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To investigate variations in the management and outcomes of peritonsillar
abscesses, and to develop a trainee collaborative network in the UK.
Data were collected prospectively on suspected peritonsillar abscess cases
presenting over a 2-month period at 42 participating secondary care centres,
covering a population of 16 million. The primary outcome was an adverse
event at 30 days, defined as re-presentation or re-drainage.
Eighteen per cent of the 325 cases experienced an adverse event. Follow-up
data were valid for 90 per cent of cases. Regression analyses showed a
significant reduction in adverse events in the 12 per cent of patients who
were discharged within 12 hours, and there was no significant increase in
adverse events for the 70 per cent receiving corticosteroids.
Out-patient management of peritonsillar abscess is not commonly practised in
the UK. Corticosteroid usage is common and appears safe. This study
demonstrates that trainees working in collaboration can effectively deliver
prospective multicentre cohort studies in the UK.
The majority of the 30–100 million people infected with Strongyloides stercoralis, a soil transmitted intestinal nematode, have subclinical (or asymptomatic) infections. These infections are commonly chronic and longstanding because of the autoinfective process associated with its unique life cycle. A change in immune status can increase parasite numbers, leading to hyperinfection syndrome, dissemination, and death if unrecognized. Corticosteroid use and HTLV-1 infection are most commonly associated with the hyperinfection syndrome. Strongyloides adult parasites reside in the small intestine and induce immune responses both local and systemic that remain poorly characterized. Definitive diagnosis of S. stercoralis infection is based on stool examinations for larvae, but newer diagnostics – including new immunoassays and molecular tests – will assume primacy in the next few years. Although good treatment options exist for infection and control of this infection might be possible, S. stercoralis remains largely neglected.
Background: Current opinions regarding the use of dexamethasone in the treatment of chronic subdural hematomas (CSDH) are only based on observational studies. Moreover, the use of corticosteroids in asymptomatic or minimally symptomatic patient with this condition remains controversial. Here, we present data from a prospective randomized pilot study of CSDH patients treated with dexamethasone or placebo. Methods: Twenty patients with imaging-confirmed CSDH were recruited from a single center and randomized to receive dexamethasone (12 mg/day for 3 weeks followed by tapering) or placebo as a conservative treatment. Patients were followed for 6 months and the rate of success of conservative treatment with dexamethasone versus placebo was measured. Parameters such as hematoma thickness and clinical changes were also compared before and after treatment with chi-square tests. Adverse events and complications were documented. Results: During the 6-month follow-up, one of ten patients treated with corticosteroids had to undergo surgical drainage and three of ten patients were treated surgically after placebo treatment. At the end of the study, all remaining patients had complete radiological resolution. No significant differences were observed in terms of hematoma thickness profile and impression of change; however, patients experienced more severe side effects when treated with steroids as compared with placebo. Dexamethasone contributed to many serious adverse events. Conclusions: Given the small sample size, these preliminary results have not shown a clear beneficial effect of dexamethasone against placebo in our patients. However, the number of secondary effects reported was much greater for corticosteroids, and dexamethasone treatment was responsible for significant complications.
Cancer-related fatigue (CRF) is a common and one of the most important issues in palliative medicine, and it has been demonstrated to have a significant impact on patient quality of life (QoL). The present pilot randomized controlled study evaluated the efficacy and toxicity of methylprednisolone (MP) for CRF in advanced cancer patients.
Our study was planned as a randomized, double-blind, multicenter, placebo-controlled trial. Patients were randomly assigned to an MP group, who received 32 mg/day of MP orally for 7 days, and a placebo group. The primary endpoint was an improvement in visual analog scale (VAS) score for fatigue from baseline to day 7. The secondary endpoints were improvements in appetite loss and QoL as well as evaluating the safety of corticosteroids as palliative therapy.
It was not possible to complete patient registration. In total, 35 patients were randomly assigned to an MP group (n = 18) and a placebo group (n = 17). The mean changes in VAS score for fatigue were –9.06 in the placebo group and –1.56 in the MP group, and for appetite loss –6.44 in the placebo group and –8.06 in the MP group. In addition, there was no evidence that methylprednisolone improved appetite loss or QoL compared to placebo. The incidence of adverse effects was not greater in the MP group.
Significant of Result:
We conclude that our sample size was too small to prove the efficacy of methylprednisolone in improving fatigue. Our results were reported as a pilot study performed to support a subsequent larger trial.
This study aimed to present the histopathological and audiological effects of mechanical trauma associated with the placement of a model electrode in the scala tympani in rats, and the effects of continuous topical corticosteroid application.
The study comprised three groups of rats. The round window membrane was perforated in all three groups and a model electrode was inserted in the round window. Group one received no further treatments. Groups two and three also had an intrathecal microcatheter compatible with a mini-osmotic pump inserted; in group two this was used to release normal saline and in group three the pump released 400 µg/ml dexamethasone.
Dexamethasone infusion given after implantation of the intracochlear model electrode was more effective for preventing hearing loss than the administration of just one dose of dexamethasone.
The findings suggest that continuous dexamethasone infusion is beneficial for preventing the loss of hair cells and neurons associated with early and late periods of intracochlear electrode trauma.
To investigate the frequency of demodex species in the external acoustic meatus in patients with an itchy ear canal.
Patients were assigned to one of three groups. Group one consisted of 54 patients with an itchy ear canal who were using a local agent, while group two was composed of 51 patients with an itchy ear canal who were not using a local agent. Group three consisted of 50 healthy individuals without an itchy ear canal.
Demodex species test results were positive in nine (5.8 per cent) of the cases. Six of these positive cases were in group one, two in group two and one in group three. The frequency of demodex species in the external acoustic meatus was similar between those patients with an itchy ear canal who did not use a local agent and the healthy individuals (p = 0.571), but it was significantly higher in those using a local steroid compared with those not using a local agent (p = 0.046).
Although demodex species was not significantly higher in patients with an itchy ear canal compared with the control group, use of a local steroid increased the parasite frequency in the external ear canal of affected patients.
To investigate endoscopic staging, and nitric oxide levels in the polyp tissue, in patients with nasal polyposis undergoing glucocorticoid therapy.
Nasal polyposis was evaluated using endoscopic staging and measurement of polyp tissue nitric oxide levels (chemiluminescence method). Forty-five nasal polyposis patients received either nasal therapy (n = 15), oral therapy (n = 15) or combined therapy (n = 15). Pre-treatment and post-treatment staging and nitric oxide levels were evaluated.
Endoscopic grading indicated significant post-treatment staging improvements in the oral (p = 0.016) and combined (p = 0.016) groups. Post-treatment staging differed significantly between the three groups (p = 0.041), with greater improvements in the oral and combined groups. All groups showed significantly lower post-treatment nitric oxide levels, compared with baseline, but post-treatment levels did not differ significantly between groups. A significant association was found between treatment response and nitric oxide level alteration.
This study demonstrates the favourable effects of glucocorticoids on nasal polyposis, and alteration in nitric oxide tissue levels post-treatment. Nitric oxide level in nasal polyp tissue could be an indicator of treatment response, and may aid surgical decision-making by detecting cases that probably will not respond to medical treatment.
We report the use of triamcinolone injections to correct severe nasal deformity due to sarcoidosis, as an alternative to formal surgical rhinoplasty.
A 30-year-old woman with a long-standing history of sarcoidosis presented to a tertiary referral rhinology clinic complaining of breathing difficulty and nasal deformity. Flexible nasoendoscopy revealed red nasal plaques typical of nasal sarcoidosis, together with significant widening of the nasal bridge. Triamcinolone, a long-acting corticosteroid, was injected both intralesionally and subcutaneously over the nasal dorsum, at zero, three and eight months, resulting in long-lasting improvement of the nasal shape.
Sarcoidosis is a non-caseating, granulomatous, epithelioid inflammation. Otorhinolaryngological manifestations occur in approximately 10 per cent of patients; however, there is little published experience of nasal reconstruction in such patients. We describe a quick, simple and relatively cost-effective technique, with little or no co-morbidity, with which to improve the aesthetic and symptomatic outcomes of nasal sarcoidosis.
Although evidence-based clinical practice guidelines (CPGs) exist, emergency department (ED) asthma management remains highly variable. Our objective was to compare asthma management at a tertiary care ED with that advised by the Canadian Association of Emergency Physicians' (CAEP) asthma CPG and current best practice.
This medical record study enrolled patients between the ages of 19 and 60 years with a previous diagnosis of asthma who were seen for an acute asthma exacerbation at the Vancouver General Hospital ED in 2008. Standard methodology guidelines for medical record review were followed, including explicitly defined criteria and determination of interrater reliability. Primary outcomes were the proportion of cases with the following: objective assessment of severity using peak expiratory flow (PEF), use of systemic corticosteroids (SCSs) in the ED and at discharge, prescription for any inhaled corticosteroids (ICSs), and documentation of outpatient follow-up.
A total of 204 patient encounters were enrolled. Kappa values for interrater assessment ranged from 0.93 to 1.00. Compliance with primary outcomes was as follows: measurement of PEF, 90% (95% CI 85–94); use of SCSs in the ED, 64% (95% CI 57–71); prescription of SCSs at discharge, 59% (95% CI 51–67); prescription of any ICS at discharge, 51% (95% CI 41–61); and documentation of outpatient follow-up, 78% (95% CI 71–84).
This study indicates an improvement in ED asthma care compared to previously published studies; however, discordance still exists between asthma management at a tertiary care ED and the CAEP asthma CPG and current best practice. Further research is warranted to understand the reasons for this finding.
Treatment of multiple sclerosis (MS) with pulses of high dose methylprednisolone (HDMP) is currently the treatment of choice for MS relapses in many parts of the world. The use of corticosteroids as a treatment for MS was first reported in 1951. There is emerging evidence regarding the benefits of HDMP administered in pulses on the course of MS, either alone or in combination with other disease modifying therapy. HDMP was found to improve Expanded Disability Status Scale (EDSS) better than placebo, with improvements primarily in pyramidal, cerebellar, and sensory systems. In general, corticosteroid toxicity is reduced with short-term pulsed administration of HDMP. Altogether, numerous clinical and magnetic resonance imaging (MRI) studies suggest that HDMP not only has transient beneficial effects on clinical relapses and established areas of inflammation and demyelination, but may also have a prolonged, dose-dependent benefit involving early events in MS lesion formation, lesion propagation, and lesion recovery.
This chapter reviews the use of corticosteroids for acute relapses in pediatric multiple sclerosis (MS). Corticosteroids are used to treat inflammatory conditions as they modulate the immune system through multiple mechanisms. Corticosteroids are considered type A drugs for treating MS relapses in adults. In patients with optic neuritis (ON), high-dose intravenous methylprednisolone (IVMP) 1 g/day for 3 days has been shown to be effective at hastening recovery. Another study showed that patients receiving IVMP within 8 weeks of an acute relapse had lower mean Expanded Disability Scale Scores (EDSS) assessed at 1 and 4 weeks compared to placebo. Most adult studies suggest that high-dose IVMP should be dosed at 500-1000 mg daily for 3-5 days. Long-term use of corticosteroids is associated with numerous and substantial adverse effects. The side effects of prolonged exposure to corticosteroids include osteoporosis, neutropenia, weight gain, adrenal suppression, acne, increased skin fragility, hypertension, and psychosis.
The birth of an infant who has a possible hypoxic ischaemic encephalopathy (HIE) is a source of great concern to the parents, obstetricians and paediatricians. Hypoxic cerebral brain injury that occurs in the perinatal period is recognised as a cause of severe long-term neurological deficit in children; it is often referred to as cerebral palsy. The absence of information and specific guidelines on HIE means that advice provided to women has to be collated from evidence-based effective antenatal and perinatal care that maximises the opportunity to deliver a healthy baby. Approaches to the prevention of HIE include the antenatal administration of corticosteroids to women in preterm labour, as this has been shown to reduce perinatal mortality, respiratory distress and intraventricular haemorrhage by over 50%. All units should have a regular continuing programme of in-service training including cardiotocography (CTG) interpretation, drills on emergency ('crash') caesarean section and neonatal resuscitation.
Vogt–Koyanagi–Harada disease is a chronic disorder involving the eye and the central nervous, auditory, vestibular and integumentary systems. This study aimed to determine the auditory and vestibular manifestations of this disease.
Twenty-four patients diagnosed with Vogt–Koyanagi–Harada disease were assessed for auditory and vestibular dysfunction.
Uveitis presents in all cases. Sensory hearing loss was present in 50 per cent of cases, tinnitus in 42 per cent, vertigo in 17 per cent and headache in 17 per cent. Nine patients received systemic steroids. Six patients who were treated early regained their hearing, but three patients whose treatment was delayed did not. One patient with bilateral profound hearing loss underwent cochlear implantation, and achieved excellent post-implantation hearing.
There is a high incidence of cochlear and vestibular end-organ involvement in patients with Vogt–Koyanagi–Harada disease. The adequacy and timing of treatment has a significant effect on the disease outcome. Vogt–Koyanagi–Harada disease appears to affect the inner ear end-organ. Patients who develop bilateral profound sensory hearing loss are suitable candidates for cochlear implantation.
Developmental plasticity is the property of a given genotype to produce different phenotypes in response to the environmental conditions experienced during development. Chordates have two basic modes of development, direct and indirect. Direct development (mode of humans) was derived evolutionarily from indirect development (mode of many amphibians), the major difference being the presence of a larval stage with indirect development; larvae undergo metamorphosis to the juvenile adult. In amphibians, environmental conditions experienced during the larval stage can lead to extreme plasticity in behaviour, morphology and the timing of metamorphosis and can cause variation in adult phenotypic expression (carry-over effects, or developmental programming). Hormones of the neuroendocrine stress axis play pivotal roles in mediating environmental effects on animal development. Stress hormones, produced in response to a deteriorating larval habitat, accelerate amphibian metamorphosis; in mammals, stress hormones hasten the onset of parturition and play an important role in pre-term birth caused by intra-uterine stress. While stress hormones can promote survival in a deteriorating larval or intra-uterine habitat, costs may be incurred, such as reduced growth and size at metamorphosis or birth. Furthermore, exposure to elevated stress hormones during the tadpole or foetal stage can cause permanent neurological changes, leading to altered physiology and behaviour later in life. The actions of stress hormones in animal development are evolutionarily conserved, and therefore amphibians can serve as important model organisms for research on the mechanisms of developmental plasticity.
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by vascular thrombosis and/or obstetric morbidity in the presence of persistent antiphospholipid antibodies (aPL) namely, lupus anticoagulant antibodies (LAC), anti-cardiolipin antibodies (aCL) and/or anti-β2-glycoprotein I antibodies. The syndrome produces a spectrum of disease, both in terms of clinical manifestations and the presence of other autoimmune conditions. The disease is classified as primary antiphospholipid syndrome (PAPS) when it occurs in the absence of any features of other autoimmune disease, and secondary where other autoimmune disease is present secondary antiphospholipid syndrome (SAPS). Upto 30% of patients with APS have minor valvular abnormalities, which usually do not cause hemodynamic disturbance. Individual treatment strategies for the management of the APS in pregnancy in part depend on the assessment of a number of different factors. The first treatment used and studied for pregnant patients with APS, was a combination of corticosteroids and low dose aspirin.
Many patients with allergic rhinitis are reluctant to use daily intranasal steroids for prolonged periods. A self-adjusted regimen which delivers reasonable control of allergic rhinitis may be more acceptable to such patients.
To compare the efficacy of daily use of mometasone furoate nasal spray, versus a self-adjusted regimen, in patients with chronic allergic rhinitis, in terms of symptom control and nasal volume change.
Ambulatory visits in an office setting.
Patients and methods:
Sixty patients with chronic allergic rhinitis were randomised: 30 were prescribed mometasone furoate nasal spray once daily for six weeks, while 30 were prescribed the same spray daily for one week, every alternate day for one week and then on a self-adjusted regimen for four weeks. Patients kept a symptom diary documenting sneezing, rhinorrhoea, nasal blockage and nasal itching. Acoustic rhinometry was used to measure the total nasal cavity volume at the first visit and at the end of the treatment period.
The total nasal score on treatment days showed an improvement in both groups, compared with baseline measurements. There was no significant difference in total nasal scores between the two groups, except on days 10 (p = 0.043), 20 (p = 0.008), 23 (p = 0.19), 30 (p = 0.008) and 37 (p = 0.000), when the daily group's total nasal score was significantly lower than the self-adjusted group's total nasal score, and on day 8 (p = 0.004), when the self-adjusted group's total nasal score was significantly lower than the daily group's total nasal score. Total nasal cavity volume significantly increased in both groups (p = 0.0001), with no statistically significant difference between the groups.
Self-adjusted dosage of mometasone furoate nasal spray gives reasonable control of allergic rhinitis (albeit with some ‘breakthrough’ symptoms). Patients should learn how to control these symptoms with the least number of steroid doses.
There has been growing concern over the impact of increased human disturbance and research effects on Antarctic species. The Weddell seal of McMurdo Sound in particular has been used as a model species for over four decades of research, with some individuals handled multiple times over a single season. Using opportunistic data, we performed an assessment of blood indicators in adult males (n = 26) and adult females (n = 24) based on high versus low disturbance areas, with results showing no variation in overall seal health. In addition, we performed a preliminary analysis of blood and faecal indicators of inflammation and stress collected from adult, non-lactating females (n = 13) handled twice in less than two weeks for research purposes. There was no indication of a change in white blood cells, platelets, globulins or haptoglobins, or faecal corticosteroids (all P > 0.05). While based on a small, opportunistic sample size with limited power in some cases, preliminary results indicate there is no acute impact of repeated handling or difference in overall traffic level on adult Weddell seals.
Temporal (giant cell) arteritis is a systemic disease, involving various medium-sized and larger arteries, that occurs mostly in elderly patients. Blindness due to ischemic optic neuropathy is probably the most common and most feared sinister manifestation of the disease, but stroke is the leading cause of death in patients with temporal arteritis. Noninvasive angiography using computed tomography (CT) or magnetic resonance imaging (MRI) may reveal sites of vascular stenoses. A typical finding is smoothly tapered stenotic lesions different from the abrupt, irregular stenoses of atherosclerotic disease. These modalities may be helpful in assessing the extent of disease or potentially to aid diagnosis especially in biopsy negative cases. Fludeoxyglucose-positron emission tomography (FD-PET) scanning may reveal uptake in the larger thoracic vessels including aorta, subclavian, and carotid arteries. The mainstay of treatment is corticosteroids, although there is much debate about the optimal dose and use of steroid sparing immunosuppressives.