Flurbiprofen in the subglottic space to prevent postoperative sore throat after cardiac surgery: A randomized double-blind study

STUDY OBJECTIVE

Postoperative sore throat (POST) and hoarseness are common complications of tracheal intubation. This study aims to evaluate the efficacy of flurbiprofen administered through the subglottic port of tracheal tubes to prevent POST after cardiac surgery.

DESIGN

Single-center, prospective, randomized, double-blind, placebo-controlled trial.

SETTING

Tertiary Care Referral University Hospital (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome).

PATIENTS

Included 71 patients undergoing for elective cardiac surgery. Inclusion criteria were (a) age between 50 and 75 years, (b) NYHA class I or II, (c) surgery for myocardial revascularization or valve repair or replacement under cardiopulmonary bypass.

INTERVENTION

Patients were double blind randomized to receive flurbiprofen or saline in the subglottic port of the endotracheal tube (groups F and P). The solution was injected ten minutes after tracheal tube placement, ten minutes after ICU admission and ten minutes before tracheal tube removal.

MEASUREMENTS

The primary outcome was to assess the effect of topical flurbiprofen administered through the subglottic port of the tracheal tube to prevent post-operative sore throat (POST). The secondary outcomes were the presence of hoarseness safety and patient's subjective satisfaction with their recovery. We did not report any exploratory outcomes.

MAIN RESULTS

We analyzed 68 patients, 34 patients in each group. In group F, two patients complained of POST and hoarseness (5.9%), while all controls did. The two groups significantly differed in the severity scores (VAS and TPS for sore throat and HOAR for hoarseness) at all time points. In group P, patients reported mild to moderate symptoms that significantly improved or disappeared 36 h after tracheal tube removal. According to the multivariable model, hoarseness affected women less than men, in the control group (p = 0.002). None of the patients in either group reported any adverse effects.

CONCLUSIONS

Repeated administration of flurbiprofen through the subglottic port of tracheal tubes reduced the incidence of sore throat and hoarseness after cardiac surgery without evidence of complications.

Effects of preoperative inhaled budesonide combined with intravenous dexamethasone on postoperative sore throat in patients who underwent thyroidectomy: A randomized controlled trial

BACKGROUND

This randomized controlled trial aimed to evaluate the efficacy of preoperative inhaled budesonide combined with intravenous dexamethasone on postoperative sore throat (POST) after general anesthesia in patients who underwent thyroidectomy.

METHODS

Patients who underwent elective thyroidectomy were randomly divided into the intravenous dexamethasone group (group A) and budesonide inhalation combined with intravenous dexamethasone group (group B). All patients underwent general anesthesia. The incidence and severity of POST, hoarseness, and cough at 1, 6, 12, and 24 hours after surgery were evaluated and compared between the 2 groups.

RESULTS

There were 48 and 49 patients in groups A and B, respectively. The incidence of POST was significantly lower at 6, 12, and 24 hours in group B than that in group A (P < .05). In addition, group B had a significantly lower incidence of coughing at 24 hours (P = .047). Compared with group A, the severity of POST was significantly lower at 6 (P = .027), 12 (P = .004), and 24 (P = .005) hours at rest, and at 6 (P = .002), 12 (P = .038), and 24 (P = .015) hours during swallowing in group B. The incidence and severity of hoarseness were comparable at each time-point between the 2 groups (P > .05).

CONCLUSION

Preoperative inhaled budesonide combined with intravenous dexamethasone reduced the incidence and severity of POST at 6, 12, and 24 hours after extubation compared with intravenous dexamethasone alone in patients who underwent thyroidectomy. Additionally, this combination decreased the incidence of postoperative coughing at 24 hours.

Role of preoperative zinc, magnesium and budesonide gargles in Postoperative Sore Throat (POST) - a randomised control trial

BACKGROUND

Post-operative sore throat (POST) has an incidence ranging from 21 to 80%. To prevent the development of POST, several pharmacological measures have been tried. Aim of this study was to compare the efficacy of preoperative zinc, magnesium and budesonide gargles in reducing the incidence and severity of POST in patients who underwent endotracheal intubation for elective surgeries.

METHODS

We conducted a prospective, randomized, double-blind, controlled equivalence trial in 180 patients admitted for elective surgical procedures under general anaesthesia. Patients were randomised into three groups; group Z received 40 mg Zinc, group M received 250 mg Magnesium Sulphate and group B received 200 µg Budesonide in the form of 30 ml tasteless and colourless gargle solutions. Sore throat assessment and haemodynamic recording was done postoperatively at immediate recovery (0 h) and 2, 4, 6, 8, 12 and 24 h post-operatively. POST was graded on a four-point scale (0-3).

RESULTS

POST score was comparable at all recorded time points i.e. 0,2,4,6,8,12 and 24 h. Maximum incidence was seen at 8 h in group B (33.3%) and the minimum incidence was at 24 h in group Z (10%) (p > 0.05). It was found that the incidence of POST was more in the surgeries lasting longer than 2 h in all groups. This difference was found to be statistically significant in Groups M and B. The incidence of POST was found to be comparable between laparoscopic and open procedures.

CONCLUSION

Magnesium, zinc and budesonide have an equivocal effect in the prevention of POST at different time points. The incidence of sore throat increases significantly in surgeries lasting more than two hours if magnesium or budesonide have been used as premedicant. Duration of surgery is an independent predictor for POST.

TRIAL REGISTRATION

CTRI/2021/05/033741 Date-24/05/2021(Clinical Trial Registry of India).

Comparison of adding magnesium sulfate, dexmedetomidine and ondansetron to lidocaine for gargling before laryngoscopy and endotracheal intubation to prevent sore throat: a randomized clinical trial

Postoperative sore throat is one well-recognized complication, occurring most frequently following tracheal intubation. Effective prevention of postoperative sore throat has been recognized as a top priority, bringing pleasant feelings and satisfaction to patients. This study aimed to assess the efficacy of magnesium sulfate, dexmedetomidine and ondansetron gargle with lidocaine administrated prior to laryngoscopy and tracheal intubation for postoperative sore throat prevention alongside hemodynamic management. This double-blind randomized clinical trial enrolled 105 general anesthesia-administered patients who had undergone laryngoscopy and endotracheal intubation, and they were equally randomized into three groups: magnesium sulfate, dexmedetomidine, and ondansetron groups. No significant intergroup difference was seen in oxygen saturation, non-invasive blood pressure, heart rate, duration of surgery, postoperative complications, analgesic consumption, and incidence of cough and hoarseness. The results showed statistically significant intergroup differences in pain scores and average pain intensity in the dexmedetomidine group was significantly lower than the other groups. Results suggest that dexmedetomidine gargle with lidocaine before general anesthesia induction could be recommended as an option depending on the patient's general condition and the anesthesiologist's discretion.

Preventive Interventions to Reduce the Burden of Rheumatic Heart Disease in Populations at Risk: A Systematic Review

BACKGROUND

Rheumatic heart disease (RHD) is a devastating yet preventable condition that disproportionately affects low-middle-income countries and indigenous populations in some high-income countries. Various preventive interventions have been implemented across the globe, but evidence for the effectiveness of these measures in reducing the incidence or prevalence of acute rheumatic fever and RHD is scattered. This systematic review aims to assess the effectiveness of preventive interventions and identify the strategies used to reduce the burden of RHD.

METHODS AND RESULTS

A comprehensive search was conducted to identify relevant studies on RHD prevention interventions including interventions for primordial, primary, and secondary prevention. Effectiveness measures for the interventions were gathered when available. The findings indicate that school-based primary prevention services targeting the early detection and treatment of Group A Streptococcus pharyngitis infection with penicillin have the potential to reduce the incidence of Group A Streptococcus pharyngitis and acute rheumatic fever. Community-based programs using various prevention strategies also reduced the burden of RHD. However, there is limited evidence from low-middle-income countries and a lack of rigorous evaluations reporting the true impact of the interventions. Narrative synthesis was performed, and the methodological quality appraisal was done using the Joanna Briggs Institute critical appraisal tools.

CONCLUSIONS

This systematic review underscores the importance of various preventive interventions in reducing the incidence and burden of Group A Streptococcus pharyngitis, acute rheumatic fever, and RHD. Rigorous evaluations and comprehensive analyses of interventions are necessary for guiding effective strategies and informing public health policies to prevent and reduce the burden of these diseases in diverse populations.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020170503.

The effect of pharyngeal packing on gastric volume in patients undergoing nasal surgery: a randomised, controlled trial

OBJECTIVE

To explore the effects of pharyngeal packing on antral cross-sectional area, gastric volume and post-operative complications.

METHODS

In this prospective, randomised, controlled study, 180 patients were randomly assigned to a control group or a pharyngeal packing group. Gastric antral dimensions were measured with pre- and post-operative ultrasound scanning. Presence and severity of post-operative nausea and vomiting and sore throat were recorded.

RESULTS

Post-operative antral cross-sectional area and gastric volume were significantly larger in the pharyngeal packing group compared to the control group. The incidence and severity of post-operative nausea and vomiting were significantly less in the pharyngeal packing group. More frequent and severe sore throat was observed in the control group within the ward. An increased Apfel simplified risk score and post-operative antral cross-sectional area were associated with post-operative nausea and vomiting during the first 2 hours, whereas septorhinoplasty and functional endoscopic sinus surgery, absent pharyngeal packing, and lower American Society of Anesthesiologists' physical status were associated with post-operative nausea and vomiting within the ward.

CONCLUSION

Regardless of operation type, pharyngeal packing use resulted in smaller gastric volume, which was associated with reduced post-operative nausea and vomiting frequency and severity, and lower sore throat incidence.

Effect of chewing gum of different weights before surgery on sore throat after total thyroidectomy: A randomized controlled trial

BACKGROUND

Postoperative sore throat (POST) is a common postoperative complication.

COMPLICATION

Chewing gum can inhibit the growth of oral bacteria, cleanse, and lubricate the oral cavity, which can help reduce postoperative sore throat. We hypothesize that chewing gum before surgery could relieve POST.

METHODS

Patients planned to undergo total thyroidectomy under general anesthesia with tracheal intubation were randomized to swallow saliva twice or chew 1.4 g/2.8 g of gum for 2 minutes before surgery. A standard anesthesia protocol was performed. The numerical rating scale scores of POST at 1, 24, and 48 h after surgery were collected. The primary outcome was the incidence of moderate/severe POST (numerical rating scale score >3) within 48 h.

RESULTS

Data from 148 patients (control group, n = 50; 1.4 g group, n = 48; and 2.8 g group, n = 50) were included in the analysis. Within 48 h, there was a significant difference among the three groups in the incidence of moderate/severe POST (control group: 74% vs. 1.4 g group: 65% vs. 2.8 g group: 50%. P = 0.04). The 2.8 g group had less incidence of moderate/severe POST than the control group (Odds Ratio = 0.351 95% Confidence Interval: (0.152 and 0.814) P = 0.02).

CONCLUSION

Chewing 2.8 g gum before total thyroidectomy can reduce the incidence of moderate/severe POST within 48 h after surgery.

Effect of thermal softening of double-lumen endobronchial tubes on postoperative sore throat in patients with prior SARS-CoV-2 infection: a randomized controlled trial

BACKGROUND

The incidence of postoperative sore throat (POST) after tracheal intubation using double-lumen endobronchial tubes (DLTs) is higher in patients with prior severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection than in the general population. This prospective trial was conducted to determine whether thermal softening of DLTs could decrease the incidence of POST or other airway injuries in patients with prior SARS-CoV-2 infection.

METHODS

A total of 120 patients with prior SARS-CoV-2 infection undergoing thoracoscopic surgery were randomly assigned to two groups (n = 60 each). In the thermal softening group, the distal portion of the DLT was placed in thermostatic saline (50 °C) for 10 min before endotracheal intubation. In the control group, the distal portion of the DLT was placed in room temperature saline for 10 min before endotracheal intubation. The incidence and severity of POST and hoarseness were assessed at 1, 6 and 24 h postoperatively. The primary outcomes were the incidence and severity of POST at 6 h postoperatively. The secondary outcomes were the incidence and severity of hoarseness, vocal cord and tracheal injuries, and hemodynamic changes in patients at intubation.

RESULTS

The incidence of POST at 6 h postoperatively was greater in the control group than in the thermal softening group [41 (68%) vs. 22 (37%), P = 0.001]. The overall incidence of POST at 24 h postoperatively was greater in the control group than in the thermal softening group [46 (76%) vs. 24 (40%), P < 0.001]. The overall incidence of tracheal injuries was also greater in the control group than in the thermal softening group (P = 0.016). Vocal cord injuries occurred more frequently in the control group than in the thermal softening group (P = 0.006).

CONCLUSION

Thermal softening of DLTs before intubation can reduce the incidence of POST and airway injuries in patients with prior SARS-CoV-2 infection undergoing DLT insertion.

TRIAL REGISTRATION

This trial has been registered at www.chictr.org.cn (registration number: ChiCTR2200066821; registration date: December 19, 2022).

Preoperative Ultrasound-Guided Internal Branch Block of Superior Laryngeal Nerve Reduces Postoperative Sore Throat Caused by Double Lumen Endotracheal Intubation: A Randomized Trial

BACKGROUND

Postoperative sore throat (POST) is one of the more common side effects of tracheal intubation patients under general anesthesia (GA) after extubation using double-lumen endobronchial tubes (DLTs). The internal branches of the superior laryngeal nerve (SLN) block (iSLNB) have been reported to anesthetize the larynx for airway manipulation (such as awake tracheal intubation) and pain treatment efficiently. We hypothesized that ultrasound-guided iSLNB (US-guided iSLNB) combined with GA would ameliorate the incidence and severity of POST and hoarseness.

METHODS

Patients (n = 82) undergoing thoracoscopic resection of pulmonary nodules/lobes/segments with one-lung ventilation (OLV) under GA were randomized into 2 groups depending on whether performed with iSLNB (S group, n = 41) or not (C group, n = 41) under GA. Patients in the S group received US-guided iSLNB bilaterally before surgery. POST and hoarseness were assessed at 2, 6, and 24 hours after surgery. The primary outcome of this study was the incidence of POST at 6 hours after surgery between groups.

RESULTS

The overall accumulated incidence of POST was lower in the S goup than in the C group (9/41 vs 20/41; 95% CI, 0.30 [0.11-0.77]; P = .011). The incidence and severity of POST was lower in the S group than in the C group at 2 hours (9/41 vs 20/41; 95% CI, 0.30 [0.11-0.77]; P = .008 and P = .004) and 6 hours after (7/41 vs 17/41; 95% CI, 0.29 [0.10-0.81]; P = .012 and P = .015) surgery. The incidence and severity of POST at 24 hours after surgery was nonsignificant. However, the incidence and severity of hoarseness was comparable between the 2 groups at 2, 6, and 24 hours after surgery.

CONCLUSIONS

Preoperative US-guided iSLNB could significantly ameliorate the incidence and severity of POST induced by double-lumen bronchial catheter intubation.

Effect of Esketamine Gargle on Postoperative Sore Throat in Patients Undergoing Double-Lumen Endobronchial Intubation: A Randomised Controlled Trial

Background

Postoperative sore throat is a frequent adverse event after double-lumen endobronchial tube (DLT) intubation. The aim of this study was to investigate whether esketamine gargle has a preventive effect on the incidence of postoperative sore throat in patients undergoing DLT intubation.

Methods

This trial included 140 patients undergoing elective thoracic surgery at the third affiliated hospital of Sun Yat-Sen University. Patients were randomly allocated into the following two groups of 70 patients each: the control group, gargling with saline of 30 mL, and the esketamine group, gargling with an esketamine solution of 30 mL (2 mL/50 mg esketamine in 28 mL saline), 5 min prior to anaesthesia induction. The primary outcome was the incidence of sore throat 24 h after surgery. The main secondary outcomes included the incidence of sore throat and hoarseness at 1 h and 48 h after surgery, as well as the intraoperative haemodynamic responses.

Results

The incidence of sore throat was significantly higher in the control group (47.1%, 33/70 patients) compared with the esketamine group (12.9%, 9/70 patients) at 24 h after surgery (RD, 0.41; 95% confidence interval, 0.26-0.57; p < 0.001). Furthermore, the incidence of sore throat at 1 h (p = 0.027), 24 h (p = 0.019), and seventh day (p = 0.031) as well as hoarseness at 1 h (p = 0.027), 24 h (p = 0.019), and 48 h (p = 0.031) after surgery were reduced in the esketamine group. Significant differences were seen in the peak levels of systolic blood pressure, mean arterial blood pressure, and heart rate between the groups during the intubation (p < 0.05). Besides, no patient developed an adverse reaction to esketamine.

Conclusion

Preoperative gargling of esketamine can provide an effect against sore throat after DLT intubation without adverse side effects and effectively inhibit sharp elevations in heart rate and blood pressure during double-lumen intubation procedures.

Effect of fluticasone-impregnated throat packs on postoperative sore throat (POST) and hoarseness of voice: A randomized clinical trial

Background: Post-operative sore throat (POST) is one of the most common complaints post-endotracheal intubation and can be decreased through various interventions. This study aimed to determine the effect of fluticasone-impregnated versus saline throat packs on the occurrence and severity of POST and voice hoarseness. Methods: This prospective, randomized, double-blinded trial was conducted on patients undergoing nasosinus surgeries at Kasturba Medical College and Hospital. Patients were randomized to groups based on a computer-generated table of random numbers post-intubation after placing a definite length of oropharyngeal packs into group F (fluticasone) who received four puffs of fluticasone furoate-soaked throat packs and group C (control) wherein normal saline-soaked throat packs were used. Determining the incidence of POST and voice hoarseness was the primary outcome; severity of POST and voice hoarseness, patient satisfaction scores at 24 hours post-surgery and adverse events were secondary outcomes. Results: Overall, 86 patients were randomized and 43 patients were included in each group. Incidence of POST (%) and voice hoarseness (%) were 55.8, 55.6, 55.8, 53.4 and 30.2, 28, 28, 28 in group C. Incidence of POST (%) and voice hoarseness (%) were 37.2, 37.2, 37.2, 34.8 and 14, 14, 14,14 in group F at 1, 2, 6 and 24 hours, respectively, however, the p values were not found to be significant at any time interval. There was no significant difference in terms of severity of POST and voice hoarseness, patient satisfaction scores between the groups and there were no reported adverse events. Conclusions: In patients undergoing nasosinus surgery under general anesthesia with endotracheal intubation, fluticasone furoate-impregnated throat packs failed to show any significant reduction in the incidence and severity of POST as well as hoarseness of voice, and even though it was not statistically significant, the fluticasone impregnated group had higher patient satisfaction scores. Registration: CTRI ( CTRI/2020/09/027946; 22/09/2020).

Effects of ultrasound-guided stellate ganglion block on postoperative sore throat and postoperative sleep disturbance after lumbar spine surgery: a randomized controlled trial

BACKGROUND

Postoperative sore throat and sleep disturbance are prevalent among patients undergoing spinal surgery, and these conditions can substantially impact their postoperative satisfaction and quality of life. The present study aimed to examine the impact of ultrasound-guided stellate ganglion block (SGB) on the occurrence of postoperative sore throat (POST) and postoperative sleep disturbance (PSD) in patients who undergo lumbar spine surgery under general anesthesia.

METHODS

Sixty patients were randomly assigned to either the experimental group (SGB group) or the control group (CG). Both groups received the same induction and maintenance drugs. However, the SGB group received a right SGB under ultrasound guidance 15 min before anesthesia induction, while the CG did not receive any block anesthesia intervention before anesthesia induction. We monitored the incidence and severity of POST at 1, 6, 24, and 48 h after surgery in both groups. Additionally, we evaluated the deep sleep quality score on the first, second, and fifth days after surgery in both groups.

RESULTS

The incidence of POST at 1 h and 6 h after surgery was significantly lower in the SGB group (10.0% and 13.3%) than in the CG (43.3% and 36.7%) (P < 0.05). The postoperative sore throat scores of the SGB group (0.10 ± 0.31 and 0.17 ± 0.46) at 1 h and 6 h after surgery were lower than those of the CG (0.57 ± 0.73 and 0.50 ± 0.77) (P < 0.05). Moreover, the deep sleep quality score on the first, second, and fifth days after surgery were significantly higher in the CG (5.40 ± 3.37, 4.70 ± 3.19, 4.53 ± 3.44) than in the SGB group (3.87 ± 2.30, 3.13 ± 1.77, 3.03 ± 1.84) (P < 0.05).

CONCLUSION

Ultrasound-guided SGB can reduce the incidence and severity of POST and improve PSD in patients undergoing lumbar spine surgery.

TRIAL REGISTRATION

This study was registered on Chinese Clinical Trial Registry, (ChiCTR2200065279) on 01/11/2022.

Effect of superior laryngeal nerve block in alleviating sore throat after application of i-gel supraglottic airway: a randomized controlled trial

BACKGROUND

Postoperative sore throat (POST) is a common complaint after supraglottic airway device (SAD) application. Internal branch of the superior laryngeal nerve (iSLN) block has the potential to alleviate POST. The aim of this trial was to explore the effect of iSLN block in alleviating sore throat, as well as to identify the potential risk factors for POST after SAD insertion.

METHODS

One hundred thirty-four patients scheduled for elective gynecological surgery were randomized to either group T: tetracaine syrup (1%) for local lubrication on i-gel supraglottic device (n = 67) or group B: i-gel insertion with water based lubricant on it and followed by bilateral iSLN block (ropivacaine, 0.375%, 2 ml for each side) (n = 67). Under ultrasound guidance, iSLN was exposed below thyrohyoid membrane. The primary outcome was the intensity of sore throat at 6 h after surgery. In addition, POST score at 0.5 h and 24 h, the severity of postoperative swallowing discomfort, acoustic analysis and complications were measured.

RESULTS

Compared with tetracaine syrup for local lubrication, iSLN block resulted in a reduced intensity of POST at 0.5 h (P = 0.044, OR = 1.99, 95%CI 1.02 to 3.88) and 6 h (P < 0.001, OR = 5.07, 95%CI 2.53 to 10.14) after surgery, as well as less severity of swallowing discomfort (P < 0.001, OR = 2.21, 95%CI 1.63 to 2.99) and cough (P = 0.039, OR = 1.97, 95%CI 1.04 to 3.73). The patients after iSLN block presented lower jitter and shimmer value in acoustic analysis at 6 h after surgery (P < 0.001).

CONCLUSIONS

iSLN block was effective in alleviating POST, improving voice function, as well as reducing postoperative swallowing discomfort and coughing.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2000037974) on 8th Sept 2020.

Alkalized lidocaine in a tapered cuff suppresses endotracheal tube-induced hemodynamic changes: a randomized controlled trial

PURPOSE

The use of an endotracheal tube (ET) cuff filled with alkalized lidocaine (AL) can suppress ET-induced emergence phenomena, such as hypertension, tachycardia and coughing, and postoperative sore throat (POST) and hoarseness (PH). The efficacy of intracuff lidocaine may vary depending on the cuff shape, but there has been no study on the effects of a tapered cuff filled with AL. We examined whether intracuff AL suppresses ET-induced emergence phenomena, POST and PH.

METHODS

Sixty-two patients were enrolled in this study and the patients were randomly allocated to a group in which the tapered cuff was filled with AL (Group AL) and a group in which the tapered cuff was filled with normal saline (Group S). The primary outcomes of this study were changes in mean blood pressure (MBP) and heart rate (HR) at extubation. MBP, HR and the number of coughs were recorded before and up to 10 min after extubation. The degree of POST and the incidences of POST and PH were recorded at 15 min, 2 h and 24 h after extubation.

RESULTS

Changes in MBP before extubation and HR before and after extubation were significantly lower in Group AL than in Group S (p < 0.025). The number of coughs at extubation and the incidence of PH at 2 h after extubation were significantly lower in Group AL than in Group S (p < 0.0001 and p = 0.014, respectively).

CONCLUSION

AL in a tapered cuff significantly suppresses ET-induced cardiovascular changes in MBP and HR.

Combined use of the ProSeal laryngeal mask airway and a bronchial blocker vs. a double-lumen endobronchial tube in thoracoscopic surgery: A randomized controlled trial

STUDY OBJECTIVE

The combined use of the ProSeal laryngeal mask airway and a bronchial blocker may reduce postoperative hoarseness and sore throat. We aimed to test the feasibility and efficacy of this combination technique in thoracoscopic surgery.

DESIGN

A single-center, patient-assessor blinded, randomized controlled trial.

SETTING

Nagoya City University Hospital (between November 2020 and April 2022).

PATIENTS

A total of 100 adult patients undergoing lobectomy or segmentectomy by video- or robotic-assisted thoracoscopic surgery.

INTERVENTIONS

Patients were randomly assigned to either group using a combination of the ProSeal laryngeal mask airway and a bronchial blocker (pLMA+BB group) or a double-lumen endobronchial tube (DLT group).

MEASUREMENTS

The primary outcome was the hoarseness incidence on 1-3 postoperative days. Secondary outcomes included sore throat, intraoperative complications (hypoxemia, hypercapnia, surgical interruption, malposition of devices, unintended lung expansion, and ventilatory difficulty), lung collapse, device placement-related outcomes, and coughing during emergence.

MAIN RESULTS

A total of 100 patients underwent randomization (51 to the pLMA+BB group and 49 to the DLT group). After drop outs, a total of 49 patients in each group were analyzed per-protocol. The incidences of hoarseness in the pLMA+BB and DLT groups were 42.9% and 53.1% (difference, -10.2%; 95% confidence interval, -30.1% to 10.3%; p = 0.419), 18.4% vs. 32.7%, and 20.4% vs. 24.5% on postoperative day 1, 2, and 3, respectively. The incidences of sore throat in the pLMA+BB and DLT groups were 16.3% vs. 34.7% (difference, -18.4%; 95% confidence interval, -35.9% to -0.9%; p = 0.063) on postoperative day 1. In the pLMA+BB group, more intraoperative complications and less coughing during emergence were observed compared to the DLT group. Lung collapse and placement-related outcomes were comparable between the groups.

CONCLUSIONS

The combination of ProSeal laryngeal mask airway and bronchial blocker did not significantly reduce hoarseness compared to the double-lumen endobronchial tube.

Study protocol for controlled human infection for penicillin G against Streptococcus pyogenes: a double-blinded, placebo-controlled, randomised trial to determine the minimum concentration required to prevent experimental pharyngitis (the CHIPS trial)

INTRODUCTION

Regular intramuscular benzathine penicillin G injections have been the cornerstone of rheumatic heart disease (RHD) secondary prophylaxis since the 1950s. As the pharmacological correlate of protection remains unknown, it is difficult to recommend changes to this established regimen. Determining the minimum effective penicillin exposure required to prevent Streptococcus pyogenes infection will accelerate development of new long-acting penicillins for RHD prevention as well as inform opportunities to improve existing regimens. The CHIPS trial will address this knowledge gap by directly testing protection afforded by different steady state plasma concentrations of penicillin in an established model of experimental human S. pyogenes pharyngitis.

METHODS AND ANALYSIS

This is a double-blinded, placebo-controlled, randomised experimental human infection study. Sixty healthy adult volunteers aged 18-40 years will be recruited and randomised 1:1:1:1:1 to continuous intravenous penicillin infusions targeting five different steady state plasma concentrations of 0 (placebo), 3, 6, 12 and 20 ng/mL via a midline catheter. Each participant's penicillin pharmacokinetic parameters will be established prior to the challenge, to ensure accurate dosing for the continuous infusion. Following the challenge with a well-characterised strain of S. pyogenes, participants will be observed for up to 6 days for the development of pharyngitis and treated with antibiotics prior to discharge. The primary objective is to determine the minimum effective steady-state plasma penicillin concentration required to prevent experimental pharyngitis. Secondary objectives will explore systemic and mucosal immunoinflammatory responses during pharyngitis, bacterial colonisation dynamics, environmental contamination and qualitative evaluation of the participant experience.

ETHICS AND DISSEMINATION

Ethical approval has been obtained (Bellberry Human Research Ethics Committee). Findings will be reported in peer-reviewed publications and presented at national/international stakeholder forums.

TRIAL REGISTRATION NUMBER

ACTRN12621000751875.

Suction Catheter-Guided Technique of ProSeal™ Laryngeal Mask Airway Insertion has a Lower Incidence of Trauma and Sore Throat Compared With a Standard Introducer Tool: A Randomized Controlled Trial

ProSeal laryngeal mask airway (PLMA) insertion is often difficult. Suction catheter-guided PLMA insertion was compared with the standard introducer tool-assisted technique. One hundred sixty female patients undergoing laparoscopic gynecologic procedures under general anesthesia were randomized into two groups-the suction catheter group (Group SC) and the introducer tool group (Group IT). First-attempt success rate, insertion time, manipulation required, incidence of trauma, and incidence and severity of throat discomfort were compared. PLMA was inserted successfully in the first attempt in 72 of 80 patients in Group SC and in 67 of 80 patients in Group IT (P = .241). Time for successful insertion was 17.31 ± 6.50 seconds in Group SC and 22.65 ± 7.17 seconds in Group IT (P = .001). Manipulation to get a proper fit was required in 9 of 80 patients in Group SC compared with 19 of 80 patients in Group IT (P = .037). Minor airway trauma was noted in 11% of patients in Group SC and 28% of patients in Group IT (P = .001). The incidence and severity of sore throat was significantly lower with the suction catheter than with the introducer tool. Suction catheter-guided PLMA insertion requires less time, fewer manipulations, and results in lower incidence and severity of sore throat than with the introducer tool. Both techniques have a similar first-attempt success rate.

The effectiveness of acupuncture point stimulation for the prevention of postoperative sore throat: A meta-analysis

BACKGROUND

Enhanced recovery pathways can be further improved for postoperative sore throat (POST) that occurs after surgery under general anesthesia. Medications have shown some effectiveness in preventing POST, but acupuncture or related techniques with better safety and lower cost can be used as an alternative or adjuvant therapy to treat perioperative symptoms by stimulating acupuncture point (acupoint). Therefore, we aimed to conduct a meta-analysis to assess whether acupoint stimulation helps patients prevent POST in adults undergoing tracheal intubation for general anesthesia.

METHODS

Publications in PubMed, the Cochrane Central Register, ScienceDirect, and ClinicalTrial.gov were surveyed from January 2000 through August 2020. Studies that compared interventions between true acupoint stimulation and no or sham acupoint stimulation were included. The primary outcomes were the incidence and severity of POST at 24h.

RESULTS

Four randomized control trials and 1 comparative study involving 1478 participants were included. Compared with the no or sham acupoint stimulation, the true acupoint stimulation was associated with a reduced incidence (risk ratio, 0.32; 95% confidence interval (CI), 0.18-0.55; P < .001) and decreased severity (standardized mean difference, -2.79; 95% CI, -4.59 to - 0.99; P = .002) of POST. There were no significant adverse events related to acupoint stimulation. The finding for POST was assured by subgroup, sensitivity, and trial sequential analyses.

CONCLUSIONS

Acupoint stimulation may reduce the occurrence of POST. It can be considered as one of nonpharmacological methods to prevent POST in enhanced recovery pathways. Further rigorous studies are needed to determine the effectiveness of acupoint stimulation.

[Effect of dexamethasone combined with oxybuprocaine hydrochloride gel on prevention of postoperative sore throat after nasal endoscopy]

OBJECTIVE

To explore the effectiveness and feasibility of dexamethasone combined with oxybuprocaine hydrochloride gel on the prevention of postoperative sore throat after nasal endoscopy.

METHODS

In the study, 60 patients with American Society of Anesthesiologist (ASA) physical statuses Ⅰ to Ⅱ, aged 18 to 72 years, scheduled for elective nasal endoscope surgery under general anesthesia requiring endotracheal intubation were randomly divided into dexamethasone combined with oxybuprocaine hydrochloride gel group (G group, n=30) and control group (C group, n=30). The patients in the G group received dexamethasone 0.1 mg/kg before induction and the oxybuprocaine gel was applied to the endotracheal catheter cuff and the front end within 15 cm. The patients in the C group received the same dose of saline and the saline was applied to the endotracheal catheter cuff and the front end within 15 cm. Then, all the patients in the two groups received the same induction and anesthesia maintainance. The operation time, anesthesia time, emergence time, extubation time and departure time were recorded. The intraoperative infusion volume, blood loss volume, propofol, remifentanil, rocuronium dosage were also recorded. The adverse reactions such as intraoperative hypotension, bradycardia and postoperative agitation were recorded. The postoperative sore throat score was recorded at the end of operation and 4 h, 8 h, 12 h, and 24 h after operation.

RESULTS

Compared with the C group, the emergence time [(8.4±3.9) min vs. (10.8±4.7) min], extubation time [(8.8±3.7) min vs. (11.9±4.8) min], and departure time [(20.0±5.3) min vs. (23.0±5.8) min] were significantly shorter, and the propofol dosage [(11.8±1.8) mg/kg vs. (15.9±4.6) mg/kg], remifentanil dosage [(10.9±4.7) μg/kg vs. (14.1±3.6) μg/kg] were significantly less in the G group, and there was no difference of rocuronium dosage in the two groups. Compared with the C group the incidence of intraoperative hypotension [10%(3/30) vs. 30%(9/30)], bradycardia [16.7%(5/30) vs. 20%(6/30)] and postoperative agitation [6.7%(2/30) vs. 23.3%(7/30)] were significantly lower in the C group. The postoperative sore throat score at the end of operation, 4 h, 8 h, 12 h and 24 h after operation in the G group were significantly lower than in the C group respectively [0 (0, 1) vs. 1 (1, 2), 0 (0, 0) vs. 1 (1, 2), 0 (0, 0) vs. 1 (1, 2), 0 (0, 0) vs. 1 (0.75, 1), 0 (0, 0) vs. 1 (0, 1)].

CONCLUSION

Dexamethasone combined with oxybuprocaine hydrochloride gel was effective and feasible on the prevention of postoperative sore throat after nasal endoscopy.

The Comparison Between Supreme Laryngeal Mask Airway and Endotracheal Tube With Respect to Adequacy of Ventilation in Patients Undergoing Laparoscopic Cholecystectomy Under General Anesthesia-A Prospective, Randomized, Double-Blind Study, and Comparative Study

BACKGROUND

Laparoscopic cholecystectomy is a commonly performed surgical procedure. Most anesthesiologists advocate tracheal intubation. Laparoscopic cholecystectomy is becoming a day care surgery, hence many anaesthesiologists have started using laryngeal masks to decrease airway manipulation seen with conventional laryngoscopy and endotracheal intubation and avoid hemodynamic pressor responses and postoperative sore throat. The Supreme laryngeal mask airway (LMA) is an innovative, sterile, single use, supraglottic airway management device which provides access to and functional separation of the respiratory and digestive tracts. In this study, there are two objectives-(1) primary objective: to assess the adequacy of ventilation when using LMA-Supreme^(TM) (LMA-S) and endotracheal tube (ETT), and (2) secondary objective: the first is to give the time for achieving effective airway and number of attempts for securing airway. The second is to assess haemodynamic parameters (heart rate and blood pressure). The last is to show the incidence of gastric distension, regurgitation and postoperative sore throat.

METHODS

A total of 132 American Society of Anesthesiologists (ASA) I-II patients were randomly assigned to LMA-S and ETT for intraoperative ventilation. After induction of general anaesthesia, the device was inserted, correct placement was checked, and parameters were recorded. SPSS version 20.0 software (IBM Corp., Armonk, NY, USA) was used for statistical analysis. A P-value less than 0.05 is statistically significant.

RESULTS

Ventilatory parameters such as inspiratory and expiratory leak volumes, and peak airway pressure values were comparable between the groups throughout the entire time interval. The number of attempts for successful insertion were comparable, but the mean time required for achieving effective airway was significantly longer in ETT than LMA-S (25.2 ± 8.3 sec vs. 18.6 ± 5.1 sec, respectively [P ＜ 0.05]). There was no situation in which the patient from the LMA-S group had to be intubated. The haemodynamic responses to insertion, pneumoperitoneum inflation and deflation, and removal of the device were greater for the ETT than the LMA-S. There were no complications like gastric distension or regurgitation in either groups. The postoperative sore throat at 2 hours and 24 hours was significantly lower in group LMA-S than group ETT.

CONCLUSIONS

Positive pressure ventilation with a correctly placed LMA-S allows adequate pulmonary ventilation, without the untoward hemodynamic and postoperative adverse effects of endotracheal intubation, in laparoscopic cholecystectomy surgery.

OUP accepted manuscript

Background

Group A Streptococcus (GAS) causes superficial pharyngitis and skin infections as well as serious autoimmune sequelae such as acute rheumatic fever (ARF) and subsequent rheumatic heart disease. ARF pathogenesis remains poorly understood. Immune priming by repeated GAS infections is thought to trigger ARF, and there is growing evidence for the role of skin infections in this process.

Methods

We utilized our recently developed 8-plex immunoassay, comprising antigens used in clinical serology for diagnosis of ARF (SLO, DNase B, SpnA), and 5 conserved putative GAS vaccine antigens (Spy0843, SCPA, SpyCEP, SpyAD, Group A carbohydrate), to characterize antibody responses in sera from New Zealand children with a range of clinically diagnosed GAS disease: ARF (n = 79), GAS-positive pharyngitis (n = 94), GAS-positive skin infection (n = 51), and matched healthy controls (n = 90).

Results

The magnitude and breadth of antibodies in ARF was very high, giving rise to a distinct serological profile. An average of 6.5 antigen-specific reactivities per individual was observed in ARF, compared to 4.2 in skin infections and 3.3 in pharyngitis.

Conclusions

ARF patients have a unique serological profile, which may be the result of repeated precursor pharyngitis and skin infections that progressively boost antibody breadth and magnitude.

Comparison of Intracuff Pressure and Postoperative Sore Throat Following Use of Laryngeal Mask Airway Protector With or Without Nitrous Oxide Anesthesia

PURPOSE

In general anesthesia, the laryngeal mask airway (LMA) is a frequently used effective option. The effect of nitrous oxide on intracuff pressure of the LMA and postoperative sore throat is well known; however, there are no studies related to the second-generation LMA Protector. The purpose of this study was to determine the differences in intracuff pressure and postoperative sore throat, depending on the use of nitrous oxide during general anesthesia using the LMA Protector.

DESIGN

This randomized double-blind prospective study was conducted among 88 patients aged 20 to 70 years.

METHODS

The cuff pressure started with a baseline of 40 cm H₂O and was measured using a digital cuff pressure manometer for 30 minutes. Postoperative sore throat, dysphonia, dysphagia, and numeric rating scale scores were also recorded.

FINDINGS

Over time, the intracuff pressure of the nitrous oxide group increased significantly compared with that of the air group. Furthermore, postoperative sore throat and pharyngolaryngeal complications were not significantly different between the two groups.

CONCLUSIONS

Intracuff pressure of the LMA Protector increased during anesthesia using nitrous oxide. When the anesthesia time was less than 2 hours, however, there was no difference in postoperative sore throat.

Nebulized pharmacological agents for preventing postoperative sore throat: A systematic review and network meta-analysis

Postoperative sore throat is one of the most common complications following endotracheal intubation. Nebulization therapy, a preferable and safety method of drug delivery, has been shown to be effective in postoperative sore throat prevention in many studies. However, the relative efficacy of various nebulized agents remains unknown. In this review, we aimed to quantify and rank order the efficacy of available nebulized agents for various postoperative sore throat-related outcomes. A comprehensive literature search of PubMed, EMBASE, CENTRAL and Google Scholar was conducted to identify eligible studies from inception to 25 May 2020. Incidence of postoperative sore throat 1hour and 24hours postoperatively and severity of postoperative sore throat 24 hours postoperatively were the primary outcomes. We conducted a Bayesian network meta-analysis to combine direct and indirect evidence to estimate the relative effects between treatments as well as the probabilities of ranking for treatments based on their protective effects. We identified 32 trials assessing 6 interventions. Overall inconsistency and heterogeneity were acceptable. Nebulized corticosteroids, magnesium, and ketamine differed from non-analgesic methods on the three primary outcomes. Based on the surface under the cumulative ranking curve, nebulized corticosteroids ranked first in almost all outcomes among the nebulized drugs. Considering only high-quality and 2-arm design studies, nebulized corticosteroids still seemed best. In conclusion, prophylactic use of nebulized corticosteroids, magnesium, and ketamine can effectively prevent postoperative sore throat, and nebulized corticosteroids appears to be the overall best approach.

Postbiotics for Preventing and Treating Common Infectious Diseases in Children: A Systematic Review

Postbiotics have recently been tentatively defined as bioactive compounds produced during a fermentation process (including microbial cells, cell constituents and metabolites) that supports health and/or wellbeing. Postbiotics are currently available in some infant formulas and fermented foods. We systematically reviewed evidence on postbiotics for preventing and treating common infectious diseases among children younger than 5 years. The PubMed, Embase, SpringerLink, and ScienceDirect databases were searched up to March 2019 for randomized controlled trials (RCTs) comparing postbiotics with placebo or no intervention. Seven RCTs involving 1740 children met the inclusion criteria. For therapeutic trials, supplementation with heat-killed Lactobacillus acidophilus LB reduced the duration of diarrhea (4 RCTs, n = 224, mean difference, MD, -20.31 h, 95% CI -27.06 to -13.57). For preventive trials, the pooled results from two RCTs (n = 537) showed that heat-inactivated L. paracasei CBA L74 versus placebo reduced the risk of diarrhea (relative risk, RR, 0.51, 95% CI 0.37-0.71), pharyngitis (RR 0.31, 95% CI 0.12-0.83) and laryngitis (RR 0.44, 95% CI 0.29-0.67). There is limited evidence to recommend the use of specific postbiotics for treating pediatric diarrhea and preventing common infectious diseases among children. Further studies are necessary to determine the effects of different postbiotics.

Does tonsillectomy reduce medical care visits for pharyngitis/tonsillitis in children and adults? Retrospective cohort study from Sweden

OBJECTIVE

To assess the effectiveness of tonsillectomy/adenotonsillectomy in reducing medical care visits for pharyngitis or tonsillitis in children and adults with chronic/recurrent tonsillitis.

DESIGN

Retrospective cohort study.

SETTING

Data were retrieved from the VEGA register, a comprehensive regional cohort in Sweden.

PARTICIPANTS

1044 children (<15 years) and 2244 adults.

INTERVENTION

Tonsillectomy/adenotonsillectomy compared with no surgical treatment.

MAIN OUTCOME MEASURES

Changes in yearly mean rates of medical care visits due to pharyngitis/tonsillitis.

RESULTS

In children, there was a significant decrease in the yearly mean medical care visits rate from 1.93 (1.82 to 2.04) before surgery to 0.129 (0.099 to 0.165) after surgery, with a mean change of -1.80 (-1.90 to -1.69), p<0.0001. In patients who did not undergo surgery, the corresponding mean change was -1.51 (-1.61 to -1.41), resulting in a mean difference in the change in visit rates between the intervention and control groups of -0.283 (-0.436 to -0.135), p=0.0002. In adults, a significant decrease in the yearly mean medical care visit rate was observed from 1.45 (1.39 to 1.51) before surgery to 0.152 (0.132 to 0.173) after surgery, with a mean change of -1.30 (-1.36 to -1.24), p<0.0001, compared with -1.18 (-1.24 to -1.13) in the control group. The difference in the change in yearly mean visit rate between the surgical and non-surgical groups was -0.111 (-0.195 to -0.028), p=0.0097. The subgroup analysis showed a greater effect of surgery in children, in patients with a higher number of medical care visits before surgery and in the first year of follow-up.

CONCLUSION

In this cohort of patients moderately or less affected with chronic/recurrent tonsillitis, the effectiveness of tonsillectomy/adenotonsillectomy in reducing medical care visits for pharyngitis and tonsillitis compared with no surgical treatment was low and of questionable clinical value.

An Experimental Group A Streptococcus Vaccine That Reduces Pharyngitis and Tonsillitis in a Nonhuman Primate Model

Group A Streptococcus (GAS) infections account for an estimated 500,000 deaths every year. This bacterial pathogen is responsible for a variety of mild and life-threatening infections and the triggering of chronic autoimmune sequelae. Pharyngitis caused by group A Streptococcus (GAS), but not asymptomatic GAS carriage, is a prerequisite for acute rheumatic fever (ARF). Repeated bouts of ARF may trigger rheumatic heart disease (RHD), a major cause of heart failure and stroke accounting for 275,000 deaths annually. A vaccine that prevents pharyngitis would markedly reduce morbidity and mortality from ARF and RHD. Nonhuman primates (NHPs) have been utilized to model GAS diseases, and experimentally infected rhesus macaques develop pharyngitis. Here we use an NHP model of GAS pharyngitis to evaluate the efficacy of an experimental vaccine, Combo5 (arginine deiminase [ADI], C5a peptidase [SCPA], streptolysin O [SLO], interleukin-8 [IL-8] protease [SpyCEP], and trigger factor [TF]), specifically designed to exclude GAS components potentially linked to autoimmune complications. Antibody responses against all Combo5 antigens were detected in NHP serum, and immunized NHPs showed a reduction in pharyngitis and tonsillitis compared to controls. Our work establishes the NHP model as a gold standard for the assessment of GAS vaccines.IMPORTANCE GAS-related diseases disproportionally affect disadvantaged populations (e.g., indigenous populations), and development of a vaccine has been neglected. A recent strong advocacy campaign driven by the World Health Organization and the International Vaccine Institute has highlighted the urgent need for a GAS vaccine. One significant obstacle in GAS vaccine development is the lack of a widely used animal model to assess vaccine efficacy. Researchers in the field use a wide range of murine models of infection and in vitro assays, sometimes yielding conflicting results. Here we present the nonhuman primate pharyngeal infection model as a tool to assess vaccine-induced protection against colonization and clinical symptoms of pharyngitis and tonsillitis. We have tested the efficacy of an experimental vaccine candidate with promising results. We believe that the utilization of this valuable tool by the GAS vaccine research community could significantly accelerate the realization of a safe and effective GAS vaccine for humans.

The influence of high-dose intraoperative remifentanil on postoperative sore throat: a prospective randomized study: A CONSORT compliant article

BACKGROUND

Endotracheal intubation for general anesthesia causes postoperative sore throat (POST). This study is designed to evaluate the effect of high-dose remifentanil on the incidence of POST in patients after general anesthesia.

METHODS

Ninety-two patients scheduled for orthopedic lower extremity surgery under general anesthesia were randomly assigned into 1 of 2 groups. In the high-dose remifentanil (HR) group (n = 46), remifentanil was infused at a rate of 0.25 μg/kg/min and subsequently increased or decreased by 0.05 μg/kg/min per clinical demand. In the low-dose remifentanil (LR) group (n = 46), remifentanil was infused at a rate of 0.05 μg/kg/min. The incidence of POST was monitored at 0, 2, 4, and 24 hours postoperatively. Complications regarding opioids were compared between groups.

RESULTS

The overall incidence of POST was higher in the HR group compared with that in the LR group [33 (72%) vs 18 (39%), P = .022]. The incidence of POST at 0, 2, and 24 hours after surgery was higher in the HR group compared with that in the LR group (P < .001, P = .001, and P = .001, respectively). The incidence of postoperative nausea, vomiting, drowsiness, and headache was similar between the groups. The incidence of postoperative shivering was higher in the HR group than in the LR group [10 (22%) vs 2 (4%), difference 17%, 95% CI 2%-33%, P = .027].

CONCLUSION

A relatively large dose of intraoperative remifentanil increased the incidence of POST in patients for orthopedic surgery under general anesthesia.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT03173339.

Maintaining endotracheal tube cuff pressure at 20 mmHg during anterior cervical spine surgery to prevent dysphagia: a double-blind randomized controlled trial

PURPOSE

Anterior cervical spine surgery is associated with postoperative dysphagia, sore throat and dysphonia. It is unclear, whether this is caused by increased endotracheal tube (ETT) cuff pressure after retractor placement. This study aims to assess the effect of ETT cuff pressure adjustment on postoperative dysphagia, sore throat and dysphonia.

METHODS

In this, single-centre, observer and patient-blinded randomized controlled trial patients treated with anterior cervical spine surgery were randomized to adjustment of the ETT cuff pressure to 20 mmHg after placement of the retractor versus no adjustment. Primary outcome was the incidence and severity of postoperative dysphagia. Secondary outcomes were sore throat and dysphonia. Outcomes were evaluated on day one and 2 months after the operation.

RESULTS

Of 177 enrolled patients, 162 patients (92.5%) could be evaluated. The incidence of dysphagia was 75.9% on day one and 34.6% 2 months after surgery. Dysphagia in the intervention and control group was present in 77.8% versus 74.1% of patients on day one (odds ratio (OR) 1.2, 95% confidence interval (CI) (0.6-2.5)) and 28.4% versus 40.7% of patients after 2 months (OR 0.6, 95% CI 0.3-1.1), respectively. Severity of dysphagia, sore throat and dysphonia was similar in both groups.

CONCLUSIONS

Anterior cervical spine surgery is accompanied by a high incidence of postoperative dysphagia, lasting until at least 2 months after surgery in over a third of our patients. Adjusting ETT cuff pressure to 20 mmHg after retractor placement, as compared to controls, did not lower the risk for both short- and long-term dysphagia. Netherlands National Trial Registry Number: NTR 3542. These slides can be retrieved under electronic supplementary material.

A method for addressing right upper lobe obstruction with right-sided double-lumen endobronchial tubes during surgery: a randomized controlled trial

BACKGROUND

A right-sided double-lumen tube (R-DLT) tends to obstruct the right upper lobe intraoperatively due to anatomical distortion during surgery. If the R-DLT is poorly matched with the patient's airway anatomy, it will not be possible to correctly replace the tube with a fiberoptic bronchoscope (FOB). In our study, we aimed to explore an efficient method for difficult repositioning caused by right upper lobe occlusion during surgery: repositioning the R-DLT from the right main bronchus into the left main bronchus. The current study was designed to assess the efficacy and safety of this method.

METHODS

Sixty adult patients scheduled to undergo left-sided thoracic surgery were randomly assigned to two groups. With the patient in the right lateral position during surgery, the R-DLT was pulled back to the trachea while being rotated 90° clockwise; it was then either rotated 90° clockwise for placement into the left main bronchus (Group L) or rotated 90° anticlockwise and returned to the right main bronchus (Group R) using FOB guidance. The primary outcomes included clinical performance, which was measured by intubation time, and the quality of lung collapse. A secondary outcome was safety, which was determined according to bronchial injury and vocal cord injury.

RESULTS

The median intubation time (IQR [range]) required for placement of a R-DLT into the left main bronchus was shorter than the time required for placement into the right main bronchus (15.0 s [IQR, 12.0 to 20.0 s]) vs 23.5 s [IQR, 14.5 to 65.8 s], P = 0.005). The groups showed comparable overall results for the quality of lung collapse during the total period of one-lung ventilation (P = 1.000). The numbers of patients with bronchial injuries or vocal cord injuries were also comparable between groups (Group R, 11/30 vs. Group L 8/30, P = 0.580 for bronchus injuries; Group R, 15/30 vs. Group L 13/30, P = 0.796 for vocal cord injuries).

CONCLUSIONS

Repositioning a R-DLT from the right main bronchus into the left main bronchus had good clinical performance without causing additional injury. This may be an efficient method for the difficult repositioning of a R-DLT due to right upper lobe occlusion during surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IPR-15006933 , registered on 15 August 2015.

Acute rheumatic fever

Acute rheumatic fever is caused by an autoimmune response to throat infection with Streptococcus pyogenes. Cardiac involvement during acute rheumatic fever can result in rheumatic heart disease, which can cause heart failure and premature mortality. Poverty and household overcrowding are associated with an increased prevalence of acute rheumatic fever and rheumatic heart disease, both of which remain a public health problem in many low-income countries. Control efforts are hampered by the scarcity of accurate data on disease burden, and effective approaches to diagnosis, prevention, and treatment. The diagnosis of acute rheumatic fever is entirely clinical, without any laboratory gold standard, and no treatments have been shown to reduce progression to rheumatic heart disease. Prevention mainly relies on the prompt recognition and treatment of streptococcal pharyngitis, and avoidance of recurrent infection using long-term antibiotics. But evidence for the effectiveness of either approach is not strong. High-quality research is urgently needed to guide efforts to reduce acute rheumatic fever incidence and prevent progression to rheumatic heart disease.

Optimal dose of succinylcholine for laryngeal mask airway insertion: systematic review, meta-analysis and metaregression of randomised control trials

OBJECTIVES

To evaluate the optimal dose of succinylcholine for laryngeal mask airway (LMA) insertion and all related morbidities.

DESIGN

Systematic review, meta-analysis and metaregression of randomised controlled trials (RCTs).

DATA SOURCE AND STUDY ELIGIBILITY CRITERIA

A comprehensive search of RCTs in the PubMed, Embase, the Cochrane Library and the ClinicalTrials.gov registry up to July 2016 and articles that evaluated the use of succinylcholine chloride for LMA insertion were included in the analyses. The relative risk (RR) and the corresponding 95% CIs were determined.

INTERVENTION

Succinylcholine as the coinduction agent and the doses were divided into mini (≤0.3 mg/kg) and low (0.3-1.0 mg/kg) doses for dose-dependent effect analyses.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was the first-attempt LMA insertion failure rate. Secondary outcomes included all related adverse events.

RESULTS

Data from 10 RCTs comprising 625 participants showed that succinylcholine reduced the first-attempt LMA insertion failure rate (RR, 0.22; 95% CI 0.12 to 0.43), coughing and gagging (RR, 0.26; 95% CI 0.15 to 0.45) and laryngospasm (RR, 0.14; 95% CI 0.05 to 0.39). The use of succinylcholine did not result in a significant increase of postoperative myalgia (RR, 2.58; 95% CI 0.79 to 8.44) and did not reduce the risk of postoperative sore throat (RR, 0.76; 95% CI 0.55 to 1.03). Subgroup analysis further showed that low-dose succinylcholine reduced the LMA insertion failure rate and its related coughing and gagging when compared with mini dose.

CONCLUSION

The use of succinylcholine compared with none can facilitate LMA insertion and reduce insertion-related reflexes without significant postoperative myalgia. However, additional prospective studies with a larger sample size are required to fully evaluate the dose-dependent effect and complications of succinylcholine for LMA insertion.

Preventive Effect of Cow's Milk Fermented with Lactobacillus paracasei CBA L74 on Common Infectious Diseases in Children: A Multicenter Randomized Controlled Trial

Background: Fermented foods have been proposed to prevent common infectious diseases (CIDs) in children attending day care or preschool. Objectives: To investigate the efficacy of dietary supplementation with cow’s skim milk fermented with the probiotic Lactobacillus paracasei CBA L74 in reducing CIDs in children attending day care or preschool. Methods: Multicenter, randomized, double-blind, placebo-controlled trial on healthy children (aged 12–48 months) consuming daily 7 grams of cow’s skim milk fermented with L. paracasei CBA L74 (group A), or placebo (maltodextrins group B) attending day care or preschool during the winter season. The main outcome was the proportion of children who experienced ≥1 episode of CID during a 3-month follow-up. Fecal biomarkers of innate (α- and β-defensins, cathelicidin) and acquired immunity (secretory IgA) were also monitored. Results: A total of 126 children (71 males, 56%) with a mean (SD) age of 33 (9) months completed the study, 66 in group A and 60 in group B. At intention to treat analysis, the proportion of children presenting ≥1 CID was 60% in group A vs. 83% in group B, corresponding to an absolute risk difference (ARD) of −23% (95% CI: −37% to −9%, p < 0.01). At per-protocol-analysis (PPA), the proportion of children presenting ≥1 CID was 18% in group A vs. 40% in group B, corresponding to an absolute risk difference (ARD) of −22% (95% CI: −37% to −6%, p < 0.01). PPA showed that the proportion of children presenting ≥1 acute gastroenteritis (AGE) was significantly lower in group A (18% vs. 40%, p < 0.05). The ARD for the occurrence of ≥1 AGE was −22% (95% CI: −37% to −6%, p < 0.01) in group A. Similar findings were obtained at PPA regarding the proportion of children presenting ≥1 upper respiratory tract infection (URTI), which was significantly lower in group A (51% vs. 74%, p < 0.05), corresponding to an ARD of −23% (95% CI: −40% to −7%, p < 0.01). Significant changes in innate and acquired immunity biomarkers were observed only in subjects in group A. Conclusions: Dietary supplementation with cow’s skim milk fermented with L. paracasei CBA L74 is an efficient strategy in preventing CIDs in children.

Comparing the effectiveness of Betamethasone Gel with Lidocaine Gel local application on endotracheal tube in preventing post-operative sore throat (POST)

OBJECTIVE

To see whether betamethasone gel or lidocaine gel is superior in reducing the incidence of post-operative sore throat after tracheal extubation.

METHODS

This clinical study was conducted at the Nishtar Hospital and Medical College, Multan, Pakistan, from July to December 2015, and comprised patients who were set to undergo elective surgery under general anaesthesia. The patients were divided into two equal groups. In group 1, endotracheal tube was lubricated with betamethasone gel (0.05%). In group 2, endotracheal tube was lubricated with 4.0% lidocaine gel. SPSS 20 was used for data analysis. Generalised estimating equation was used to see the association between the treatment methods and severity of sore throat over time.

RESULTS

Of the 120 patients, there were 60(50%) each in the two groups. The mean intubation time was 5.58±1.31 hours in group 1and 5.43±1.21 hours in group 2. Besides, 7(11.7%) patients developed mild sore throat and 3(5.0%) moderate sore throat in group 1,whereas 13(21.7%) patients developed mild sore throat, 7(11.6%) moderate and 2(3.3%) severe sore throat after one hour of extubation (p=0.04). After 6 hours, there were 2(3.3%) patients with moderate and 1(1.7%) with severe sore throat in group 1 compared to 8(13.3%) with moderate and 4(6.7%) with severe sore throat in group 2. After 24 hours,5(8.3%) patients developed mild and 2(3.3%) moderate sore throat in group 1 compared to 14(23.7%) patients with mild sore throat, 5(8.5%) with moderate and 1(1.7%) with severe throat in group 2. Generalised estimating equation analysis showed a significant positive association between application of lidocaine gel on endotracheal tube and severity of sore throat (p<0.001).

CONCLUSIONS

Local application of betamethasone gel was associated with reduced risk of post-operative sore throat as compared to local application of lidocaine gel on the endotracheal tube.

Effect of administration of Streptococcus salivarius K12 on the occurrence of streptococcal pharyngo-tonsillitis, scarlet fever and acute otitis media in 3 years old children

OBJECTIVE

Streptococcus salivarius K12 (BLIS K12) is a probiotic strain strongly antagonistic to the growth of Streptococcus pyogenes, the most important bacterial cause of pharyngeal infections in humans. Shown to colonize the oral cavity and to be safe for human use, BLIS K12 has previously been reported to reduce pharyngo-tonsillitis episodes in children or adults known to have experienced recurrent streptococcal infection. The present study was focussed upon evaluating the role of BLIS K12 in the control of streptococcal disease and acute otitis media in children attending the first year of kindergarten.

PATIENTS AND METHODS

By randomization, 222 enrolled children attending the first year of kindergarten were divided into a treated group (N = 111) receiving for 6 months a daily treatment with BLIS K12 (Bactoblis®) and a control group (N = 111) who were monitored as untreated controls. During the 6 months of treatment and 3 months of follow-up, the children were evaluated for treatment tolerance, and for episodes of streptococcal pharyngo-tonsillitis, scarlet fever and acute otitis media.

RESULTS

During the 6-month trial (N = 111 per group) the incidence of streptococcal pharyngo-tonsillitis, scarlet fever and acute otitis media was approximately 16%, 9% and 44% respectively in the treated group and 48%, 4% and 80% in the control group. During the 3-months follow-up (N = 29 per group) the corresponding rates of infection were 15%, 0% and 12% in the treated group and 26%, 6% and 36% in the controls. No apparent side effects were detected in the treated group either during treatment or follow-up. All of the enrolled children completed the study.

CONCLUSIONS

The daily administration of BLIS K12 to children attending their first year of kindergarten was associated with a significant reduction in episodes of streptococcal pharyngitis and acute otitis media. No protection against scarlet fever was detected.

[Efficacy of bFGF atomization inhalation on postoperative sore throat following oral and maxillofacial surgery under general anesthesia]

PURPOSE

To observe the effect of recombinant human basic fibroblast growth factor (bFGF) atomization inhalation on postoperative sore throat following oral and maxillofacial operation under general anethesia.

METHODS

Forty patients in whom oral and maxillofacial operation trachea was removed under general anesthesia were randomly divided into treatment and control groups; the treatment group received bFGF 35000IU + normal saline 20 mL, compression inhalation, day 1, every 20min, continued for 3 d; the control group was given normal saline 5 mL + dexamethasone 5 mg + gentamicin 80000 U + chymotrypsin 4000 U, compression inhalation, twice a day, every 20 min, continued for 3 d. Occurrence of postoperative sore throat 12 h after operation was recorded and visual analog scale (VAS) of sore throat (swallowing) 12,24,48,72 h after operation was measured. SPSS l4.0 software package was used for statistical analysis.

RESULTS

The incidence of sore throat in the treatment group was significantly lower than that in the control group (P<0.01) 12 h after operation; sore throat (swallowing) VAS 12,24,48 and 72 h after operation in the treatment group were significantly lower than that in the control group (P<0.05).

CONCLUSIONS

bFGF atomization inhalation can reduce the incidence of sore throat and sore throat level in oral and maxillofacial surgery after endotracheal intubation.

Inside-Out Complete Tonsillectomy: Extended Intracapsular Tonsillectomy for Severe Sore Throat

Objectives:

This consecutive case series is presented to describe inside-out complete tonsillectomy and to assess its effects on postoperative pain and bleeding and its initial effectiveness in controlling recurrent sore throat and peritonsillar abscess formation.

Methods:

Bipolar electrosurgical scissors are used for bloodless resection of 90% of the tonsillar mass. During controlled resection, tonsil tissue is intentionally left at the superior and inferior poles and at the deepest part of the tonsillar fossa to provide coverage for nutrient arteries and the tonsillar plexus of veins. This tissue is then electrodesiccated and removed under direct vision and indirect mirror guidance to achieve complete tonsillectomy.

Results:

One hundred eighty-three consecutive tonsillectomies were performed by a single surgeon in a 16-month period, 47 of which were for the indication of recurrent sore throat (44) or recurrent peritonsillar abscess (3). Among these 47 children, there were 2 readmissions for dehydration. There were no immediate or delayed bleeding episodes. The average child required 4 days of narcotic pain medication. The mean annualized number of severe sore throats decreased from 5.24 before operation to 0.36 after operation (p <.0001, Student's paired t-test). There were no recurrent peritonsillar abscesses.

Conclusions:

Inside-out complete tonsillectomy achieves the surgical goal of complete tonsillectomy with the smallest possible wound and minimal injury to the surrounding tissue. The perioperative morbidity is markedly decreased compared to that of historical controls. The initial results suggest effectiveness similar to that of extracapsular tonsillectomy.

Lidocaine for preventing postoperative sore throat

BACKGROUND

Sore throat is a common side-effect of general anaesthesia and is reported by between 30% and 70% of patients after tracheal intubation. The likelihood of a sore throat varies with the type, diameter, and cuff pressure of the endotracheal tube used. If intubation is essential, it may be helpful to give drugs prophylactically to alleviate postoperative sore throat. Local anaesthetics and steroids have been used for this purpose. This review was originally published in 2009 and was updated in 2015.

OBJECTIVES

The objective of this review was to evaluate the efficacy and any harm caused by topical and systemic lidocaine used prophylactically to prevent postoperative sore throat in adults undergoing general anaesthesia with endotracheal intubation.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library 2013, Issue 9), MEDLINE (January 1966 to October 2013), and EMBASE (1980 to October 2013). We also contacted manufacturers and researchers in the field. The original search was undertaken in June 2007. We reran the search in February 2015 and found four studies of interest. We will deal with those studies when we next update the review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of topical and systemic prophylactic lidocaine therapy versus control (using air or saline) that reported on the risk and severity of postoperative sore throat as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information, such as the risk of any adverse effects.

MAIN RESULTS

We included 19 studies involving 1940 participants in this updated review. Of those 1940 participants, 952 received topical or systemic lidocaine therapy and 795 were allocated to the control groups. Topical and systemic lidocaine therapy appeared to reduce the risk of postoperative sore throat (16 studies, 1774 participants, risk ratio (RR) was 0.64 (95% confidence interval (CI) 0.48 to 0.85), the quality of the evidence was low), although when only high-quality trials were included (eight studies, 814 participants) the effect was no longer significant (RR 0.71, 95% CI 0.47 to 1.09). Lidocaine given systemically in two studies (320 participants) did not reveal evidence of an effect (RR 0.44, 95% CI 0.19 to 1.05 ). The severity of sore throat as measured on a visual-analogue scale (VAS) was reduced by lidocaine therapy (six trials, 611 participants, (mean difference (MD) -10.80, 95% CI -14.63 to -6.98). The adverse effects of lidocaine were not reported in these studies, though toxicity is generally rare.

AUTHORS' CONCLUSIONS

In our revised systematic review, although the results of included studies show generally positive results, they should be interpreted carefully. The effect size of lidocaine appeared to be affected by study quality; drug concentration; route of administration; management of cuff pressure during anaesthesia; the included population; and the type of outcome measured.

Antibiotics for preventing recurrent sore throat

BACKGROUND

Antibiotics are sometimes used to prevent recurrent sore throat, despite concern about resistance. However, there is conflicting primary evidence regarding their effectiveness.

OBJECTIVES

To assess the effects of antibiotics in patients with recurrent sore throat.

SEARCH METHODS

The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co-ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 June 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of antibiotics in adults and children suffering from pre-existing recurrent sore throat, defined as three or more sore throats in a year, examining the incidence of sore throat recurrence, with follow-up of at least 12 months post-antibiotic therapy.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Multiple attempts to contact the authors of one study yielded no response.

MAIN RESULTS

We identified no trials that met the inclusion criteria for the review. We discarded the majority of the references retrieved from our search following screening of the title and abstract. We formally excluded four studies following review of the full-text report.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effectiveness of antibiotics for preventing recurrent sore throat. This finding must be balanced against the known adverse effects and cost of antibiotic therapy, when considering antibiotics for this purpose. There is a need for high quality RCTs that compare the effects of antibiotics versus placebo in adults and children with pre-existing recurrent sore throat on the following outcomes: incidence of sore throat recurrence, adverse effects, days off work and absence from school, and the incidence of complications. Future studies should be conducted and reported according to the CONSORT statement.

Dexamethasone for the prevention of postoperative sore throat: a systematic review and meta-analysis

STUDY OBJECTIVE

To determine the antiemetic efficacy of dexamethasone in the prevention of postoperative sore throat (POST) and postoperative hoarseness (PH).

DESIGN

Meta-analysis.

SETTING

Metropolitan university medical center.

MEASUREMENTS

This systematic review and meta-analysis was conducted and reported in agreement with the PRISMA guideline. We searched online databases of MEDLINE (from 1966 to August 2013), EMBASE (from 1982 to August 2013), Google Scholar, and the Cochrane Database of Systematic Review. Relative ratios (RRs) and 95% confidence interval (CI) were calculated.

RESULTS

Four trials with a total of 480 patients were included for the analysis: 283 received prophylactic dexamethasone and 197 received placebo. Pooled result by random-effects model showed that dexamethasone significantly decreased the incidence of POST at 1 hour (RR = 0.51, 95% CI 0.27-0.94, P = .03; P for heterogeneity = .0005, I(2) = 83%) and at 24 hour postextubation (RR = 0.46, 95% CI 0.26-0.79, P < .05; P for heterogeneity = .01, I(2) = 72%). Our analysis indicated that dexamethasone significantly decreased the incidence of PH at 1 hour (RR = 0.22, 95% CI 0.11-0.46, P < .01; P for heterogeneity = .48, I(2) = 0%), but did not affect the incidence of PH at 24 hours postextubation (RR = 0.67, 95% CI 0.37-1.20, P > .1; P for heterogeneity = .12, I(2) = 59%).

CONCLUSION

Our meta-analysis suggested that intravenous dexamethasone can effectively reduce the incidence of POST both at 1 and at 24 hours postextubation. In addition, the present study showed that prophylactic dexamethasone reduced the incidence of PH at 1 hours but not at 24 hours postextubation.

Novel preoperative pharmacologic methods of preventing postoperative sore throat due to tracheal intubation

Postoperative sore throat (POST) is usually self-limiting but was rated by patients as one of the top 10 most undesirable anesthetic outcomes. Pharmacologic interventions that have been suggested to decrease the incidence of POST include application of local anesthetics and corticosteroids to the cuff of the endotracheal tube. These interventions often require extra steps during induction of general anesthesia. We sought evidence for using nonsteroidal, nonlocal anesthetic, topical pharmacologic interventions conveniently implemented preoperatively to decrease the incidence of POST. One hundred seventeen potential evidence sources were located, with 11 randomized controlled trials meeting inclusion criteria. The evidence examined ketamine, aspirin, and azulene gargle; benzydamine gargle or oral spray; dexpanthenol pastilles; and lozenges containing amyl-m-cresol or magnesium. Although there were methodologic concerns with the studies, the evidence suggested that all the treatment medications decreased the incidence of POST at early and late intervals. The severity of POST was also typically reduced. Preoperative ketamine and aspirin gargle are probably the most promising for providers practicing in the United States. However, before these agents are recommended for general use, large multicenter trials should be done exploring not only efficacy but also dose-response relationships and side effects.

[Evaluation of factors associated with postoperative sore throat]

BACKGROUND

Postoperative sore throat should be recognized seriously as an avoidable complication because of high incidence and dissatisfaction with anesthesia. The aim of the study was to identify the risk factors of postoperative sore throats in patients undergoing general anesthesia.

METHODS

We retrospectively studied 1,733 patients (above 18 years of age) who had undergone general anesthesia from January to December 2010 and who had visited Department of Anesthesia, postoperative anesthesia clinic.

RESULTS

Age, ASA classification, position, airway device, methods of postoperative pain management and site of surgery were significantly identified as the associated factors for postoperative sore throat using univariate analysis. Under 65 year of age (odds ratio 2.3), operation of head and neck and pharynx (odds ratio 1.6), spine surgeries (odds ratio 0.33), laryngeal mask (odds ratio 0.47), and postoperative intravenous patient-controlled analgesia (IV-PCA, odds ratio 0.4) were significantly identified as the factors with multivariate studies.

CONCLUSIONS

Six associated factors for postoperative sore throat were identified in this study.

Lidocaine reduces endotracheal tube associated side effects when instilled over the glottis but not when used to inflate the cuff: A double blind, placebo-controlled, randomized trial

BACKGROUND

Tracheal intubation results in an alteration of the laryngeal mucosa which can lead to undesirable effects at emergence from anaesthesia. Local anesthetics, when administered topically, may represent an interesting alternative to reduce these side effects.

AIM

In this trial, we aimed to evaluate the effect of lidocaine in preventing tracheal intubation related side effects at emergence from anaesthesia, when instilled onto the glottis before intubation or used to inflate the endotracheal tube cuff.

METHODS

Eighty patients scheduled to elective surgery of less than 120 minutes under general anaesthesia were enrolled in this prospective, randomized, controlled, double blind study. As they receive instillation of 2% lidocaine or saline onto the glottis before intubation, and as they have their endotracheal tube cuff filled with 2% lidocaine or saline, the patients were randomized in four groups. S-S (Saline instillation and saline in the cuff); S-Lido (saline instillation and lidocaine in the cuff); Lido-S (lidocaine instillation and saline in the cuff); Lido-Lido (lidocaine instillation and lidocaine in the cuff). The primary outcome was the incidence of coughing before extubation. The secondary outcomes were sore throat scores at H1 and H24 postoperatively and incidence of dysphagia, dysphonia and laryngeal dyspnea during the first 24 hours.

RESULTS

Coughing occurred in 80%, 70%, 30% and 20% of patients in S-S, S-Lido, Lido-S and Lido-Lido groups respectively. When compared to S-S group, the incidence of coughing was significantly reduced in Lido-S and Lido-Lido groups but not in S-Lido group (p1=0.003; p2=0.0003; p3=0.7 respectively). Sore throat scores at H1 and H24 were significantly lower in Lido-S and Lido-Lido groups (p1=0.00002 and p2=0.01). There was no significant difference between groups regarding the incidence of dysphagia, dysphonia and laryngeal dyspnea.

CONCLUSION

When instilled onto the glottis before intubation, lidocaine reduced both the incidence of coughing and the severity of postoperative sore throat in surgery of less than 120 minutes. Intracuff lidocaine was not effective to reduce neither coughing nor sore throat severity.

Efficacy of benzydamine hydrochloride dripping at endotracheal tube cuff for prevention of postoperative sore throat

BACKGROUND

Postoperative sore throat (POST) is a frequent consequence following ETT intubation, which may negatively affect the postoperative course and patient satisfaction. Benzydamine hydrochloride is a topically-applied non-steroidal anti-inflammatory drug (NSAID). The authors evaluated the analgesic effect of benzydamine hydrochloride dripping on the ETT cuff on POST.

MATERIAL AND METHOD

Eighty-six patients participated in this randomized controlled trial. They were assigned into either the benzydamine hydrochloride or the control group. The whole ETT cuff was dripped either with 3 ml (4.5 mg) of benzydamine hydrochloride or nothing five minutes prior to anesthesia induction. The incidence and severity of POST at 0, 2, 4, 6, 12 and 24 hours postoperatively were assessed. The potential adverse effects of benzydamine hydrochloride (throat numbness throat burning sensation, dry mouth, and thirst) were also evaluated.

RESULTS

Twenty-five patients (58.14%) in each group had POST (p-value = 1). The severity of POST (calculated from affected patients) in both groups at different time points was not significantly different. Patients in the benzydamine hydrochloride group did not have a higher incidence of adverse effects.

CONCLUSION

We found that dripping benzydamine hydrochloride on the ETT cuff neither reduced the incidence of POST nor increased the incidence of adverse effects in comparison with no intervention.

Seven-year surveillance of emm types of pediatric Group A streptococcal pharyngitis isolates in Western Greece

Background

An experimental 26-valent M protein Group A streptococcal (GAS) vaccine has entered clinical studies. Pharyngeal GAS emm type surveillances in different areas and time-periods enhance the understanding of the epidemiology of GAS pharyngitis. Moreover, these surveillances, combined with the data on GAS invasive disease, can play a significant role in the formulation of multivalent type-specific vaccines.

Methods

During a 7-year period (1999–2005), 2408 GAS isolates were recovered from consecutive children with pharyngitis in Western Greece. The overall macrolide resistance rate was 22.8%. Along the study period we noted a tendency towards significantly decreased rates of resistance, with the lowest rates occurring in 2002 (15.3%), 2003 (15%) and 2004 (16.7%). A random sample of isolates from each year, 338 (61.7%) of the 548 macrolide-resistant and 205 (11%) of the macrolide-susceptible, underwent molecular analysis, including emm typing.

Results

The 543 typed isolates had 28 different emm types. A statistically significant association was found between macrolide resistance and emm4, emm22 and emm77, whereas emm1, emm3, emm6, emm12, emm87 and emm89 were associated with macrolide susceptibility. A significant yearly fluctuation was observed in emm4, emm28 and emm77. The most common macrolide-resistant GAS were emm77 isolates harboring erm(A), either alone or in combination with mef(A), emm4 carrying mef(A), emm28 possessing erm(B), emm75 carrying mef(A), emm12 harboring mef(A) and emm22 carrying erm(A). We estimated that 82.8% of the isolates belonged to emm types included in the novel 26-valent M protein vaccine. The vaccine coverage rate was determined mainly by the increased frequency of nonvaccine emm4 isolates.

Conclusions

A limited number of emm types dominated among macrolide-susceptible and macrolide-resistant GAS isolates. We observed seasonal fluctuations, which were significant for emm4, emm28 and emm77. This type of data can serve as baseline information if the novel 26-valent M protein GAS vaccine is introduced into practice.

Effect of preoperative licorice lozenges on incidence of postextubation cough and sore throat in smokers undergoing general anesthesia and endotracheal intubation

INTRODUCTION

Post-Operative Sore Throat (POST) is an undesirable side effect ofendotracheal intubation. Pharmacological and non-pharmacological measures have been utilized for minimizing the morbidity caused by POST. We have tested whether medicated lozenges of Licorice provides efficacy in decreasing POST in smokers presenting for surgery under general anesthesia with endotracheal intubation.

METHODS

100 patients, 20 - 65 years, American Society ofAnaesthesiologists (ASA) physical status Grade I & II, of either sex, with history of smoking, and posted for elective surgical procedure lasting more than one hour and requiring general anesthesia with endotracheal intubation were included and randomly divided into two groups (n = 50) to receive Licorice lozenges (Group A) and Sugar Candy (Group B). The patients were assessed for cough, sore throat and hoarseness of voice immediately after extubation and then at 30 min, 12 hrs and 24 hrs after extubation utilizing scoring system of Harding and McVey.

RESULTS

Overall incidence of postextubation cough was less in Group A (12 patients, 24%) compared to Group B (26 patients, 52%) (p = 0.002). Magnitude of sore throat (Grades 0/1/2/3) was seen in 48/2/0/0 patients (Group A) and 46/4/0/0 (Group B) at extubation (p = 0.40) and 34/16/0/0 (Group A) and 28/20/2/0 (Group B) at 30 min (p = 0.17). At 12 and 24 hours, the magnitudes of sore throats were 24/25/1/0 (Group A) & 12/38/0/0 (Group B) (p = 0.02) and 26/23/1/0 (Group A) & 15/35/0/0 (Group B) (p = 0.03) respectively.

CONCLUSION

Use of licorice lozenges is efficacious for reducing the distressing complaint of POST in postoperative period among smokers.

Prevalence and clonal distribution of pcpA, psrP and Pilus-1 among pediatric isolates of Streptococcus pneumoniae

Streptococcus pneumoniae is the leading cause of vaccine-preventable deaths globally. The objective of this study was to determine the distribution and clonal type variability of three potential vaccine antigens: Pneumococcal serine-rich repeat protein (PsrP), Pilus-1, and Pneumococcal choline binding protein A (PcpA) among pneumococcal isolates from children with invasive pneumococcal disease and healthy nasopharyngeal carriers. We studied by Real-Time PCR a total of 458 invasive pneumococcal isolates and 89 nasopharyngeal pneumococcal isolates among children (total = 547 strains) collected in Barcelona, Spain, from January 2004 to July 2010. pcpA, psrP and pilus-1 were detected in 92.8%, 51.7% and 14.4% of invasive isolates and in 92.1%, 48.3% and 18% of carrier isolates, respectively. Within individual serotypes the prevalence of psrP and pilus-1 was highly dependent on the clonal type. pcpA was highly prevalent in all strains with the exception of those belonging to serotype 3 (33.3% in serotype 3 isolates vs. 95.1% in other serotypes; P<.001). psrP was significantly more frequent in those serotypes that are less apt to be detected in carriage than in disease; 58.7% vs. 39.1% P<.001. Antibiotic resistance was associated with the presence of pilus-1 and showed a negative correlation with psrP. These results indicate that PcpA, and subsequently Psrp and Pilus-1 together might be good candidates to be used in a next-generation of multivalent pneumococcal protein vaccine.