Immunological profiling of key inflammatory drivers of nasal polyp formation and growth in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a chronic inflammatory condition of the upper airways, often associated with the formation of nasal polyps (CRSwNP). It is well established that macroscopically normal (non-polypoidal) sinonasal mucosa in CRSwNP patients can undergo polypoidal change over time, turning into frank polyps. However, little is known about what drives this process. This study aimed to investigate potential drivers of nasal polyp formation or growth through comparison of the immunological profiles of nasal polyps with contiguous non-polypoidal sinonasal mucosa, from the same patients. METHODS: The immune profiles of three types of tissue were compared; nasal polyps and adjacent non-polypoidal sinonasal mucosa from 10 CRSwNP patients, and sinonasal mucosa from 10 control patients undergoing trans-sphenoidal pituitary surgery. Nasal polyp and control samples were also stimulated with Staphylococcus aureus enterotoxin B (SEB) using a nasal explant model, prior to cytokine analysis. Real time quantitative polymerase chain reaction (IL-5, T-bet, IL-17A, FoxP3, TLR-4, IL-8, IL-1beta and IL-6) and Luminex (IFNgamma, IL-5 and IL-17A) were used to quantify pro-inflammatory responses. RESULTS: Nasal polyps and contiguous non-polypoidal sinonasal mucosa from CRSwNP patients displayed a very similar pro-inflammatory profile. When stimulated with SEB, nasal polyps displayed a Th2/Th17 mediated response when compared to controls. CONCLUSIONS: In CRSwNP, nasal polyps and non-polypoidal sinonasal mucosa from the same patient displayed a similar pro-inflammatory profile skewed towards the Th2/Th17 pathway in nasal polyps following SEB stimulation, with evidence of disordered bacterial clearance. These factors may contribute to enhanced survival of bacteria and development of a chronic inflammatory milieu, potentially driving new polyp formation and recurrence following surgical removal.

Controversies in the management of acute tonsillitis: an evidence-based review.

BACKGROUND: Patients admitted with acute tonsillitis generate a substantial workload for the National Health Service (NHS), placing huge financial pressures on an already overstretched budget. OBJECTIVE OF REVIEW: Due to the difficulty of accurate diagnosis and varying practices across the UK, there exist a number of controversial areas and non-standardised practice. These will be highlighted and tackled within this article. TYPE OF REVIEW AND SEARCH STRATEGY: A literature review, last performed in September 2013, searched PubMed citing variations on the areas of controversies with 'tonsillitis', 'pharyngitis' and 'pharyngotonsillitis' - from 1956 to present with language restrictions. Excluded articles included those regarding sore throat after tonsillectomy and peritonsillar abscess. EVALUATION METHOD: Titles and abstracts were initially screened, and full text of potentially relevant articles obtained. The bibliographies of articles were searched for relevant references. The references were then compiled and reviewed independently by two authors (JB & TB), overseen by the senior author (EK). RESULTS: (i) Diagnosis and investigation: Use of the Centor criteria is inadequate within the secondary care setting. Blood testing is unnecessary in the majority of cases where patients do not require admission, as they are unlikely to change management. (ii) Antibiotics: Antibiotics are likely to be indicated in all those presenting to secondary ENT care, with penicillin being the antibiotic of choice for first-line therapy. (iii) Corticosteroids: Moderate evidence supports the benefit of steroid administration in this patient cohort, advocating a single dose initially followed by reassessment. (iv) Analgesia: Paracetamol and NSAIDs have good evidence of action. Codeine should be used with caution in the paediatric population. (v) Reduced admission rates and early discharge: There is evidence suggesting that a trial of medical therapy prior to admission is beneficial in reducing rates of admission and length of stay. CONCLUSIONS: Management of acute tonsillitis within a secondary care setting largely consists of anecdotal or relatively low-quality evidence. Thus, much evidence from management comes from expert opinion or practice within a primary care setting. Management across the UK can also vary greatly. An evidence-based review of best practice has been presented here, but further evidence will be required in the future examining the significance of corticosteroids and antibiotic administration in this patient cohort specifically, ensuring practice is evidence based and clinically relevant.

Does use of a World Health Organization obstetric safe surgery checklist improve communication between obstetricians and anaesthetists? A retrospective study of 389 caesarean sections.

We evaluated the impact of the World Health Organization Obstetric Safe Surgery Checklist (WHO Checklist) on perioperative communication between anaesthetists and obstetricians by performing a retrospective audit in a Teaching hospital in London, UK. Caesarean section births from February to March 2009 and April to May 2011 were studied. Caesarean section notes from obstetricians and anaesthetists managing the same woman during the study period were reviewed. Grading differences between obstetricians and anaesthetists before and after checklist introduction were evaluated. Communication failure (where obstetricians and anaesthetists had documented different caesarean section grades [level of urgency]) and good communication (where obstetricians and anaesthetists had documented the same caesarean section grade) were observed. In total, 195 caesarean sections before introduction of the WHO safe surgery checklist and 194 caesarean sections after checklist introduction were studied. Grading differences occurred in 24.1% of caesarean sections without checklists compared with 10.3% with checklists (P < 0.001). During emergency caesarean section alone, grading differences between obstetricians and anaesthetists were smaller, although this was not significant (P = 0.222). We conclude that implementation of a WHO Obstetric Safe Surgery checklist improves the communication of caesarean section grade (urgency) between obstetricians and anaesthetists.

Salvage intratympanic steroid therapy for sudden sensorineural hearing loss: our real-life experience in 32 patients.

OBJECTIVE: To examine the role of salvage intratympanic steroid injections in patients presenting with idiopathic sudden sensorineural hearing loss following a poor response to initial oral steroid treatment. METHODS: A retrospective analysis of patient records over the course of four years was conducted, and pure tone thresholds were reviewed before treatment, after oral steroid therapy and six weeks after intratympanic steroid injection therapy. RESULTS: After oral steroid therapy alone, there was a mean average threshold change of 6.2 dB HL (range, -13.8-33.8 dB). This change was statistically significant for severely affected patients (those with an average presenting threshold of over 71 dB). The mean average threshold improvement following intratympanic steroid injection therapy was 2.9 dB (range, -22.5-61.3 dB); this was not statistically significant. CONCLUSION: Some patients experienced moderate improvement following intratympanic steroid injection therapy; however, no specific subgroup was identified to benefit more from intratympanic steroid injection therapy.

Safety of a non-viral plasmid-encoding dual isoforms of hepatocyte growth factor in critical limb ischemia patients: a phase I study.

We aimed to evaluate in a phase I dose-escalation study, the safety of intramuscular injections of a novel non-viral plasmid DNA expressing two isoforms of human hepatocyte growth factor (HGF) (VM202) in patients with critical limb ischemia (CLI). In total, 12 patients with CLI and unsuitable for revascularization were consecutively assigned to increasing doses (2 to 16 mg) of VM202 administered into the ischemic calf muscle at days 1 and 15. Patients were evaluated for safety and tolerability, changes in ankle- and toe brachial index (ABI and TBI), and pain severity score using a visual analog scale (VAS) throughout a 12-month follow-up period. Median age was 72 years and 53% of the patients were male. VM202 was safe and well tolerated with no death during the 12-month follow-up. Median ABI and TBI significantly increased from 0.35 to 0.52 (P=0.005) and from 0.15 to 0.24 (P=0.01) at 12 months follow-up. Median VAS decreased from 57.5 to 16.0 mm at 6 months follow-up (P=0.03). In this first human clinical trial, VM202, which expresses two isoforms of human HGF, appear to be safe and well tolerated with encouraging clinical results and thus supports the performance of a phase II randomized controlled trial.

Effect of methionine chelated Zn and Mn and corn particle size on Large White male turkey live performance and carcass yields.

Most turkey research has been conducted with a regular corn particle size set through phase-feeding programs. This study's first objective was to determine the effect of increasing corn particle size through the feed phases on performance, processing yield, and feed milling energy usage in Large White commercial male turkey production. Zinc (Zn) and manganese (Mn) are essential microminerals for animals' healthy growth. The source in which these elements are supplied to the bird will determine their bioavailability, effect on bird growth, and subsequent environmental impact. This study's second objective was to measure both inorganic and chelated Zn and Mn sources on turkey performance, turkey carcass processing yields, and subsequent litter residues. Twelve hundred Nicolas Select male poults were randomly assigned to 48 concrete; litter-covered floor pens. The experimental design was a completely randomized block design with a 2 × 2 factorial arrangement of 2 sources of minerals (organic blend vs. inorganic) formulated to match breeder recommendations and 2 types of corn mean particle size (coarse corn [1,000-3,500 µm] vs. fine corn [276 µm]). The ASABE S319.4 standard was used to measure corn mean particle size. Bird performance, carcass processing yield, litter content of Zn and Mn, and pellet mill energy consumption were analyzed in SAS 9.4 in a mixed model. There was a reduction of pellet mill energy usage of 36% when coarse corn was added post-pelleting. Birds fed increasing coarse corn mean particle size were 250 g lighter on average in body weight (BW) than birds fed a constant control mean particle size. No difference was found in feed intake (FI) or feed conversion ratio (FCR). Birds fed methionine chelated Zn and Mn blended with inorganic mineral sources were 250 g heavier on average than birds fed only an inorganic source of minerals. In addition, feeding an organic blend of Zn and Mn resulted in greater breast meat yield. Litter from birds fed the control corn mean particle size, and inorganic minerals had a higher concentration of Zn in the litter but were not different when the chelated Zn/Mn were fed. In conclusion, increasing the corn mean particle size and adding it post pellet could save money during feed milling; however, birds might have a slightly lower BW. A combination of inorganic and chelated Zn and Mn may improve performance and increase total breast meat yields.

The utility of lateral neck radiographs in the management of fish bones.

BACKGROUND: Lateral neck radiographs are commonly used in the investigation and management of patients presenting with suspected fish bone impaction. The effectiveness of these is questioned, as many fish do not have radio-opaque bones. OBJECTIVE: This study evaluated the utility of lateral neck radiographs in the management of patients presenting with fish bones retained in the upper aerodigestive tract, with the creation of a treatment algorithm to guide further management. METHODS: An audit of practice was undertaken at the University Hospital of Southampton, identifying all patients admitted with potential fish bone impaction in the upper aerodigestive tract. Following analysis, a treatment algorithm was constructed for use by junior doctors. RESULTS: In total, 34 per cent of patients with a normal radiograph were subsequently found to have a fish bone present under local or general anaesthetic assessment. The sensitivity of radiographs in the detection of fish bones was found to be 51.6 per cent. CONCLUSION: Lateral neck radiographs have limited value in the management of suspected fish bone impaction, and should only be used following detailed clinical examination of the upper aerodigestive tract.

Rhabdomyosarcoma of the middle ear cavity presenting with Horner's syndrome.

Rhabdomyosarcoma is a rare malignant tumour of striated muscle accounting for 3% of all primary soft tissue tumours of the middle ear cavity. We describe a unique case of a rhabdomyosarcoma of the middle ear cavity in a four-year-old boy, presenting as an otherwise asymptomatic ipsilateral Horner's syndrome. This case involved tumour erosion through the tensor tympani semicanal, accessing the carotid canal and the sympathetic plexus running through it. This child was treated successfully with chemotherapy and proton beam therapy, and remains disease free at six years of follow-up. This case highlights the importance of investigating patients with non-resolving ear infections, polyps or granulation tissue.

A five-year follow-up observational study of the T-14 paediatric throat disorders outcome measure in tonsillectomy and adenotonsillectomy.

INTRODUCTION: The T-14 questionnaire is a validated outcome measurement tool to assess the value of paediatric tonsillectomy from a parent's perspective. There is a paucity of data regarding the long-term postoperative effects of tonsillectomy on quality of life in the paediatric population. Our previous study assessed T-14 scores up to year 2 postoperatively, with this study extending follow-up to 5 years. MATERIALS AND METHODS: We undertook a prospective uncontrolled observational study examining 54 paediatric patients undergoing tonsillectomy at Portsmouth Hospitals NHS Trust. Parents of children undergoing surgery were invited to complete a T-14 questionnaire preoperatively, as well as at 3 months, 6 months, 1 year, 2 years and now 5 years postoperatively. RESULTS: In total, 44 of 54 patients completed questionnaires preoperatively and at all postoperative time points, with 46 being completed at 5 years. There was a highly significant (P < 0.001) difference between the preoperative scores and all other measured T-14 scores postoperatively. The mean score preoperatively was 33.3 compared with 1.0 at 5 years. CONCLUSIONS: This is the first study to assess long-term quality of life following paediatric tonsillectomy using the T-14 questionnaire. The benefits of tonsillectomy on long-term quality of life further confirms its value within the paediatric population.

The use of visual distraction to improve the tolerability of flexible laryngoscopy.

BACKGROUND: Flexible laryngoscopy is a commonly performed procedure in otolaryngology. Although this procedure is not considered painful, many patients describe it as uncomfortable. This study investigated the role of visual distraction as a form of pain relief during flexible laryngoscopy. METHODS: The study included patients undergoing flexible laryngoscopy at the University Hospital Southampton. Patients were self-allocated to one of four groups: with or without co-phenylcaine anaesthetic spray; and with and without visual distraction. Visual distraction involved the patient watching the procedure concurrently with the clinician, via a video monitor. Pre- and post-procedural discomfort was assessed using a visual analogue scale. RESULTS: The use of topical anaesthetic spray was not associated with significantly reduced discomfort scores (p > 0.05). Discomfort scores were significantly reduced in the visual distraction groups (p = 0.04), irrespective of the use of topical anaesthetic spray. CONCLUSION: This small study showed that visual distraction should be considered as a simple and cost-effective alternative to local anaesthetic for flexible laryngoscopy.

Quality of online otolaryngology health information.

OBJECTIVE: Up to 70 per cent of the population search online for medical or health-related information. This study aimed to assess the quality of online health resources available to educate patients on a variety of otolaryngological conditions. METHODS: Two clinicians independently analysed the quality and content of educational websites (patient.co.uk and wikipedia.org) for common and uncommon diagnoses, with cancerresearchuk.org also used to assess two head and neck cancers. RESULTS: Cancerresearchuk.org, followed by patient.co.uk, scored most highly in their ability to inform readers on a selection of otolaryngological conditions. Although wikipedia.org was less likely to include all relevant information and was more difficult to read, it still provided mostly accurate information. CONCLUSION: Where possible, patients should be advised to access professionally maintained health information websites (patient.co.uk and cancerresearchuk.org). However, wikipedia.org can provide adequate information, although it lacks depth and can be difficult to understand.

Whole-Genome Sequences of Variants of Bacillus anthracis Sterne and Their Toxin Gene Deletion Mutants.

Here, we report the draft genome sequences of three laboratory variants of Bacillus anthracis Sterne and their double (Δlef Δcya) and triple (Δpag Δlef Δcya) toxin gene deletion derivatives.