Factors that might impact intrathecal drug delivery (IDD) dose escalation: a longitudinal study.

BACKGROUND: Intrathecal drug delivery (IDD) system with implantable pumps has been used to treat cancer-related pain as well as noncancer-related chronic pain. Opioids, including morphine and hydromorphone, are the most commonly used intrathecal (IT) agents. Although technology, techniques, and knowledge of IDD have improved, dose escalation occurs relatively rapidly in noncancer pain. METHODS: Retrospective chart review of IDD pump patients, implanted for a minimum of 2 years, was designed to investigate possible existing predictors that might impact IDD dose escalation, such as patient's demographic risk factors, duration of the treatment, and diagnosis of the patient's pain correlates with increase in medication requirement. Primary outcome was defined as the annual percent escalation in daily opioid dosage, and secondary outcome was the average annual percent reduction in VRS pain scores. RESULTS: Median dosage escalation was 17% per year for patients with neuropathic pain compared with 12% per year for patients with other pain modalities. Mean opioid dosage increased 30.4% more rapidly for patients with neuropathic pain than for other pain modalities. The adjusted difference in means was 28.8% (P = 0.001). None of the secondary exposures were statistically significant after the Bonferroni adjustment. No association was found between pain modality and annual percent change in VRS pain score. CONCLUSION: Annual increases in daily opioid dosage were higher among patients with neuropathic pain than among patients with other modalities; we also found no evidence of difference in annual pain reduction.

Endonasal endoscopic dacryocystorhinostomy: how to achieve optimal results with simple punch technique.

Endonasal endoscopic dacryocystorhinostomy (EEDCR) has been popularized as a minimally invasive technique. Although preliminary reports revealed less success in comparison with external approaches, recent endonasal endoscopic surgeries on various types of DCR have preserved advantages of this technique while diminishing the failures. We described our experience on EEDCR, including the main advantages and disadvantages of it. Hundred consecutive cases of lachrymal problems underwent EEDCR utilizing simple punch removal of bone, instead of powered instrumentation or lasers. The medial aspect of the sac was removed in all of patients, while preserving normal mucosa around the sac. Hundred cases of EEDCR were performed on 81 patients, with 19 bilateral procedures. Nine procedures were performed under local anesthesia. Based on a mean 14 months follow-up, 95 cases were free of symptoms, revealing 95% success rate. The punch technique diminishes the expenses of powered or laser instrumentation with comparable results. It seems that preserving normal tissues and creating a patent rhinostomy with least surgical trauma and less subsequent scar, plays the most important role in achieving desirable results.

Membranous labyrinth volumes in normal ears and Ménière disease: a three-dimensional reconstruction study.

OBJECTIVES: The purpose of this study was to determine the normal volume ranges of cochlear duct, saccule, and utricle, and to assess endolymphatic hydrops in Ménière disease. STUDY DESIGN: Retrospective temporal bone study. METHODS: Three-dimensional (3-D) images of membranous labyrinth were reconstructed from 31 normal temporal bones, six temporal bones from three patients with bilateral Ménière disease, and 16 temporal bones from eight patients with unilateral Ménière disease. Volumes of each part of membranous labyrinth were measured in each temporal bone group after 3-D reconstruction. RESULTS: The mean volumes and upper normal volume limits (over the 95% confidence interval) of the cochlear duct, saccule, and utricle were 7.67 and 9.77 mm(3), 2.42 and 3.68 mm(3), and 10.65 and 16.45 mm(3), respectively. All three patients with bilateral Ménière disease showed endolymphatic hydrops (excess of volume over normal limits) in both ears. Of eight patients with unilateral Ménière disease, five had no symptom in the contralateral ear, whereas three patients had histories of progression from unilateral to bilateral Ménière disease 13-21 years after the initial onset. All of the diseased and three of eight contralateral ears showed endolymphatic hydrops. In contrast, no hydrops was observed in any part of the membranous labyrinth in asymptomatic ears. CONCLUSIONS: Our findings suggest that cochleosaccular hydrops is a sensitive finding in Ménière disease. In addition, the volume data obtained from this study could be useful as a standard value for the assessment of hydrops in diagnostic imaging of the inner ear in Ménière disease.

Regression of polypoid nasal mucosa after systemic corticosteroid therapy: a proteomics study.

BACKGROUND: Nasal polyposis (NP) treatment and pathophysiology have always been challenging for otolaryngologists. Among the medical treatments for NP, glucocorticoids (GCs) have been always one of the mainstays but the mechanisms of their action are not well defined. Identifying and comparing the protein profile of chronic rhinosinusitis (CRS) with NP before and after treatment with GCs can help to clarify NP pathogenesis and mechanisms of corticosteroid effects on NP. METHODS: Samples of nasal polyps were taken from selected NP patients in workup for endoscopic sinus surgery. None of the patients used local or systemic GCs within 30 days before the sampling. The patients were given prednisone, 30 mg/day, for 4 days before the surgery to shrink the NP tissue. Nasal polyp samples were collected during surgery. Proteins from samples were extracted and separated by immobilized pH gradient-based two-dimensional difference gel electrophoresis (2D DIGE). Resulting 2D-gel images were statistically analyzed using Delta2D software and differently expressed protein spots were identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. RESULTS: A reference map of 1963 proteins could be established. Expression of 20 proteins changed significantly (twofold, p<0.05) after treatment of NP with GCs. Heat shock proteins and retinoic acid were induced by GCs. Ingenuity pathway analysis of all identified proteins indicated that apoptosis pathway is triggered in NP after GC administration. CONCLUSION: Identifying the changes of NP proteome due to GCs and the biological functions of proteins can lead to new ways of treatment and open new fields in NP research.