Post-Tonsillectomy Pain and Vomiting:Role of Pre-operative Steroids

Objective: To evaluate the effects of a single pre-operative dose of dexamethasone with the frequency of postoperative vomiting and severity of throat pain in children undergoing electrocautery tonsillectomy under standard general anaesthesia. Study Design: Randomised controlled trial. Place and Duration of Study: ENT Department, Combined Military Hospital, Kharian, from January to December 2010. Methodology: Children of either gender aged between 4 - 12 years, undergoing tonsillectomy were divided into two groups of 50 each. One group was selected to receive dexamethasone 0.5 mg/kg (maximum of 8 mg); the second group was given equivalent volume of saline, pre-operatively. The frequency of early and late vomiting was assessed postextubation. Mean time of first oral intake in minutes after extubation and mean score of postoperative throat pain were compared in both groups. Severity of throat pain was monitored by Visual Analogue Scale (VAS) score 0-10 after 4,8,12 and 24 hours of extubation. Results: Dexamethasone group showed significantly less postoperative early vomiting (12%, n = 6) as compared to placebo (30%, n = 15) group (p < 0.05). The mean time of first oral intake was earlier in the dexamethasone group (4 hours and 16 minutes postextubation), while in saline group it was 5 hours and 20 minutes (p < 0.001). Pain score was also significantly lower and swallowing was less painful in patients after 4,8,12 and 24 hours in dexamethasone group. Pain score on the average was 0.8 - 1.2 factors less in dexamethasone group than in saline group in first 24 hours on a VAS score of 1 -10. Conclusion: Pre-operative intravenous dexamethasone reduced postoperative vomiting and pain significantly in children undergoing electrocautery tonsillectomy.     

Pain management after traumatic spinal cord injury

Pain is experienced by people suffering from spinal cord injury leading to disability and affecting the person's functional ability, independence, psychological well - being, ability to return to work and quality of life. Pain management in these patients is notoriously difficult due to multiple factors and varied mechanism leading to pain. Only few treatments have been assessed in randomized, controlled trials and management is based on different case reports. We are reporting our experience of managing 2 patients with neuropathic pain following traumatic spinal cord injury. Both the patients were refractory to conventional pain medications but there was significant reduction in pain following lignocaine infusion in the first patient and with ketamine in the second patient.     

Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis

Introduction

Tuberculous spondylitis (TBS) is the most common form of extra-pulmonary tuberculosis. The mainstay of TBS management is anti-tuberculous chemotherapy. Most of the patients with TBS are treated conservatively; however in some patients surgery is indicated. Most common indications for surgery include neurological deficit, deformity, instability, large abscesses and necrotic tissue mass or inadequate response to anti-tuberculous chemotherapy. The most common form of TBS involves a single motion segment of spine (two adjoining vertebrae and their intervening disc). Sometimes TBS involves more than two adjoining vertebrae, when it is called multilevel TBS. Indications for correct surgical management of multilevel TBS is not clear from literature.

Materials and methods

We have retrospectively reviewed 87 patients operated in 10 years for multilevel TBS involving the thoracolumbar spine at our spine unit. Two types of surgeries were performed on these patients. In 57 patients, modified Hong Kong operation was performed with radical debridement, strut grafting and anterior instrumentation. In 30 patients this operation was combined with pedicle screw fixation with or without correction of kyphosis by osteotomy. Patients were followed up for correction of kyphosis, improvement in neurological deficit, pain and function. Complications were noted. On long-term follow-up (average 64 months), there was 9.34 % improvement in kyphosis angle in the modified Hong Kong group and 47.58 % improvement in the group with pedicle screw fixation and osteotomy in addition to anterior surgery (p < 0.001). Seven patients had implant failures and revision surgeries in the modified Hong Kong group. Neurological improvement, pain relief and functional outcome were the same in both groups.

Conclusion

We conclude that pedicle screw fixation with or without a correcting osteotomy should be added in all patients with multilevel thoracolumbar tuberculous spondylitis undergoing radical debridement and anterior column reconstruction.

     

Quantitative stress radiography of the patella and evaluation of patellar laxity before and after lateral release for recurrent dislocation patella

Purpose

The aims of the present controlled clinical study were to (1) compare patella laxity determined in the outpatient clinic with that in anaesthetized patients and (2) evaluate patella laxity before and after lateral release.

Method

The study evaluated data on 33 knees from 33 patients (average age 19.7 years) between 2007 and 2011. All patients were diagnosed with recurrent dislocation of the patella. Patellar stability was evaluated in each patient thrice: patellas were first imaged in the outpatient clinic prior to surgery at 45° knee flexion with 20 N stress from the medial to lateral side and from the lateral to medial side; then, at the time of surgery, patella stress images were obtained in the same manner before and after the lateral release procedure. Radiological assessments were performed using the medial stress shift ratio (MSSR) and lateral stress shift ratio (LSSR).

Results

There were no significant differences in the LSSR and MSSR before surgery (outpatient data) and in anaesthetized patients before the lateral release procedure. Furthermore, there was no significant difference in MSSR at the time of surgery before and after the lateral release procedure. However, LSSR increased significantly after the lateral release procedure.

Conclusion

The results of the present study suggest that quantitative patella stress radiography in the outpatient clinic is useful when it comes to investigating laxity of the patella, and that lateral release significantly increases lateral, but not medial, laxity in patients with recurrent patellar dislocation.

Level of evidence

IV.     

Pre-ablative diagnostic whole-body scan following total thyroidectomy for well-differentiated thyroid cancer: is it necessary?

OBJECTIVE: This study reviewed the incidence of positive pre-ablative diagnostic scan after total thyroidectomy and the efficacy of the current ablative dose. The predictive factors for outcome using a standard ablative dose and postoperative complications of total thyroidectomy were also examined. METHODS: This was a retrospective review of patients referred for radioiodine ablation after total thyroidectomy between September 1997 and September 2001. RESULTS: Forty patients were included in this study, of whom 95% had a positive scan after total thyroidectomy. Of the 30 patients who underwent standard 80-mCi radioiodine ablation, 21 (70%) had successful single ablation while the remaining nine patients needed a higher ablative dose. There were no significant differences between patients who had successful ablation with the standard dose and those who did not in terms of tumour size, patient age, lymph node status and extra-thyroidal extension. Fifteen percent suffered from permanent hypoparathyroidism requiring calcium supplementation. Three patients had documented recurrent laryngeal nerve paralysis. CONCLUSION: Bypassing the pre-ablative diagnostic scan is feasible. The present ablation dose of 80 mCi of radioiodine is effective. The relatively high postoperative morbidity after difficult total thyroidectomy suggests less aggressive excision and postoperative radioiodine ablation of the remnant tissue.     

Photodynamic inactivation of <Emphasis Type="Italic">Klebsiella pneumoniae</Emphasis> biofilms and planktonic cells by 5-aminolevulinic acid and 5-aminolevulinic acid methyl ester

The treatment of Klebsiella pneumoniae, particularly extended-spectrum β-lactamase (ESBL)-producing K. pneumoniae, is currently a great challenge. Photodynamic antimicrobial chemotherapy is a promising approach for killing antibiotic-resistant bacteria. The aim of this study was to evaluate the capacity of 5-aminolevulinic acid (5-ALA) and its derivative 5-ALA methyl ester (MAL) in the presence of white light to cause photodynamic inactivation (PDI) of K. pneumoniae planktonic and biofilm cells. In the presence of white light, 5-ALA and MAL inactivated planktonic cells in a concentration-dependent manner. Biofilms were also sensitive to 5-ALA and MAL-mediated PDI. The mechanisms by which 5-ALA and MAL caused PDI of ESBL-producing K. pneumonia were also investigated. Exposure of K. pneumonia to light in the presence of either 5-ALA or MAL induced cleavage of genomic DNA and the rapid release of intracellular biopolymers. Intensely denatured cytoplasmic contents and aggregated ribosomes were also detected by transmission electron microscopy. Scanning electron microscopy showed that PDI of biofilms caused aggregated bacteria to detach and that the bacterial cell envelope was damaged. This study provides insights into 5-ALA and MAL-mediated PDI of ESBL-producing K. pneumoniae.