Academic Referral Practice Research Articles

Survey of Ménière’s disease in a subspecialty referral practice

To define the prevalence of definite Ménière's disease (MD) among patients presenting with characteristic symptoms and examine the utility of published diagnostic guidelines. Retrospective review in an academic referral practice. The prevalence of definite MD in these 295 individuals was 64%. The next-largest group (23%) consisted of patients with only cochlear symptoms. Those initially classified as probable are usually reclassified as definite with extended follow-up. Of those with definite MD, the mean duration of disease at last follow-up was 7.6 years, 56% were female, 19% had bilateral disease, and 34% required surgical management for vertigo. The 1995 AAO-HNS guidelines are useful for classification of MD according to certainty of diagnosis and severity of disease, though some modifications could be considered. Application of consistent diagnostic criteria is essential for epidemiological, genetic, or outcomes studies of Ménière's disease.

Evaluation of outcome of otitis media after lavage of the tympanic bulla and long-term antimicrobial drug treatment in dogs: 44 cases (1998-2002).

To evaluate the outcome of otitis media in dogs after video-otoscopic lavage of the tympanic bulla and long-term antimicrobial drug treatment. Retrospective study. 44 dogs with otitis media treated in an academic referral practice. Medical records were reviewed for signalment, duration of ear canal disease, previous medical treatments, dermatologic diagnosis, results of cytologic examination and microbial culture of ear canal exudate, findings during video-otoscopy, medical treatment, days to resolution, and maintenance treatments prescribed. Four independent variables (age, duration of ear canal disease prior to referral, use of corticosteroids in treatment regimens, and infection with Pseudomonas aeruginosa) were evaluated statistically for potential influence on time to resolution. Mean +/- SD (range) duration of ear canal disease prior to referral was 24.9 +/- 21.6 (3 to 84) months. Otitis media in 36 dogs resolved after lavage of the tympanic bulla and medical management; mean +/- SD (range) time to resolution was 117 +/- 86.7 (30 to 360) days. Time to resolution was not significantly influenced by any variable evaluated. Three dogs were lost to follow-up, and 4 dogs eventually required surgical intervention. Seven of 36 dogs in which otitis had resolved relapsed; 4 required additional lavage procedures. Results indicate that lavage of the tympanic bulla combined with medical management is an effective and viable option for treatment of otitis media in dogs.

Scanning laser polarimetry with variable corneal compensation and optical coherence tomography in normal and glaucomatous eyes

Purpose To evaluate the relationship between visual function and retinal nerve fiber layer (RNFL) measurements obtained with scanning laser polarimetry with variable corneal compensation (SLP-VCC) and optical coherence tomography (OCT). Design Cross-sectional analysis of normal and glaucomatous eyes in a tertiary care academic referral practice. Methods A commercial GDx nerve fiber analyzer was modified to enable the measurement of corneal polarization axis and magnitude so that compensation for corneal birefringence was eye specific. Complete examination, SLP with fixed corneal compensation (FCC) and variable corneal compensation (VCC), optical coherence tomography (OCT) imaging of the peripapillary RNFL, and automated achromatic perimetry were performed in all subjects. Exclusion criteria were visual acuity less than 20/40, diseases other than glaucoma, and unreliable perimetry. Results Fifty-nine patients (59 eyes; 29 normal, 30 glaucomatous) were enrolled (mean age, 56.7 ± 20.3 years, range, 20–91). All eyes with glaucoma had associated visual field loss (average mean defect, −8.4 ± 5.8 dB). Using SLP-FCC, nine of 12 retardation parameters (75%) were significantly less in glaucomatous eyes. Using SLP-VCC, 11of 12 retardation parameters (92%) were significantly less in glaucomatous eyes. Multiple regression models constructed for each retardation parameter with visual field demonstrated that the following VCC parameters were statistically significant whereas FCC parameters were not: ellipse average (FCC, P = .28, VCC, P = .001), superior average (FCC, P = .38, VCC, P < .001), inferior average (FCC, P = .10, VCC, P = .008), average thickness (FCC, P = .30, VCC, P = .031), and superior integral (FCC, P = .43, VCC, P = .001). Similar results were obtained for multiple regression models constructed with OCT-derived RNFL thickness: ellipse average (FCC, P = .99, VCC, P = .002), superior average (FCC, P = .90, VCC, P < .001), inferior average (FCC, P = .61, VCC, P = .007), and superior integral (FCC, P = .92, VCC, P < .001). Conclusions Compared with fixed compensation, mean-based SLP parameters generated with SLP-VCC have greater correlation with visual function and RNFL thickness assessments obtained with OCT.

Functional improvement after phacoemulsification cataract surgery

Purpose To evaluate subjective functional visual improvement after phacoemulsification and intraocular lens (IOL) implantation and identify patient characteristics and treatment features associated with no functional improvement. Setting Academic referral practice, Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA. Methods A retrospective review was performed of the surgical results in 106 consecutive eyes of 102 patients who completed the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Data Collection Form © preoperatively and 1 month postoperatively. One surgeon performed all the surgery. The relationship of patient characteristics and treatment features and reported visual function was analyzed using an analysis of variance and the Wilcoxon rank sum and Fisher exact tests. Results One month postoperatively, all patients demonstrated improved visual acuity. However, 15 patients (14%) reported unimproved or decreased visual function. No statistically significant intergroup difference ( P > .05) was detected in mean preoperative, postoperative, and fellow eye best spectacle-corrected visual acuities or refractive errors; reported severity of preoperative symptoms or satisfaction with vision; reported preoperative daily activity functioning or prevalence of hypertension and diabetes; type of anesthesia, lens material, or wound closure used; intraoperative or postoperative complication rates. However, patients reporting unimproved vision tended to be older and less satisfied with their quality of life and medical care than those reporting improved vision ( P = .02, .03, .01, respectively). Conclusions Self-reported visual function generally improved after phacoemulsification and IOL implantation; however, some older patients less satisfied with their quality of life and medical care reported no functional improvement despite improved visual acuity. These patients might benefit from an extended preoperative discussion of postoperative expectations.

Postmenopausal dehydroepiandrosterone administration increases free insulin-like growth factor-I and decreases high-density lipoprotein: a six-month trial

Objective: To determine the effect of administering 6 months of oral postmenopausal DHEA therapy on serum DHEA, DHEAS, and T levels and on physiologic endpoints including lipoproteins and insulin-like growth factor-I (IGF-I). Design: Randomized, double-blind, parallel trial. Setting: Academic referral practice. Patient(s): Thirteen normal-weight or overweight, healthy, nonsmoking, postmenopausal women. Intervention(s): Administration of oral micronized DHEA (25 mg/d). Main Outcome Measure(s): Monthly fasting 23 hours postdose levels of serum DHEA, DHEAS, T, lipoproteins, IGF-I, IGF binding protein-3 (IGFBP-3), and liver function tests. Morphometric indices by dual-energy x-ray absorptiometry scan (percent body fat; lean body mass), immune indices, and insulin sensitivity. Result(s): Levels of DHEA, DHEAS, and T all rose into premenopausal ranges, but after 6 months, levels of DHEA and T did not differ from baseline or placebo. At 3 months, the ratio of IGF-I to IGFBP-3 rose by 36.1% ± 12.7%, but it fell to placebo values by 6 months. High-density lipoprotein and apolipoprotein A1 levels declined. Conclusion(s): Patients appeared to tolerate 6 months of DHEA therapy well. Given the small study size, no statistically significant differences in morphometric indices, immune indices, or insulin-sensitizing properties were observed, but significant attenuation of bioavailability occurred. Supplementation with DHEA increased IGF-I/IGFBP-3 levels at 3 months and decreased high-density lipoprotein and apolipoprotein A1 levels at 6 months.

Needle knife papillotomy in a university referral practice. Safety and efficacy of a modified technique.

To study the utility of needle knife papillotomy (NKP), we retrospectively reviewed 575 consecutive endoscopic retrograde cholangiopancreatography (ERCP) procedures performed over a 3.5-year period. Seventy patients (12.2%) underwent NKP utilizing a shallow ampullary mucosal incision followed by probing with a taper-tipped cannula. Usually a prelude to anticipated therapeutic intervention, NKP was also performed purely for diagnosis in 15 patients (21.4%). The incised ampulla was normal-sized in the majority (53 of 70, 75.7%), and ductal dilatation was present in 49 of 70 cases (70%). NKP was performed de novo in 63 patients, one of whom had Billroth II anatomy, and stent-guided NKP was performed in seven patients (10%), two of whom had Billroth II anatomy. Biliary access was immediate in 68 patients (97.1%) and successful 24 h later in two cases. The NKP incision was completed with a traction sphincterotome in 45 patients (64.3%). Complications occurred after NKP in five patients (7.1%), compared with 11 complications (4.2%) among a concurrent 261 patients who underwent standard ES without NKP. All complications following NKP were selflimited, including pancreatitis (n = 2) and bleeding (n = 2). Our experience indicates that NKP is versatile, effective, and safe with broad applicability in an academic referral practice.