Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis).

BACKGROUND: Idiopathic acute vestibular dysfunction (vestibular neuritis) is the second most common cause of peripheral vertigo after benign paroxysmal positional vertigo (BPPV) and accounts for 7% of the patients who present at outpatient clinics specialising in the treatment of dizziness. The exact aetiology of the condition is unknown and the effects of corticosteroids on the condition and its recovery are uncertain. OBJECTIVES: To assess the effectiveness of corticosteroids in the management of patients with idiopathic acute vestibular dysfunction (vestibular neuritis). SEARCH STRATEGY: We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 28 December 2010. SELECTION CRITERIA: Randomised controlled trials comparing corticosteroids with placebo, no treatment or other active treatments, for adults diagnosed with idiopathic acute vestibular dysfunction. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies from the search results and extracted data. Three authors independently assessed risk of bias. MAIN RESULTS: Four trials, involving a total of 149 participants, compared the effectiveness of oral corticosteroids against placebo. All the trials were small and of low methodological quality. Although there was an overall significant effect of corticosteroids compared with placebo medication on complete caloric recovery at one month (risk ratio (RR) of 2.81; 95% confidence interval (CI) 1.32 to 6.00, P = 0.007), no significant effect was seen on complete caloric recovery at 12 months (RR 1.58; 95% CI 0.45 to 5.62, P = 0.48), or on the extent of caloric recovery at either one month (mean difference (MD) 9.60%; 95% CI -20.66 to 39.86, P = 0.53) or at 12 months (MD 6.83%; 95% CI -27.69 to 41.36, P = 0.70). In addition, there was no significant difference between corticosteroids and placebo medication in the symptomatic recovery of vestibular function following idiopathic acute vestibular dysfunction with respect to vertigo at 24 hours (RR 0.39; 95% CI 0.04 to 3.57, P = 0.40) and use of the Dizziness Handicap Inventory score at one, three, six and 12 months. AUTHORS' CONCLUSIONS: Overall, there is currently insufficient evidence from these trials to support the administration of corticosteroids to patients with idiopathic acute vestibular dysfunction. We found no trials with a low risk of methodological bias that used the highest level of diagnostic criteria and outcome measures. We recommend that future studies should include health-related quality of life and symptom-based outcome measures, in addition to objective measures of vestibular improvement, such as caloric testing and electronystagmography.

Persistent sore throat: a case of laryngeal mucous membrane pemphigoid.

We present a case of a 72-year-old women who presented with a persistent sore throat and productive cough. On flexible nasendoscopy examination, she was found to have a fairly superficial ulcer affecting the laryngeal surface and tip of her epiglottis. On her second microlaryngoscopy and biopsy, direct immunofluorescent staining of the biopsy was analysed and the histological findings were in keeping with a diagnosis of mucous membrane pemphigoid (MMP). MMP is a rare chronic autoimmune condition characterised by the presence of blistering subepithelial lesions that can cause scarring. Laryngeal MMP affects only 1 in 10 million people and can lead to life-threatening airway compromise arising from scarring and stenosis. As there is a large spectrum of disease, it is important to adopt a multidisciplinary approach including dermatologists, otolaryngologists and ophthalmologists for prompt diagnosis and early recognition of potential complications, maximising functional outcomes for patients.

Developing a spinal clearance protocol for unconscious pediatric trauma patients.

BACKGROUND: Spinal injury in pediatric trauma is associated with significant morbidity and mortality, but no current consensus exists on the safest and most effective method of clearance in the high-risk pediatric trauma patient. METHODS: A retrospective analysis was performed on the records of 115 pediatric patients who had suffered major trauma and required admission to the pediatric intensive care unit of a United Kingdom level I trauma centre during a 7-year period from January 2000 to December 2006. The spinal imaging performed, and methods of clearance for each spinal region were obtained from analysis of written and electronic medical documentation. RESULTS: In the cohort of 115 patients, there was a male predominance (63%) with motor vehicle accidents as the major mechanism of injury (63.5%). Ten patients (8.7%) were identified with spinal injuries, all of whom had sustained closed head injuries. Two of these patients had spinal cord injuries; one subsequently died. Spinal injury resulted in longer intubation times and intensive care stays, but no difference in new injury severity score or outcome. Clearance methods ranged from clinical examination to imaging with radiographs, computed tomography (CT), and dynamic screening. Magnetic resonance imaging was used as a secondary modality in two cases only, and in neither case was it used for clearance. CT demonstrated 100% specificity and sensitivity with positive and negative predictive values of 1 for all spinal regions. There were no cases of Spinal Cord Injury WithOut Radiologic Abnormality and no evidence of missed injuries. CONCLUSIONS: There is a need for an evidence-based protocol for the clearance of the spine in the obtunded and high-risk pediatric trauma patient. High-resolution CT with sagittal and coronal reconstructions should be the basis for cervical spinal clearance, in combination with the interpretation of films by an expert radiologist. All spinal regions should be imaged, and clearance should be formally documented. The role of magnetic resonance imaging in routine clearance remains controversial. Multicenter prospective studies are needed to develop consensus for an evidenced-based protocol for clearance in this high-risk group.

Predicting diffuse microbial pollution risk across catchments: The performance of SCIMAP and recommendations for future development.

Microbial pollution of surface waters in agricultural catchments can be a consequence of poor farm management practices, such as excessive stocking of livestock on vulnerable land or inappropriate handling of manures and slurries. Catchment interventions such as fencing of watercourses, streamside buffer strips and constructed wetlands have the potential to reduce faecal pollution of watercourses. However these interventions are expensive and occupy valuable productive land. There is, therefore, a requirement for tools to assist in the spatial targeting of such interventions to areas where they will have the biggest impact on water quality improvements whist occupying the minimal amount of productive land. SCIMAP is a risk-based model that has been developed for this purpose but with a focus on diffuse sediment and nutrient pollution. In this study we investigated the performance of SCIMAP in predicting microbial pollution of watercourses and assessed modelled outputs of E. coli, a common faecal indicator organism (FIO), against observed water quality information. SCIMAP was applied to two river catchments in the UK. SCIMAP uses land cover risk weightings, which are routed through the landscape based on hydrological connectivity to generate catchment scale maps of relative in-stream pollution risk. Assessment of the model's performance and derivation of optimum land cover risk weightings was achieved using a Monte-Carlo sampling approach. Performance of the SCIMAP framework for informing on FIO risk was variable with better performance in the Yealm catchment (rs=0.88; p<0.01) than the Wyre (rs=-0.36; p>0.05). Across both catchments much uncertainty was associated with the application of optimum risk weightings attributed to different land use classes. Overall, SCIMAP showed potential as a useful tool in the spatial targeting of FIO diffuse pollution management strategies; however, improvements are required to transition the existing SCIMAP framework to a robust FIO risk-mapping tool.

KRAS mutation is associated with elevated myeloblastin activity in human lung adenocarcinoma.

Lung cancer is the leading cause of all cancer deaths worldwide with suboptimal prognosis and treatment options. Therefore this study aimed to identify molecular characteristics with a predictive clinical utility which at the same time might represent novel therapeutic targets for human lung adenocarcinoma. Within this study mutations of v-Ki-RAS2 Kirsten rat sarcoma viral oncogene homolog (KRAS), a gene frequently mutated in lung adenocarcinoma, and their association with enzymatic activities, as assessed by activity-based proteomics, of members of the serine hydrolase (SH) superfamily, a large class of enzymes that have previously been linked to cancer was investigated. The results revealed that the activity of myeloblastin was significantly altered in the lung adenocarcinoma biopsies harboring a KRAS gene mutation. In conclusion myeloblastin is a potential therapeutic target for human lung adenocarcinoma, indicating that the combination of activity-based proteomics with mutational analysis is a valid approach for the discovery of novel biomarkers.