synthetized in vitro and was digoxigenin-labeled. Then the riboprobe was used to detect the CF53 HAV strain. Conditions of virus denaturation (with or without SDS and proteinase K, timing of assay) to release viral RNA were tested by dot-blot hybridization on a ten fold dilution of HAV suspension. Densitometric measures of dot-blot spots allowed to appreciate optimization of the method. Sensitivity of hybridization was compared with sensitivity of radioimmunoassay (RIA) and cell culture methods. Hybridization signals and scale of HAV suspension were consistent when 0.05% SDS, 0.17 micrograms/ml Proteinase K, 37 degrees C, 30 mn or 3 hours are used. 8.10(2) TCID50 HAV was detected by hybridization with digoxigenin-labeled RNA probes. Detection threshold was the same as radioimmunoassay and lower comparatively to cell culture.

[Early effects of neutron-gamma or gamma irradiation on the group toxicity induced by (+) amphetamine in mice]

To better understand the mechanism of action of gamma and neutron radiation on the dopaminergic system, the influence of the two irradiation modalities on the group toxicity of (+) amphetamine was studied in mice. Neutron-gamma irradiation (3.6-4.95 Gy) leads to an early toxicity reduction, while gamma-exposure (7-12 Gy) induces an increase in toxicity. This suggests that these two types of radiation induce different early effects on central dopaminergic system. Possible mechanisms are discussed.

Laryngeal stridor in myasthenia gravis

Two patients with laryngeal stridor secondary to myasthenia gravis are reported. The cause of bilateral abductor weakness in myasthenia is discussed; anticipation of the stridor in myasthenic patients is highlighted.

Medical management of pseudocyst of the auricle

Four male patients with pseudocyst of the auricle were successfully treated with oral corticosteroids. This condition is an asymptomatic, non-inflammatory, cystic swelling, usually located in the scaphoid or triangular fossa of the anti-helix which if untreated, leads to deformity of the pinna. All successful methods of treatment described in the literature so far have been invasive. All four patients in the above series responded to oral steroid therapy alone.

Solitary fibrous tumour of the nasopharynx

A case of benign ‘Solitary Fibrous Tumour of the Nasopharynx’, a rare, recently recognized entity, is presented and the clinical and pathological details discussed.

Roentgen examination of maxillary sinus, antral puncture and irrigation--a comparative study

The various radiological findings of maxillary sinus were compared to those at antral puncture and irrigation in patients with chronic maxillary sinusitis. It was noted that roentgen findings of opacity and fluid level of the maxillary sinus are definite evidences of sinus infection and a mucosal thickening is not an indication of sinus infection.

Reactional states in the nasal mucosa: a clinical and histopathological study

Twenty leprosy patients in the reactive phase of the disease were studied clinically and histologically for evidence of reactive lesions in the nasal mucosa. Ten of 14 patients with erythema nodosum leprosum (ENL) showed characteristic polymorphonuclear leukocytic infiltration and two patients showed vasculitis. The histological changes of reversal reactions in the nasal mucosa, one with upgrading reaction and the other with downgrading reaction, are reported.