Hemostatic glues in tonsillectomy: A systematic review.

OBJECTIVES/HYPOTHESIS: The aim of this study was to compare use of hemostatic glues to conventional techniques of intraoperative hemostasis for tonsillectomy. STUDY DESIGN: A systematic review of the literature and meta-analysis. METHODS: All published prospective controlled trials that compared hemostatic glues to conventional techniques of hemostasis were identified. We performed a meta-analysis of articles comparing fibrin sealant to electrocautery, and of those comparing electrocautery to electrocautery plus fibrin hemostasis. RESULTS: Seven studies were identified that made qualifications for review, with a total of 748 patients. Outcome measures were postoperative hemorrhage recorded by investigators, and visual analogue scores of pain for day 1, day 3, and day 10 postoperatively. Use of fibrin sealant was not associated with a reduction in hemorrhage rates following tonsillectomy when compared to electrocautery (pooled relative risk [RR] 0.315; 95% confidence intervals [CI]: 0.047-2.093, 224 patients). No statistical difference in bleeding rate was seen between electrocautery hemostasis alone, compared to electrocautery with fibrin sealant (pooled RR 1.742; 95% CI: 0.433-7.005, 108 patients). No statistically significant difference in pain was identified. CONCLUSIONS: Pain and bleeding are significant causes of morbidity post-tonsillectomy. We conclude that there is no significant evidence to support hemostatic glues over current techniques for reducing severity of these outcomes. Consequently, we do not recommended hemostatic glues for routine use in current clinical practice. Studies were generally of low quality and inadequately powered to detect a statistical difference, even when pooled. We advocate further research to facilitate future meta-analysis.

Thrombolysis for acute ST elevation myocardial infarction: a pilot study comparing results from GP led small rural health emergency departments with results from a physician led sub-regional emergency department.

INTRODUCTION: Urgent angiogram is best treatment for patients presenting with ST elevation myocardial infarction (STEMI) in the first 90 min after contacting medical help. For Australian residents of inner and outer regional areas and remote or very remote areas, quick access to angiograms is not available. Numerous approaches have been developed to maximize reperfusion but delays due to systematic and patient factors persist. Diminishing confidence of some GPs in small rural health services to administer thrombolytics was one barrier to timely reperfusion identified in northeast Victoria, Australia. The aim of this study was to compare the frequency and outcomes of STEMI patients treated with thrombolysis by GPs in small rural emergency departments (EDs) with the outcomes from thrombolysis for STEMI in the physician-led, sub-regional ED in northeast Victoria. METHODS: Data were gathered by a medical file audit. Outcome measures were the frequency of STEMI, symptom to presentation times, mode of transport to hospital, ambulance call to presentation at ED times, door to needle (DTN) times, subsequent percutanous intervention (PCI) or coronary artery bypass grafts (CABG), physician follow up and death. RESULTS: In total 68 cases were audited. Univariate analysis showed no significant differences between the GP-led or physician-led EDs in time from onset of symptoms to presentation, DTN times, thrombolysis related complications or subsequent access to PCI or CABG. Follow-up care was similar in both groups. Transport to hospital differed between the groups with only half of all cases arriving at the ED by ambulance, almost all of which went to the sub-regional hospital. CONCLUSIONS: Thrombolysis for STEMI in the small GP-led EDs had similar results to thrombolysis administered by the physician-led ED. There is substantial time benefit to be gained by encouraging GP-led EDs to provide thrombolysis treatment, thereby improving patient prognosis and survival.

Meta-analysis of minimally invasive video-assisted thyroidectomy.

OBJECTIVES: The aim of this study is to compare minimally invasive video-assisted thyroidectomy (MIVAT) to conventional thyroidectomy. STUDY DESIGN: A systematic review of the literature and meta-analysis. METHODS: All published prospective controlled trials that compared MIVAT to conventional thyroidectomy were identified. The trials data were extracted and statistical analyzed using Statsdirect 2.5.7. RESULTS: Five trials were identified. The total number of patients was 318. The primary outcome measures were pain, postoperative hypocalcaemia, and postoperative recurrent laryngeal nerve palsy. There was no difference in rates of postoperative hypocalcaemia or postoperative recurrent laryngeal nerve palsy between the techniques. Reported pain scores at 24 hours were significantly lower in MIVAT compared to conventional surgery. Pooled effect size was -4.496 (95% confidence interval [CI] = -7.146 to -2.045, P = .0004). The secondary outcome measures were operative time, blood loss, and cosmesis. There was significant improvement in patient reported scores for cosmesis with MIVAT. The pooled effect size was 3.669 (95% CI 0.636-60.702, P = .0178). MIVAT was associated with a significant increase in operative time. Pooled effect size was 1.681 (95% CI 0.600-2.762, P = .0023). There was no difference in blood loss between the groups. CONCLUSIONS: This study demonstrates that MIVAT is as safe as the existing gold standard operation. Furthermore, it has better cosmetic and pain outcomes for patients when compared to conventional surgery. MIVAT is a promising new technique, with obvious benefits over the established surgery, for small-volume thyroid disease that mainly affects a young female patient population.

Tympanic membrane rupture in the survivors of the July 7, 2005, London bombings.

OBJECTIVE: The goal of this study was to analyze the prevalence of tympanic membrane rupture in the survivors of the London bombings of July 2005 and to assess whether tympanic membrane rupture provides a useful biomarker for underlying primary blast injuries. STUDY DESIGN: Cross-sectional study. SUBJECTS AND METHODS: Survivors of the 4 blasts of London bombings on July 7, 2005. Data were gathered from medical records and the London's Metropolitan Police evidence documenting the injuries sustained by 143 survivors of the blasts. All patients with tympanic membrane rupture or primary blast injury were identified. Analysis was made of distance against prevalence of tympanic membrane rupture. Correlation between tympanic membrane rupture and other forms of primary blast injury was then assessed. RESULTS: Results from the 143 survivors showed a 48% prevalence of tympanic membrane rupture across all 4 sites. Fifty-one patients had isolated tympanic membrane rupture with no other primary blast injuries. Eleven patients had tympanic membrane rupture and other primary blast injuries, but only one of these was an initially concealed injury (blast lung). CONCLUSIONS: Tympanic membrane rupture in survivors of the London bombings on July 7, 2005, had a high prevalence affecting half of patients across a range of distances from the blasts. Tympanic membrane did not act as an effective biomarker of underlying blast lung. In a mass casualty event, patients with isolated tympanic membrane rupture with normal observations and chest radiography can be monitored for a short period and safely discharged with arrangement for ear, nose, and throat follow-up.