Instrumentation and patient characteristics that influence postoperative haemorrhage rates following tonsil and adenoid surgery

Objectives: To investigate the effect of the type instrumentation used and the age and gender characteristics of patients on postoperative haemorrhage rates following tonsil and adenoid surgery. Design: A retrospective analysis of 13 593 procedures was performed from The Patient Episode Database for Wales between 1 January 1999 and 31 March 2004. Setting: National health policy changes created four periods of different instrument usage (reusable, single‐use with diathermy, single‐use alone, specified single‐use with diathermy). These and the age and gender distribution of the patients were examined against four categories of postoperative haemorrhage. Main outcome measures: Postoperative haemorrhage rates were expressed as the number of complications per operations performed. Primary postoperative haemorrhage that occurred during the initial admission either required a return to theatre [R1] or was managed conservatively [N1]; secondary postoperative haemorrhage that required a return to hospital either returned to theatre [R2] or was managed conservatively [N2], were compared. Results: Primary haemorrhage with return to theatre doubled, from the baseline rate with reusable instruments, from 0.6% (CI 0.5–0.8) to 1.2% (CI 0.7–1.9) when single‐use instruments were introduced and remained high at 1.4% (CI 0.9–2.1) after the withdrawal of single‐use diathermy. This haemorrhage rate returned to the baseline rate (0.6% CI 0.3–1.0) when specified single‐use instruments were introduced. None of the other haemorrhage rates changed significantly throughout the four observation periods. Adenotonsillectomy and tonsillectomy patients have different age and gender patterns. In a univariate analysis, males over the age of 12 years were twice as likely to have haemorrhage with return to theatre than girls of the same age, 3.8% (CI 3.0–4.7) versus 1.7% (CI 1.4–2.1). Conclusions: A significant rise in serious postoperative primary haemorrhage but not secondary haemorrhage was seen following the initial introduction of single‐use instruments that reverted to baseline with the introduction of specified single‐use instruments. Diathermy does not appear to have affected the haemorrhage rates. There is a distinct age and gender pattern for tonsil and adenoid surgery and risk of postoperative haemorrhage. The use of arbitrary divisions of age may be misleading in studies that examine post‐tonsillectomy haemorrhage.     

GDF-8 propeptide binds to GDF-8 and antagonizes biological activity by inhibiting GDF-8 receptor binding

GDF-8 is a new member of the TGF-beta superfamily which appears to be a negative regulator of skeletal muscle mass. Factors which regulate the biological activity of GDF-8 have not yet been identified. However, the biological activities of TGF-beta superfamily members, TGF-beta1, -beta2 and -beta3, can be inhibited by noncovalent association with TGF-beta1, -beta2 and beta3 propeptides cleaved from the amino-termini of the TGF-beta precursor proteins. In contrast, the propeptides of other TGF-beta superfamily members do not appear to be inhibitory. In this investigation, we demonstrate that purified recombinant GDF-8 propeptide associates with purified recombinant GDF-8 to form a noncovalent complex, as evidenced by size exclusion chromatography and chemical crosslinking analysis. Furthermore, we show that GDF-8 propeptide inhibits the biological activity of GDF-8 assayed on A204 rhabdomyosarcoma cells transfected with a (CAGA)12 reporter construct. Finally, we demonstrate that GDF-8 propeptide inhibits specific GDF-8 binding to L6 myoblast cells. Collectively, these data identify the GDF-8 propeptide as an inhibitor of GDF-8 biological activity.     

A novel ENT iBook: what do junior doctors think?

Exposure to the specialty of Otolaryngology is limited. It may be consolidated by the use of an iBook as a self-study tool. The purpose of this study was to ascertain the perceptions of junior doctors on the clinical relevance of this novel educational resource. Three focus groups were formed each consisting of five junior doctors (eight female: seven male, median age 27 years). The iBook was found to be clinically relevant to the work of junior doctors, have a clear layout, with adequate interactivity and a good range of integrated multimedia elements.     

POLD1 variants leading to reduced polymerase activity can cause hearing loss without syndromic features

DNA polymerase δ, whose catalytic subunit is encoded by POLD1, is responsible for synthesizing the lagging strand of DNA. Single heterozygous POLD1 mutations in domains with polymerase and exonuclease activities have been reported to cause syndromic deafness as a part of multisystem metabolic disorder or predisposition to cancer. However, the phenotypes of diverse combinations of POLD1 genotypes have not been elucidated in humans. We found that five members of a multiplex family segregating autosomal recessive nonsyndromic sensorineural hearing loss (NS‐SNHL) have revealed novel compound heterozygous POLD1 variants (p.Gly1100Arg and a presumptive null function variant, p.Ser197Hisfs*54). The recombinant p.Gly1100Arg polymerase δ showed a reduced polymerase activity by 30–40%, but exhibited normal exonuclease activity. The polymerase activity in cell extracts from the affected subject carrying the two POLD1 mutant alleles was about 33% of normal controls. We suggest that significantly decreased polymerase δ activity, but not a complete absence, with normal exonuclease activity could lead to NS‐SNHL.     

Physiological correlates of bilateral symmetry in humans

Departures from perfect bilateral symmetry are thought to mirror an organism's ability to maintain developmental homeostasis. There is evidence showing that symmetry is negatively correlated with evolutionary and physical fitness. The purpose of this study was to determine the relationship between symmetry and health-related physiological characteristics in males and females. Forty-six male and female subjects participated in this study. Both facial and anthropometric traits were investigated for deviations from perfect bilateral symmetry. After measurements were made the subjects were tested on a range of physiological variables. There was no pattern of consistent significant correlations between fluctuating asymmetry and the physiological variables across all traits, and poor inter-correlations between the fluctuating asymmetries measured at different sites. The study failed to confirm the hypothesis that symmetric individuals were physiologically fitter when compared to their asymmetric counterparts.     

Mucin-secreting papillary adenocarcinoma of the hyoid bone: a unique case

We present a unique case of a mucin-secreting papillary adenocarcinoma of intestinal type which has invaded and completely destroyed the hyoid bone and metastasized to the cervical lymph nodes bilaterally. The tumour is believed to have originated from a malignant thyroglossal duct remnant, and was managed with surgery and radiotherapy. We describe the case and discuss the literature regarding hyoid bone tumours.     

Migration and accumulation of eosinophils toward regional lymph nodes after airway allergen challenge

BACKGROUND: Eosinophils play a major role in allergic airway inflammation because of their ability to release toxic mediators. In addition, they are able to migrate toward draining thoracic lymph nodes (TLNs) after intratracheal administration, where they can function as antigen-presenting cells. OBJECTIVE: In this study, we evaluated in vivo eosinophil migration toward the TLN after allergen sensitization and analyzed expression of molecules involved in antigen presentation. METHODS: Mice were sensitized by intraperitoneal injection of ovalbumin on days 1 and 10 and challenged once intranasally with ovalbumin on day 20. The kinetics of eosinophilia was evaluated in blood, lung tissue homogenate, bronchoalveolar lavage fluid, and TLN. Cell surface staining was analyzed by flow cytometry. RESULTS: The kinetics of eosinophil recruitment was similar in TLN, lung tissue, and blood, beginning at 12 hours and peaking at 48 hours after allergen challenge. Approximately 70% of TLN eosinophils expressed MHC class II molecules, compared with less than 25% in blood and lungs. Moreover, TLN eosinophils expressed higher levels of MHC class II and CD86 compared with blood and lung eosinophils. Most eosinophils expressed CD80 and CD54, whereas only a few eosinophils expressed CD40. Eosinophils in lungs and TLN appeared to be activated with lower CD62-ligand expression compared with blood eosinophils. CONCLUSION: The presence of eosinophils with a different phenotype in the TLN at early time points after allergen challenge of sensitized mice supports their capacity to serve as antigen-presenting cells, sustaining allergic/inflammatory responses in the airways.     

Preferential binding of Staphylococcus aureus to skin sites of Th2-mediated inflammation in a murine model

Staphylococcus aureus is found on over 90% of atopic dermatitis skin lesions and is thought to contribute to skin inflammation via the production of potent exotoxins. In contrast, less than 5% of normal subjects harbor S. aureus. This suggests that an atopic immune response itself may play a role in preferential binding of S. aureus to the skin. To examine this issue more directly, we analyzed the S. aureus binding characteristics of skin in mice undergoing different T helper type 1 cell versus T helper type 2 cell inflammatory responses using a novel in vitro bacterial binding assay. BALB/C female mice were first sensitized to ovalbumin with alum or ovalbumin with complete Freund's adjuvant to induce T helper type 2 or T helper type 1 responses, respectively. Mice were then challenged intradermally with either saline (control) or ovalbumin. Forty-eight hours later, skin specimens were obtained from the challenge sites, and the number of S. aureus binding to each skin section was quantitated. Bacterial binding was found to be significantly greater at skin sites of BALB/C mice that had been ovalbumin/alum sensitized compared with ovalbumin/complete Freund's adjuvant sensitized (p < or = 0.01). When compared to the ovalbumin sensitized/challenged skin of wild type BALB/C mice or interferon-gamma gene knockout mice, interleukin-4, but not interferon-gamma, gene knockout mice had significantly less S. aureus binding at their ovalbumin sensitized/challenged skin sites. Mutant S. aureus strains that lacked either fibronectin- or fibrinogen-binding protein expression showed significantly reduced S. aureus binding compared with the parent wild type strain (p < 0.005). Moreover, preincubation of the wild type bacteria with fibronectin or fibrinogen, but not collagen, resulted in significantly less skin binding of S. aureus (p < 0.01). Incubation of skin with interleukin-4, and less so with interferon-gamma, led to more binding of wild type S. aureus but not of an S. aureus mutant deficient in fibronectin binding protein expression. After interleukin-4 incubation, but not interferon-gamma, epidermal immunoreactivity for fibronectin was observed in murine skin explants. These results show that a T helper type 2 inflammatory environment can promote skin binding by S. aureus and that this binding is mediated by fibronectin and fibrinogen.     

A laboratory and clinical evaluation of single‐use instruments for tonsil and adenoid surgery

Objectives: To compare the quality and consistency of single‐use adenotonsillectomy instruments available in the UK with reusable instruments and examine their performance in a clinical setting. Design: A laboratory assessment of each reusable instrument created a detailed specification for the respective single‐use equivalent. A surveillance system monitored the performance of a selected set of specified single‐use instruments. Setting: Single‐use instruments were withdrawn shortly after their introduction in 2001. Persisting concerns from the Spongiform Encephalopathy Advisory Committee led to an investigation into the feasibility of continuing to use such instruments. Main outcome measures: The numbers of instruments from each set judged as unacceptable or as good as the original. The number and cause of instrument failure during clinical surveillance. Results: Between 40% and 93% of the instruments on each set were as good as the original and between 0% and 40% of the instruments were unacceptable from six sets of steel and one set of polymer instruments. 4151 procedures were monitored between 1 February 2003 and 31 March 2004 using a total of 41 376 instruments. Problems were reported with 335 (0.8%) instruments, 46% attributable to instrument design, 14% to poor design control and 13% to instruments escaping quality control systems. Following correction of the faults, between 1 January 2004 and 31 March 2004 the problem rate fell to 0.4%. Conclusions: High quality single‐use instruments for tonsil and adenoid surgery are available in the UK. Some companies offered inferior instruments not fit for their purpose. The procurement, introduction and subsequent clinical approval of single‐use instruments requires a radically different approach to that currently applied to the purchase of reusable surgical equipment. Careful monitoring of their introduction is essential.