Tonsillectomy by guillotine is less painful than by dissection

Most tonsillectomies are carried out by dissection. Only a small minority of otolaryngologists still routinely perform guillotine tonsillectomy. We carried out a prospective study on 86 children undergoing tonsillectomy utilising a standard anaesthetic and analgesic regimen to compare post-operative pain after dissection tonsillectomy and guillotine tonsillectomy using a Popper's hemostatic guillotine. Guillotine tonsillectomy was significantly less painful (P<0.001) than dissection tonsillectomy. The relative risk of experiencing moderately severe to severe pain was 0.36 (95% CI, 0.18-0.72) in the guillotine group. A significant proportion of children experience moderately severe to severe pain despite a comprehensive analgesic regimen confirming that post operative pain remains an important issue after this operation. On the basis of our findings we advocate tonsillectomy by guillotine in children. The less pain that arises within the first 24 h may be particularly important if performing tonsillectomy as a day-case procedure.     

Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma

RATIONALE: One-quarter to one-third of individuals with asthma smoke, which may affect response to therapy and contribute to poor asthma control. OBJECTIVES: To determine if the response to an inhaled corticosteroid or a leukotriene receptor antagonist is attenuated in individuals with asthma who smoke. METHODS: In a multicenter, placebo-controlled, double-blind, double-dummy, crossover trial, 44 nonsmokers and 39 light smokers with mild asthma were assigned randomly to treatment twice daily with inhaled beclomethasone and once daily with oral montelukast. MEASUREMENTS AND MAIN RESULTS: Primary outcome was change in prebronchodilator FEV(1) in smokers versus nonsmokers. Secondary outcomes included peak flow, PC(20) methacholine, symptoms, quality of life, and markers of airway inflammation. Despite similar FEV(1), bronchodilator response, and sensitivity to methacholine at baseline, subjects with asthma who smoked had significantly more symptoms, worse quality of life, and lower daily peak flow than nonsmokers. Adherence to therapy did not differ significantly between smokers and nonsmokers, or between treatment arms. Beclomethasone significantly reduced sputum eosinophils and eosinophil cationic protein (ECP) in both smokers and nonsmokers, but increased FEV(1) (170 ml, p = 0.0003) only in nonsmokers. Montelukast significantly increased a.m. peak flow in smokers (12.6 L/min, p = 0.002), but not in nonsmokers. CONCLUSIONS: In subjects with mild asthma who smoke, the response to inhaled corticosteroids is attenuated, suggesting that adjustments to standard therapy may be required to attain asthma control. The greater improvement seen in some outcomes in smokers treated with montelukast suggests that leukotrienes may be important in this setting. Larger prospective studies are required to determine whether leukotriene modifiers can be recommended for managing asthma in patients who smoke.     

N-acetylneuraminic acid transport by Streptococcus oralis strain AR3.

Streptococcus oralis has emerged as one of the most important organisms of the viridans streptococcus group in terms of infections and is recognised as an agent of infective endocarditis and, in immunocompromised patients, septicaemia. The mechanisms by which this organism proliferates in vivo are unknown. However, host-derived sialic acids -- including N-acetylneuraminic acid (NeuNAc) which is present in serum and cell-associated glycoproteins -- are a potential source of fermentable carbohydrate for bacterial proliferation, especially for sialidase-producing bacteria, including S. oralis. To further elucidate the role of NeuNAc in supporting growth, this study determined the ability of S. oralis strain AR3 (isolated from a patient with infective endocarditis) to transport NeuNAc and characterised the transport system. The transport of [14C]-labelled NeuNAc into S. oralis was monitored and this transport system was induced by growth of the bacteria in the presence of the N-acetylated sugars NeuNAc, N-acetylglucosamine and N-acetylmannosamine. The transport system followed typical Michaelis-Menten kinetics, with a Km of 21.0 microM and a Vmax of 2.65 nmoles of NeuNAc transported/min/mg of dry cell mass. NeuNAc transport was inhibited by the presence of exogenous N-glycolylneuraminic acid, a related sialic acid. Chlorhexidine, NaF and 2,4-dinitrophenol were potent inhibitors of the transport system, suggesting that the uptake of NeuNAc occurs via a proton motive force-dependent permease system. This is the first report of the mechanism by which NeuNAc transport occurs in pathogenic streptococci. This transport process may have relevance to the acquisition of a source of fermentable carbohydrate and thus bacterial proliferation in vivo.     

The use of 18F-fluorodeoxyglucose positron emission tomography for the diagnosis and management of invasive mould infections.

There is limited information on the utility of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) for the diagnosis and management of invasive mould infections (IMIs). We retrospectively evaluated patients with IMIs who underwent FDG-PET in our institution (n = 13; December 1999 to April 2004), and reviewed the available literature (n = 9). In 16 non-neutropenic patients with available FDG-PET imaging studies (11 from our institution), FDG-PET revealed an occult IMI site (n = 3; 2 unidentified CNS involvement) and was helpful in guiding the duration of treatment (n = 8). Prospective evaluation of the role of FDG-PET in the work-up and management of IMIs is needed.     

Serum lipids and lipoproteins are less powerful predictors of extracranial carotid artery atherosclerosis than are cigarette smoking and hypertension

The effect of serum lipids and lipoproteins on extracranial carotid artery atherosclerosis (CAS) was studied in patients who underwent carotid arteriography. Serum lipid and lipoprotein values along with data on other potential predictors of extracranial CAS were determined in 240 patients who had at least one extracranial carotid artery visualized. In a multiple logistic regression analysis, the independently significant predictors of the presence of extracranial CAS were, in decreasing order of significance, duration of smoking of cigarettes, hypertension, age, and low-density lipoprotein cholesterol. Serum cholesterol, triglycerides, high-density lipoprotein cholesterol, and apolipoprotein A-I did not show an independent effect. Although low-density lipoprotein cholesterol was an independent predictor of the presence of extracranial CAS, its effect as a predictor was far outweighed by the effects of the duration of smoking of cigarettes and a history of hypertension.     

Factors influencing compliance with dietary advice: the Diet And Reinfarction Trial (DART)

Factors influencing compliance with dietary advice were investigated in the Diet and Reinfarcation Trial (DART). In terms of achieved intakes, smokers had a lower mean P/S ratio and fibre intake than non-smokers; manual workers had a lower mean fibre intake than non-manual workers; and obese men had a higher percentage of energy from fat and lower P/S ratio than non-obese men. However the effect of the advice (difference in intakes of those advised and thosen not advised) was similar in smokers and non-smokers and was similar in all social classes. The effect of fat advice was less among obese men than among non-obese men, probably as a result of weight-reducing advice given to all overweight men. Fat advice tended to have a greater effect among those who gave up smoking after their heart attack than among non-smokers and those who continued to smoke but the difference was not statistically significant. This suggests that advice on diet and smoking can be given simultaneously and still be effective.