Intraocular Pressure Spike Following Stand-Alone Phacoemulsification in the IRIS® Registry (Intelligent Research in Sight).

PURPOSE: To evaluate risk factors for intraocular pressure (IOP) spike after cataract surgery using the IRIS® Registry (Intelligent Research in Sight). DESIGN: Retrospective clinical cohort study. PARTICIPANTS: Adults with IRIS Registry data who underwent stand-alone phacoemulsification from January 1, 2013, through September 30, 2019. METHODS: Intraocular pressure spike was defined as postoperative IOP of > 30 mmHg and > 10 mmHg from the baseline within the first postoperative week. Odds ratios (ORs) for demographic and clinical characteristics were calculated with univariable and multivariable logistic regression analyses. MAIN OUTCOME MEASURES: Incidence and OR of IOP spike. RESULTS: We analyzed data from 1 191 034 eyes (patient mean age, 71.3 years; 61.2% female sex; and 24.8% with glaucoma). An IOP spike occurred in 3.7% of all eyes, 5.2% of eyes with glaucoma, and 3.2% of eyes without glaucoma (P < 0.0001). Multivariable analyses of all eyes indicated a greater risk of IOP spike with higher baseline IOP (OR, 1.57 per 3 mmHg), male sex (OR, 1.79), glaucoma (OR, 1.20), Black race (OR, 1.39 vs. Asian and 1.21 vs. Hispanic), older age (OR, 1.07 per 10 years), and complex surgery coding (OR, 1.22; all P < 0.0001). Diabetes (OR, 0.90) and aphakia after surgery (OR, 0.60) seemed to be protective against IOP spike (both P < 0.0001). Compared with glaucoma suspects, ocular hypertension (OR, 1.55), pigmentary glaucoma (OR, 1.56), and pseudoexfoliative glaucoma (OR, 1.52) showed a greater risk of IOP spike and normal-tension glaucoma (OR, 0.55), suspected primary angle closure (PAC; OR, 0.67), and PAC glaucoma (OR, 0.81) showed less risk (all P < 0.0001). Using more baseline glaucoma medications was associated with IOP spike (OR, 1.18 per medication), whereas topical ß-blocker use (OR, 0.68) was protective (both P < 0.0001). CONCLUSIONS: Higher baseline IOP, male sex, glaucoma, Black race, older age, and complex cataract coding were associated with early postoperative IOP spike, whereas diabetes and postoperative aphakia were protective against a spike after stand-alone phacoemulsification. Glaucomatous eyes demonstrated different risk profiles dependent on glaucoma subtype. The findings may help surgeons to stratify and mitigate the risk of IOP spike after cataract surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Salary Negotiations: Gender Differences in Attitudes, Priorities, and Behaviors of Ophthalmologists.

PURPOSE: To investigate attitudes, priorities, and behaviors of ophthalmologists in salary negotiations. DESIGN: Cross-sectional study. METHODS: A Qualtrics survey was disseminated to U.S.-based practicing ophthalmologists between November 1, 2021 and March 31, 2022 and assessed attitudes, behaviors, and priorities surrounding salary negotiation during the respondents' first negotiation as a practicing physician and currently. Optional case-based scenarios were also included. RESULTS: Of 424 respondents, 155 (36.5%) identified as male (M) and 269 (63.3%) identified as female (F). Men were more likely to negotiate salary for their first position as an independent ophthalmologist (M 78.3%, F 68.2%; P = .04). Respondents of both genders assessed their success similarly; 85.0% of men and 75.7% of women (P = .07) felt that their negotiation was very successful or somewhat successful. Women were more likely to select "flexibility in clinic/OR schedule for personal commitments" as a priority during salary negation for their first position (M 14.8%, F 23.1%; P = .04). Women ophthalmologists reported feeling more uncomfortable (M 36.1%, F 49.1%; P = .01), intimidated (M 20.0%, F 43.5%; P < .01), and were less likely to feel well-trained (M 24.5%, F 13.0%; P < .01). Most respondents never received formal training in negotiation. CONCLUSIONS: We found significant gender differences among ophthalmologists in attitudes, priorities and behaviors surrounding salary negotiation. There were low reported levels of formal negotiation training, which appears to disadvantage women more than men. These gender disparities suggest that incorporating education about negotiation skills and career development early in training may be impactful.

Bilateral exudative retinal detachments after subretinal gene therapy with voretigene neparvovec-rzyl for RPE65 Leber Congenital Amaurosis.

Purpose: To report panuveitis with exudative retinal detachments in a healthy 27-year-old woman with biallelic mutations in the RPE65 gene, who underwent bilateral sequential gene therapy with subretinal administration of voretigene neparvovec-rzyl. Observations: Visual acuity improved for 30 days after surgery as oral corticosteroids were tapered. At postoperative week 6, vision declined due to sudden onset uveitis and exudative retinal detachments in both eyes. HLA Class II typing revealed the haplotype associated with sympathetic ophthalmia and Vogt-Koyanagi-Harada (VKH). The inflammation improved after corticosteroid, mycophenolate mofetil, and adalimumab therapy while vision remained poor. Conclusions and Importance: Surgically-induced sympathetic ophthalmia is a plausible explanation for the clinical findings; surgery of both eyes within one week would conceal the inciting eye. VKH or inflammation related to the gene therapy are other possible etiologies but severe bilateral panuveitis has not been reported with voretigene neparvovec-rzyl. Informed consent for gene therapy surgery should include a discussion of the rare complication of sympathetic ophthalmia following vitrectomy surgery.

Choroidal Effusions after Glaucoma Drainage Implant Surgery: Risk Factors and Surgical Management.

OBJECTIVE: To report the incidence of patients who developed choroidal effusions after glaucoma drainage implant (GDI) surgery and determine risk factors for and outcomes of surgical intervention. DESIGN: Retrospective case series. SUBJECTS: Medical records of 605 patients who underwent GDI surgery from January 1, 2017 to June 7, 2021 at New York University Langone Health and New York Eye and Ear Infirmary of Mount Sinai were reviewed. METHODS: Preoperative, intraoperative, and postoperative clinical data were obtained. Multivariate logistic regression evaluated the factors associated with the need for surgical intervention. Patient records were analyzed for effusion resolution, intraocular pressure (IOP), visual acuity (VA), and complications across treatment modalities. MAIN OUTCOME MEASURES: Incidence of choroidal effusion development and need for surgical intervention. RESULTS: Choroidal effusions developed in 110 (18%) patients (110 eyes). Surgical intervention to drain the effusion or ligate the implant tube was performed in 19 (17%) patients. The average time to surgical intervention was 47.6 days. Among patients who developed postoperative effusions, risk factors for requiring surgical intervention included history of selective laser trabeculoplasty (SLT) (P = 0.004; odds ratio [OR], 14.4), prior GDI surgery (P = 0.04; OR 8.7), 350-mm2 Baerveldt glaucoma implant placement (P = 0.05; OR, 4.8), and anterior chamber shallowing (AC; P < 0.001; OR, 25.1) in the presence of effusions. The subgroup that required multiple surgeries for effusion resolution had a significantly lower mean IOP at the most recent follow-up compared with those who received medical management only (P < 0.001). A higher percentage of patients who required surgical intervention lost VA at the most recent follow-up compared with patients whose effusions resolved with conservative management (i.e., medical management, AC viscoelastic injection). CONCLUSIONS: Choroidal effusions after GDI surgery resolved with conservative management in most patients. A history of SLT or GDI placement, implantation of a BGI-350, and the presence of a shallow chamber were risk factors for surgical intervention. Although interventions, such as surgical drainage are at times necessary, a better understanding of their impacts can help guide postoperative decisions. The risks and benefits of these procedures must be carefully considered in these high-risk eyes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Myositis of an Extraocular Muscle, a Possible Drug Reaction: Histopathologic and Immunopathologic Analysis.

A 58-year-old man presented with left-sided orbital inflammation, including chemosis and a lateral rectus abduction defect. Initially presumed to represent cellulitis, the condition responded poorly to oral and intravenous antibiotics. CT showed the epicenter of an infiltrate to involve the lateral rectus. The patient improved dramatically when oral prednisone was added. Lateral rectus biopsy displayed intramuscular polyclonal lymphoid infiltrates, rich with eosinophils. Complete resolution of the inflammatory process was confirmed by a follow-up CT. The presumptive diagnosis was idiopathic orbital myositis, an uncommon condition of unknown etiology. However, the patient had taken rosuvastatin, which has been rarely associated with diplopia and ophthalmoplegia, raising the question of whether this case was truly idiopathic.

Gender Compensation Gap for Ophthalmologists in the First Year of Clinical Practice.

PURPOSE: To identify the role of gender and other factors in influencing ophthalmologists' compensation. DESIGN: Cross-sectional study. PARTICIPANTS: U.S. practicing ophthalmologists. METHODS: Between January and March 2020, an anonymous survey was sent to U.S. residency program directors and practicing ophthalmologists who recently completed residency training. Respondents who completed residency ≤ 10 years ago and responded to questions about gender, fellowship training, state of practice, and salary were included. Propensity score match (PSM) analysis was performed with age, academic residency, top residency, fellowship, state median wage, practice type, ethnicity, and number of workdays. Multivariate linear regression (MLR) analysis controlled for additional factors along with the aforementioned variables. MAIN OUTCOME MEASURES: Base starting salary with bonus (SWB) received in the first year of clinical position was the main outcome measure. A multiplier of 1.2 (20%) was added to the base salary to account for bonus. RESULTS: Of 684 respondents, 384 (56% were female, 44% were male) from 68 programs were included. Female ophthalmologists received a mean initial SWB that was $33 139.80 less than that of their male colleagues (12.5%, P = 0.00). The PSM analysis showed an SWB difference of -$27 273.89 (10.3% gap, P = 0.0015). Additionally, SWB differences were calculated with the number of workdays substituted by operating room (OR) days (-$27 793.67 [10.5% gap, P = 0.0013]) and clinic days (-$23 597.57 [8.90% gap, P = 0.0064]) in separate PSM analyses. The SWB differences between genders were significant using MLR analyses, which also controlled for work, clinic, and OR days separately (-$22 261.49, $-18 604.65, and $-16 191.26, respectively; P = 0.017, P = 0.015, P = 0.002, respectively). Gender independently predicted income in all 3 analyses (P < 0.05). Although an association between gender and the attempt to negotiate was not detected, a greater portion of men subjectively reported success in negotiation (P = 0.03). CONCLUSIONS: Female ophthalmologists earn significantly less than their male colleagues in the first year of clinical practice. Salary differences persist after controlling for demographic, educational, and practice type variables with MLR and PSM analyses. These income differences may lead to a substantial loss of accumulated earnings over an individual's career.

An adult with COVID-19 kawasaki-like syndrome and ocular manifestations.

PURPOSE: The severe acute respiratory syndrome coronavirus-2 and its associated infection known as COVID-19 have resulted in a global pandemic. Ocular manifestations of COVID-19 are nonspecific and include hyperemia, chemosis, epiphora, secretions, and eyelid edema. There is a paucity in the literature regarding COVID-19 related inflammatory syndromes which may also include ocular manifestations. OBSERVATIONS: In pediatric patients, conjunctivitis has been recently reported in association with a multisystem inflammatory condition related to COVID-19 that shares features with Kawasaki disease and toxic shock syndrome. We describe the clinical course of an adult patient with symptoms and signs consistent with a Kawasaki-like syndrome. CONCLUSIONS AND IMPORTANCE: To our knowledge, this report may be the first case of a Kawasaki-like syndrome in an adult with COVID-19 infection.

Asthma onset pattern and patient outcomes in a chronic rhinosinusitis population.

BACKGROUND: Chronic rhinosinusitis (CRS) is strongly associated with comorbid asthma. This study compares early-onset and late-onset asthma in a CRS population using patient-reported and clinical characteristics. METHODS: At enrollment into a clinical registry, CRS patients completed the 22-item Sino-Nasal Outcome Test (SNOT-22), Asthma Control Test (ACT), mini-Asthma Quality of Life Questionnaire (miniAQLQ), the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29), and medication use questionnaires. Patients also reported comorbid asthma and age at first asthma diagnosis. Early-onset (<18 years) and late-onset (>18 years) asthma groups were defined. Analysis of variance (ANOVA), chi-square, and Kruskal-Wallis tests were used to compare patient responses. RESULTS: A total of 199 non-asthmatic (56.1%), 71 early-onset asthmatic (20.0%), and 85 late-onset asthmatic (23.9%) CRS patients completed the survey. Body mass index (BMI) was significantly higher in late-onset asthmatic (p = 0.046) while age, gender, race, and smoking history did not differ with time of asthma onset. SNOT-22, ACT, and miniAQLQ were not different between asthma groups, but late-onset asthmatics had significantly lower physical function than non-asthmatics (p = 0.008). Compared to non-asthmatics, late-onset asthmatics showed increased rates of nasal polyps (p < 0.001), higher Lund-Mackay scores (p = 0.005), and had received more oral steroid courses (p < 0.001) and endoscopic surgeries (p = 0.008) for CRS management. Late-onset asthmatics compared to early-onset asthmatics showed increased nasal polyposis (p = 0.011) and oral steroid courses for CRS (p = 0.003). CONCLUSION: While CRS-specific and asthma-specific patient-reported outcome measures (PROMs) were not significantly different among groups, CRS patients with late-onset asthma had poorer physical function, more frequent nasal polyposis, and required increased treatment for CRS. Late-onset asthma may predict more severe disease in CRS.

A prospective analysis evaluating tissue biopsy location and its clinical relevance in chronic rhinosinusitis with nasal polyps.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) has a high propensity for recurrence. Studies suggest that eosinophilia influences disease severity and surgical outcomes, but the selection of sinonasal site for measuring eosinophilia has not been examined. The aim of this study was to investigate how region-specific tissue eosinophilia affects radiographic severity, comorbidity prevalence, and polyp recurrence risk following sinus surgery. METHODS: Eosinophil cationic protein (ECP) levels in uncinate tissue (UT) and nasal polyp (NP) homogenates from 116 CRSwNP patients were measured using enzyme-linked immunosorbent assay (ELISA). Clinical history, radiographic severity, and time to polyp recurrence were obtained from electronic health records. The correlations between baseline Lund-Mackay scores and comorbidities were compared between UT and NP ECP levels. Cox regression and Kaplan-Meier analysis were then performed to assess whether UT or NP ECP better predicted recurrence. Censoring occurred at 4 years or at last follow-up if there was no endoscopic diagnosis of recurrent polyps. RESULTS: Lund-Mackay scores were significantly correlated with UT and NP ECP (r = 0.46 and 0.26 respectively, p < 0.05). UT but not NP ECP was significantly higher in patients with asthma (p < 0.01) and aspirin-exacerbated respiratory disease (AERD) (p < 0.05). Polyp recurrence risk was only significantly higher for patients with eosinophilic UT tissue (hazard ratio [HR] = 2.84, p = 0.025). When measured in NP, eosinophilia did not predict recurrence. CONCLUSION: Although ECP in NP was higher than in UT tissue, eosinophilia in UT tissue was a more clinically coherent biomarker of baseline radiographic severity, comorbid asthma and AERD, and prospective polyp recurrence risk than NP eosinophilia.

Early and late outcomes with prolonged open chest management after cardiac surgery.

OBJECTIVES: Open chest management (OCM) is an important intervention for patients who are unable to undergo sternal closure after cardiac surgery. This study reviews the factors associated with a prolonged need for this intervention and investigates its association with early and late mortality. METHODS: Patients undergoing OCM from January 2009 to December 2014 were reviewed. Differences in the median duration of OCM when a perioperative variable was present versus its absence were determined and variables significant at P ≤ .1 were analyzed using Poisson regression for factors associated with prolonged OCM. Multivariable logistic regression and Cox proportional hazards models were developed to investigate perioperative factors that were associated with early and late mortality. RESULTS: A total of 201 patients (5%) required OCM and the overall median duration of this intervention was 3 days. The use a temporary assist device (median, 7 vs 2 days; P < .001), pneumonias (median, 11 vs 3 days; P < .001), sternal re-explorations (median, 6 vs 2 days; P < .001), and renal failure (median, 6 vs 3 days; P = .02) were among the factors that were highly associated with prolonged OCM using Poisson regression. Thirty-day mortalities occurred in 32 patients (16%) and were significantly associated with emergency surgery (P = .03), sternal re-explorations (P = .001), and OCM duration (median, 6 vs 3 days; P = .02). On multivariable logistic regression and Cox analysis, delaying sternal closure by 1-day increments increased the risk of early and late mortality by 11% (P = .01), and 9% (P < .001), respectively. CONCLUSIONS: Prolonged OCM was associated with increasing perioperative morbidity and a higher risk of early and late mortality.

Superior turbinate eosinophilia correlates with olfactory deficit in chronic rhinosinusitis patients.

OBJECTIVE: To evaluate if molecular markers of eosinophilia in olfactory-enriched mucosa are associated with olfactory dysfunction. STUDY DESIGN: Cross-sectional study of tissue biopsies from 99 patients, and an additional 30 patients who underwent prospective olfactory testing prior to sinonasal procedures. METHODS: Tissue biopsies were processed for analysis of inflammatory markers using quantitative real time polymerase chain reaction (qRT-PCR). Ipsilateral olfactory performance was assessed using the Sniffin' Sticks (Burghart, Wedel, Germany) threshold component and the University of Pennsylvania Smell Identification Test (Sensonics, Haddon Heights, NJ). Age-adjusted data was correlated with inflammatory marker expression and clinical measures of obstruction from computed tomography and endoscopy. RESULTS: Gene expression of the eosinophil marker CLC (Charcot Leyden crystal protein) was elevated in superior turbinate (ST) tissue in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) compared to ST and inferior turbinate tissue in CRS without nasal polyps (CRSsNP) and control patients (all P < 0.001, respectively). CLC in ST tissue was correlated with IL-5 and eotaxin-1 expression (all P < 0.001; P = 0.65, and 0.49, respectively). CLC expression was strongly correlated with eosinophilic cationic protein levels (P < 0.001; r = -0.76), and ST CLC expression was inversely related to olfactory threshold (P = 0.002, r = -0.57) and discrimination scores (P = 0.05, r = -0.42). In multiple linear regression of CLC gene expression, polyp status, and radiographic and endoscopic findings with olfactory threshold, CLC was the only significantly correlated variable (P < 0.05). CONCLUSION: Markers of eosinophils are elevated in the ST of patients with CRSwNP and correlate with olfactory loss. These findings support the hypothesis that olfactory dysfunction in CRS correlates local eosinophil influx into the olfactory cleft. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:2210-2218, 2017.

Evaluating metrics of responsiveness using patient-reported outcome measures in chronic rhinosinusitis.

BACKGROUND: Responsiveness, or sensitivity to clinical change, is important when selecting patient-reported outcome measures (PROMs) for research and clinical applications. This study compares responsiveness of PROMs used in chronic rhinosinusitis (CRS) to inform the future development of a highly responsive instrument that accurately portrays CRS patients' symptom experiences. METHODS: Adult CRS patients initiating medical therapy (MT; n = 143) or undergoing endoscopic sinus surgery after failing MT (ESS; n = 123) completed the 22-item Sino-Nasal Outcome Test (SNOT-22), European Position Statement on Rhinosinusitis (EPOS) visual analog scale (VAS), and 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29) at baseline and 3 months after treatment. Cohen's d and paired t statistics were used to evaluate the responsiveness of each measure. RESULTS: Fifty-two (36.4%) subjects and 42 (34.1%) subjects in the MT and ESS groups, respectively, completed baseline and 3-month questionnaires. Subjects with and without 3-month data were similar with respect to baseline demographics, VAS scores, and SNOT-22 scores (p > 0.05). In MT patients, CRS-specific measures, like VAS (d = -0.58, p < 0.01; t = -1.81, p > 0.05) and SNOT-22 (d = -0.70, p < 0.01; t = -3.29, p < 0.05) scores, were more responsive than PROMIS-29 general health domains (p > 0.05 for Cohen's d). In ESS patients, VAS (d = -1.97; t = -9.63, both p < 0.01) and SNOT-22 (d = -1.56; t = -9.99, both p < 0.01) scores were similarly more responsive, although changes in PROMIS-29 domains of Fatigue (d = -0.82, p = 0.01; t = -4.63, p < 0.01), Sleep Disturbance (d = -0.83; t = -3.77, both p < 0.01), and Pain Intensity (d = -1.0; t = -5.67, both p < 0.01) were significant. All 22 individual SNOT-22 items differed significantly after surgery, whereas only 8 items were consistently responsive after MT. CONCLUSIONS: For both MT and ESS patients, CRS-specific PROMs are more responsive to posttreatment clinical changes than general health measures. Still, the SNOT-22 contains items that likely decrease its overall responsiveness. Our findings also indicate that existing PROMs had a greater response to ESS than MT.

Anticoagulation Reversal Strategies for Left Ventricular Assist Device Patients Presenting with Acute Intracranial Hemorrhage.

The safety of alternative vitamin K antagonist (VKA) reversal strategies in patients with left ventricular assist devices (LVAD's) who present with intracranial hemorrhage (ICH) are not well known. A review of LVAD patients with ICH from May 2008 to 2015 was conducted, comparing the safety and efficacy of 4-factor prothrombin complex concentrate-assisted VKA reversal (4F-PCC group, n = 10) to reversal with traditional agents alone (no-PCC group, n = 10). An analysis of a no-reversal strategy in selected patients (n = 11) with ICH was additionally performed. Thirty-one cases of ICH on LVAD support were reviewed. The rate of post reversal thromboembolic events was not significantly different between 4F-PCC and no-PCC patients (0% vs. 10%, p = 1.0); however, the time to VKA reversal was shorter (474 vs. 945 minutes, p = 0.02) and fresh frozen plasma (FFP) requirements lower (1.9 vs. 3.6 units, p = 0.05) in 4F-PCC patients, with no difference in mortality between groups (p = 1.0). Eleven patients (mean ICH volume: 0.4 cm) were successfully managed without active VKA reversal, with no increased hemorrhage noted on neuroimaging. These results suggest that 4F-PCC-assisted reversal in LVAD patients is safe and may improve the efficacy of VKA reversal. Our findings also indicate that carefully selected patients with small ICH volumes may be safely managed by discontinuing anticoagulation and allowing the international normalized ratio (INR) to normalize physiologically.

Oropharyngeal pH Testing Does Not Predict Response to Proton Pump Inhibitor Therapy in Patients with Laryngeal Symptoms.

OBJECTIVES: Predicting response to proton pump inhibitor (PPI) therapy in patients with laryngeal symptoms is challenging. The Restech Dx-pH probe is a transnasal catheter that measures oropharyngeal pH. In this study, we aimed to investigate the prognostic potential of oropharyngeal pH monitoring to predict responsiveness to PPI therapy in patients with laryngeal symptoms. METHODS: We conducted a physician-blinded prospective cohort study at a single academic institution between January 2013 and October 2014. Adult patients with Reflux Symptom Index scores (RSI) ≥13 off PPI therapy were recruited. Patients underwent video laryngoscopy and 24-h oropharyngeal pH monitoring, followed by an 8- to 12-week trial of omeprazole 40 mg daily. Prior to and following PPI therapy, patients completed various symptom questionnaires. The primary outcome was the association between PPI response and oropharyngeal pH metrics. PPI response was separated into three subgroups based on the post-treatment RSI score and % RSI response: non-response=RSI ≥13; partial response=post-treatment RSI <13 and change in RSI <50%; and complete response=post-treatment RSI <13 and change in RSI ≥50%. The primary analysis utilized a multinomial logistic regression controlling for the pre-treatment RSI score. A secondary analysis assessed the relationship between the change in RSI (post-pre) and oropharyngeal pH metrics via ordinary least square regression. RESULTS: Thirty-four patients completed the study and were included in final analysis. Symptom response to PPI therapy was as follows: 50% no response, 15% partial response, and 35% complete response. Non-responders had a higher pre-treatment RSI (P<0.01). There were no significant differences in oropharyngeal acid exposure (below pH of 4.0, 5.0, 5.5, 6.0, and RYAN scores) between responder types. The secondary analysis noted a trend between lower PPI response and a greater total percent time below pH of 5.0 (P=0.03), upright percent time below pH of 5.0 (P=0.07), and RYAN supine (corrected; P=0.03), as well as an association between PPI response and greater decreases in the Anxiety Sensitivity Inventory (P<0.01), Brief Symptom Inventory-18 (P<0.01), and Negative Affect Scale (P<0.01). CONCLUSIONS: Oropharyngeal pH testing did not predict laryngeal symptom response to PPI therapy. Contrary to hypothesis, our study signaled that the degree of oropharyngeal acid exposure is inversely related to PPI response. In addition, reduction in negative affect and psychological distress parallels PPI response.

Abilities of Oropharyngeal pH Tests and Salivary Pepsin Analysis to Discriminate Between Asymptomatic Volunteers and Subjects With Symptoms of Laryngeal Irritation.

BACKGROUND & AIMS: It has been a challenge to confirm the association between laryngeal symptoms and physiological reflux disease. We examined the ability of oropharyngeal pH tests (with the Restech Dx-pH system) and salivary pepsin tests (with Peptest) to discriminate between asymptomatic volunteers (controls) and subjects with a combination of laryngeal and reflux symptoms (laryngeal ± reflux). METHODS: We performed a physician-blinded prospective cohort study of 59 subjects at a single academic institution. Adult volunteers were recruited and separated into 3 groups on the basis of GerdQ and Reflux Symptom Index scores: controls (n = 20), laryngeal symptoms (n = 20), or laryngeal + reflux symptoms (n = 19). Subjects underwent laryngoscopy and oropharyngeal pH tests and submitted saliva samples for analysis of pepsin concentration. Primary outcomes included abnormal acid exposure and composite (RYAN) score for oropharyngeal pH tests and abnormal mean salivary pepsin concentration that was based on normative data. RESULTS: Complete oropharyngeal pH data were available from 53 subjects and complete salivary pepsin data from 35 subjects. We did not observe any significant differences between groups in percent of time spent below pH 4.0, 5.0, 5.5, 6.0, or RYAN scores or percent of subjects with positive results from tests for salivary pepsin (53% vs 40% vs 75%; P = .50, respectively). The laryngeal + reflux group had a significantly higher estimated mean concentration of salivary pepsin (117.9 ± 147.4 ng/mL) than the control group (32.4 ± 41.9 ng/mL) or laryngeal symptom group (7.5 ± 11.2 ng/mL) (P = .01 and P = .04, respectively). CONCLUSIONS: By using current normative thresholds, oropharyngeal pH testing and salivary pepsin analysis are not able to distinguish between healthy volunteers and subjects with a combination of laryngeal and reflux symptoms.

Measurement and comparison of health utility assessments in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common condition encountered in primary care medicine and is estimated to affect 12.5% of the United States population. This study aims to compare methods of assessing health utility in CRS. METHODS: A cross-sectional sample of CRS patients (n = 137) were interviewed using direct health utility assessment measures: the visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG). General quality of life (QOL) scores were obtained via the 36-item Short Form Health Survey (SF-36) and converted to SF-6D health utility values using a Bayesian algorithm. Disease-specific QOL was measured with the 22-item Sino-Nasal Outcome Test (SNOT-22). A selected subgroup of patients (n = 51) not initiating surgery or new treatment for CRS were re-interviewed within 3 weeks. RESULTS: The mean ± SD health utilities were VAS 0.69 ± 0.19; TTO 0.80 ± 0.27; SG 0.93 ± 0.11; and SF-6D 0.72 ± 0.12; they differed significantly (p < 0.001). Only VAS scores differed based on disease state classification or the presence of nasal polyposis. Correlations between methods of determining health utility were weak, but significant. VAS, TTO, and SF-6D scores were significantly associated with SNOT-22 (p < 0.001 for all); however, SG and SNOT-22 were poorly correlated (Spearman correlation = -0.33). The test-retest reliability of TTO (Spearman correlation = 0.71) and SG (0.73) was strong. CONCLUSION: CRS patients show significant impairment in QOL, with health utility values similar to those of patients with acquired immune deficiency syndrome (AIDS) or intermittent claudication using similar methods. The method of ascertainment significantly affects measured health utility, but the degree of impairment warrants improved recognition and appropriate treatment of the condition.

Patient knowledge and perception of computed tomography scan in the management of chronic rhinosinusitis symptoms.

OBJECTIVES/HYPOTHESIS: The objective of this study was to report patients' knowledge and comfort level with computed tomography (CT) imaging for sinus disease and evaluate patient willingness to undergo empiric medical therapy (EMT) versus CT-directed therapy (CTDT). STUDY DESIGN: Prospective survey study. METHODS: A 22-item survey was administered to patients with nasal/sinus symptoms in a tertiary care rhinology clinic. Questions elicited patient demographics, imaging history, and knowledge/comfort regarding imaging-related radiation exposure. Patients were presented with the theoretical choice of EMT versus CTDT, given the expected positive predictive value, in chronic rhinosinusitis (CRS) management. RESULTS: Two hundred patients (52% female, age range 18-83 years) participated. Of these, 85% had symptoms for over 3 months. Only 91 patients (45.5%) were aware that CT imaging involved radiation exposure. Prior CT experience and past sinus surgery (P < .05), but not sex or education level, were associated with increased comfort with CT imaging. Most patients (78%) preferred CTDT over EMT. If a CT sinus was recommended, 77 patients (38.5%) had concerns, of which 26% identified radiation exposure as the leading concern. The majority (70%) were unsure about the relative radiation dose of a conventional CT. CONCLUSIONS: Patients with CRS symptoms prefer CTDT over EMT if a diagnosis cannot be established definitively using exam findings. Although most patients deferred to the physician regarding the decision to utilize CT imaging, there is low awareness of CT-related radiation exposure, and a significant minority of patients have radiation-related concerns with regard to medical imaging for nasal and sinus symptoms.

The relationship of the natural sphenoid ostium to the skull base.

OBJECTIVES/HYPOTHESIS: Various intranasal landmarks have been described to aid in the localization of the natural sphenoid sinus ostium. The objectives of this study are to identify the ostium location relative to the skull base and assess the relationships between the location of the ostium and sphenoid disease or pneumatization pattern. DESIGN: Descriptive study. METHODS: Consecutive Xoran Mini-CAT (Ann Arbor, MI) scans of patients with no history of sinus surgery (n = 202) were evaluated. The natural sphenoid ostium was identified in axial, coronal, and sagittal planes. Distances from the planum to the ostium and from the planum to the sinus floor were calculated. Lund-Mackay score and pneumatization pattern were recorded for each sphenoid sinus. RESULTS: The mean distance from planum to ostium was 11.2 ± 2.6 mm (range 4.4-19.2). On average, this encompassed 45.5% ± 10% of the total sphenoid height. ANOVA with posthoc Tukey analysis revealed that the ostium was closer to the planum in sinuses with sellar (P = 0.05) or presellar (P = 0.02) pneumatization, compared to those with postsellar pneumatization. There was no significant relationship between the ostium location and degree of sinus disease. There was a significant difference in the pneumatization pattern between males and females (P = .04). More males had postsellar pneumatization than expected, and more females had sellar pneumatization than expected. CONCLUSIONS: The natural ostium of the sphenoid sinus is located at approximately the midpoint of the sphenoid face. Nevertheless, significant variability can be observed based on the pneumatization pattern. Surgeons should recognize that the ostium may be closer to the skull base when the sinus is less pneumatized.