Trainee-trainer outcomes in mastoid surgery: a comparative study.

BACKGROUND: Mastoid exploration remains an advanced, mainstay operation within ENT, in which the surgical trainees' role has been debated. This audit compares mastoid exploration outcomes between trainees and consultants. METHODS: Cortical mastoidectomy, atticotomy, atticoantrostomy, modified radical mastoidectomy, combined-approach tympanoplasty and revision mastoidectomy operations performed between 2009 and 2020 were reviewed. Complications assessed were: facial palsy, labyrinth injury, dead ear, disease recurrence and time to recurrence. The chi-square test was used to determine significant associations. RESULTS: A total of 118 operations were surveyed. Thirty-five per cent of procedures (n = 41) were performed by trainees under supervision, and 65 per cent (n = 77) were carried out solely by consultants. Patients from 5 per cent of trainees' operations (n = 2) developed recurrence, compared with 7.8 per cent of consultants' (n = 6) (p = 0.55). No other complications developed in either group. CONCLUSION: The results corroborate those of other studies, indicating no significant increase in complication rate from consultants to trainees. Trainees likely completed less complicated cases. The stepwise incorporation of trainees did not compromise patient safety.

Adam Brown Kelly and his operating chair.

BACKGROUND: Adam Brown Kelly, well known for lending his name to Paterson-Brown Kelly syndrome, is steeped in the early history of otolaryngology. To date, little light has been shone on his contributions to the specialty in that exciting period and to his home town of Glasgow. METHOD: A historical review of his life and times was undertaken based on surviving accounts of his life, published work and archived memoirs. RESULTS: This article summarises his life and connections, with particular reference to his unique chair that has survived to this day. CONCLUSION: Brown Kelly remains a pioneer of modern otolaryngology, and deserving of prominence within the medical history of Glasgow.

Anterior chamber angle anomalies associated with signs of pigment dispersion in a group of black probands and their first-degree relatives.

PURPOSE: To evaluate the presence of iridocorneal angle anomalies associated with signs of pigment dispersion among a group of black probands and their first-degree relatives. METHODS: Eleven blacks who exhibited pigment dispersion syndrome (PDS) signs, including Krukenberg's spindles, moderate-to-heavy trabecular meshwork pigmentation, and peripheral lenticular/zonular pigmentation, received a complete eye examination that included gonioscopy. Overt iridocorneal angle abnormalities other than pigment deposition were photo-documented. Twenty-two first-degree relatives (6 siblings, 15 children, and 1 parent) of these probands underwent similar examination. RESULTS: Among the subjects, 5 of 11 probands (age range 13 to 59 years) and 4 of 22 relatives (age range 14 to 51 years) exhibited definite angle anomalies. The nine subjects with angle anomalies belonged to 7 of 11 separate families. The four relatives with angle anomalies did not have PDS according to our criteria, but two other relatives from two additional families did have signs consistent with clinical PDS. Types of angle anomalies included (1) peripheral anterior synechia-like lesions; (2) a prominent concavity of the peripheral iris at the 6-o'clock meridian; (3) a whitish, thread-like band of tissue near the iris base; (4) a prominent, externally-visible Schwalbe's line at the 6-o'clock meridian; and (5) a prominent, web-like confluence of exaggerated iris processes 360 degrees along the angle wall. Iris processes and prominent Schwalbe's lines were not considered abnormal or anomalous unless they were clearly atypical. CONCLUSIONS: Iridocorneal angle anomalies, other than pigment deposition, were common among our black group who exhibited signs of pigment dispersion as well as among their first-degree relatives. Further consideration should be given to the possibility that among some patient groups, overt goniodysgenesis could be part of a constellation of signs indicative of a pigment dispersion syndrome. Potentially, clinically detectable goniodysgenesis could prove to be a useful marker to identify certain subjects who carry PDS genetic traits but who have not expressed complete phenotypical disease.

Successful transplantation of kidneys from a donor with HELLP syndrome-related death.

We report on the successful use of kidneys procured from a donor with HELLP syndrome. The use of organs from a donor with HELLP syndrome has not been reported previously, perhaps because of the renal complications associated with it. Both recipients have been doing well since renal transplantation, with immediate graft function and acceptable graft function at 2 years of follow-up. In view of the continuing shortage of cadaveric kidneys for transplantation, this report highlights how organs from "marginal" donors should not be discarded without worthy consideration.

Retrospective longitudinal study of visual acuity change in patients with retinitis pigmentosa.

PURPOSE: To determine the extent that clinically evident macular lesions in patients with retinitis pigmentosa (RP) help to establish their prognosis for visual acuity (VA) retention. METHODS: The records of 182 patients with RP were reviewed. The macular lesion status at the initial examination was determined to be no lesion, a bull's-eye atrophic lesion, or a geographic atrophic lesion. Multiple linear regression analysis was used to evaluate the relationship of initial VA, macular lesion type, and RP genetic subtype to predict the VA change per 5-year period. RESULTS: The regression effect of lesion type on the VA change was statistically significant (P < 0.0001). Patients with no macular lesion had a predicted 5-year change of less than 1 line, whereas those with either a bull's-eye or geographic atrophic lesion had a predicted 5-year change of three to four lines. The 5-year changes were not related to a patient's age or level of VA at initial presentation, when controlling for type of macular lesion. CONCLUSION: By examining longitudinal data, the authors found that the presence or absence of a macular lesion at the patient's initial visit was an important determinant of VA loss in this cohort of patients with RP. These findings are of value when counseling patients with RP regarding their prognosis for preservation of VA.

Fundus albipunctatus and other flecked retina syndromes.

BACKGROUND: Several ophthalmic conditions manifest a flecked retina. Developing an understanding of their clinical presentations will enable the practitioner to most appropriately manage these conditions. CASE REPORT: A 27-year-old Middle Eastern woman manifested flecked retinas and nyctalopia. She had been given a diagnosis of retinitis punctata albescens, an inherited, progressive, night blindness; however, the medical history and clinical findings were not consistent with this disorder. Rather, they were consistent with fundus albipunctatus, an autosomal recessive, stationary, night blindness. The clinical presentation of fundus albipunctatus is characterized by discrete, white dots at the level of the retinal pigment epithelium and stable night blindness. A prolonged time for dark adaptation is required to produce normal amplitude electroretinograms in fundus albipunctatus as the result of a delay in the regeneration of rhodopsin. An electroretinogram administered after a prolonged dark adaptation time confirmed the diagnosis of stationary night blindness. CONCLUSION: In order to ensure an accurate diagnosis for fundus albipunctatus, it is important to be aware of the clinical characteristics and appropriate electroretinogram protocol for this disorder.

Effect of ovariohysterectomy on maintenance energy requirement in cats.

OBJECTIVE: To determine whether maintenance energy requirement (MER) to maintain stable body weight (BW) is substantially lower for spayed female cats than for sexually intact female cats and to assess whether an equation commonly used to estimate MER would accurately predict caloric need in spayed cats. DESIGN: Prospective study. ANIMALS: 10 spayed and 5 sham-operated young adult female cats. PROCEDURE: During an acclimatization period, initial daily food allowance was determined by estimating MER as 1.4 x (30 x BW + 70), then adjusted weekly to maintain BW within 200 g of baseline. Ovariohysterectomy (OHE) or sham laparotomy was performed at week 7, and the study was continued for 15 additional weeks (period 1). To correct for a presumptive effect of continued musculoskeletal growth that resulted in some cats becoming unacceptably thin during period 1, the study was repeated over an additional 10 weeks (period 2), using a new estimate of MER calculated from BW measured after reestablishing normal body condition. RESULTS: Substantial restriction in food allowance was necessary to prevent BW gain in the OHE group during both periods. Caloric intake of spayed cats in dietary balance was significantly lower than that of control cats at the end of each study period. Sexually intact cats appeared to self-regulate food intake, whereas spayed cats tended to eat all food available to them. Significant differences were not detected between OHE and control groups in observations of physical activity before or after surgery. The equation used to predict caloric needs overestimated the apparent MER for spayed and sexually intact cats. CLINICAL IMPLICATIONS: Ad libitum feeding of spayed cats may be inadvisable, and careful monitoring of food allowance, relative to body condition, is suggested to prevent excessive weight gain.

Congenital ocular motor apraxia with torsional oscillations: a case report.

Congenital ocular motor apraxia (C-OMA) is an infrequently reported eye movement disorder associated with malformation or delayed maturation of the brain. Patients with C-OMA are unable to initiate voluntary horizontal saccades. This results in characteristic head thrusts into the desired field of gaze to compensate for the lack of saccadic ability. Careful examination of an 8-year-old Hispanic male revealed uncoordinated eye movements, lack of voluntary saccades, head thrusts, and gross/fine motor delays all consistent with congenital ocular motor apraxia. Torsional oscillations that resembled rotary nystagmus were also present. These have not been previously reported in association with C-OMA. Because young patients with this condition may appear to have cortical blindness, C-OMA is an important differential to be aware of in making a diagnosis.

Comparison of intra-articular and epidural morphine for analgesia following stifle arthrotomy in dogs.

We prospectively studied 18 dogs that presented for exploratory stifle arthrotomy, with or without meniscectomy, and lateral extracapsular stabilization as a result of cranial cruciate ligament rupture. Dogs were premedicated with acepromazine, induced with thiopental, and maintained with halothane in oxygen. Preoperatively, dogs were assigned to one of three groups. Group 1 (n = 6) received intra-articular morphine (0.1 mg/kg diluted in 1 mL/10 kg body weight of saline) and epidural saline (1 mL/5 kg body weight saline plus the volume of saline representing 0.1 mg/kg of morphine). Group 2 (n = 6) received intra-articular saline (1 mL/10 kg body weight of saline plus the volume of saline representing 0.1 mg/kg of morphine) and epidural saline (1 mL/5 kg body weight saline plus the volume of saline representing 0.1 mg/kg of morphine). Group 3 (n = 6) received intra-articular saline (1 mL/10 kg body weight of saline plus the volume of saline representing 0.1 mg/kg of morphine) and epidural morphine (0.1 mg/kg of morphine diluted in 1 mL/5 kg body weight saline). The efficacy of each analgesia regimen was evaluated for 6 hours postoperatively with a pain score based on subjective and objective variables. Serum cortisol and blood glucose concentrations were measured. Butorphanol was used to provide analgesia as needed based on a predetermined maximum pain score. Supplemental analgesics were required postoperatively every 2 to 3 hours for 6 hours in all dogs that did not initially receive analgesics (group 2). Pain scores were significantly lower in dogs administered morphine intra-articularly (group 1) and epidurally (group 3) at 30 minutes and 30, 120, and 360 minutes, respectively, compared with dogs that did not initially receive analgesics (group 2). One dog in group 1 and one dog in group 3 required supplemental analgesia with butorphanol. There was no difference between analgesia produced by intra-articular morphine compared with that of epidural morphine. Side effects after intra-articular or epidural morphine were not observed. Intra-articular administration of morphine can produce effective analgesia in dogs comparable with that produced by epidural administration of morphine.

Biomechanical evaluation of a toggle pin technique for management of coxofemoral luxation.

Toggle pin stabilization is an accepted technique for the management of coxofemoral (CF) luxation in dogs. The purpose of this study was to determine, in vitro, the respective contributions of several aspects of toggle pin repair to the overall stability of fixation. Factors evaluated were the manner and frequency with which toggle pins oriented on insertion, effect of orientation on toggle pin strength, effect of suture type on ligament prosthesis strength and load sustained by the fixation, and comparison of repair using a modified toggle design to that of capsulorrhaphy. When placed in cadavers using standard technique, conventional toggle pins were found to orient significantly more frequently in one of two possible positions. Mechanical testing of fixations performed in experimentally luxated cadaver hips demonstrated a high (12/20) incidence of toggle pin failure using the conventional implant in the most common orientation. When tested alone, toggle pins were weakest mechanically in this orientation. Rotating the implant 180 degrees increased mean load to failure by 249%. There was no significant difference in load sustained by conventional toggle fixations using No. 2 braided polyester versus 50 lb test monofilament nylon as the suture ligament prosthesis. However, the higher stiffness of the polyester suture may be more favorable for use in this application. Fixation using a toggle rod designed to allow evaluation of construct stability when failure of the toggle is eliminated resulted in an increase in maximum load sustained before luxation (47% of the intact control hips). This load was not significantly different than the resistance to luxation afforded by capsulorrhaphy. This study suggests that when implanting conventional toggle pins, consideration should be given to ensuring placement in the strongest orientation.

Ocular manifestations of Sotos syndrome.

BACKGROUND: Sotos syndrome (cerebral gigantism) is a congenital syndrome characterized by large body size for patient age, advanced bone age, and unusual facial characteristics with varying levels of cognitive, developmental and perceptual deficits. While more than 150 cases have been reported, only a single case report has been published in the ophthalmic literature. This study briefly reviews the pertinent aspects of this syndrome and reports on the medical, physical, developmental and ocular manifestations of 32 subjects. METHODS: Our patient population was obtained from several schools and colleges of optometry and private offices and clinics of optometrists and ophthalmologists. The Sotos Syndrome Support Association assisted in obtaining patients for this study as well. All children had been previously diagnosed as having SS. Commonly accepted methods for evaluating young, non-verbal, and/or handicapped children were used. RESULTS: Our findings indicate that moderate to high refractive error (hyperopia), nystagmus, and strabismus (esotropia) are commonly associated conditions of this syndrome. CONCLUSIONS: Since many of our subjects exhibited these amblyogenic precursors, a routine optometric vision evaluation should be an essential part of the individual educational and habilitation plan for all children with Sotos syndrome.

Measuring the clinical appropriateness of the use of a procedure. Can we do it?

Increasing attention is being paid to data on geographic differences in population-based rates of use of medical and surgical procedures. To understand these differences and to determine what level of use is appropriate, a method is needed to judge the clinical appropriateness of services. We recently developed and tested such a method in two large, urban geographic areas. Eighty-one medical records from a randomly selected sample of 30 billing entities (46 physicians) who performed upper gastrointestinal endoscopy (UGIE) on Medicare patients were abstracted. Ninety-four percent of physicians who were asked agreed to participate. Reliability testing showed 99% agreement on items abstracted from a subset of records independently reviewed by two abstractors. Based on the abstractions, each patient could be assigned at least one (mean 2.2) specific clinical indication for which UGIE was performed. Using ratings derived from a previously held panel meeting, it was possible to evaluate the appropriateness of the indications for each UGIE.

Obtaining clinical data on the appropriateness of medical care in community practice.

We sought the voluntary cooperation of a randomly selected sample of community physicians and hospitals in five states for a study of how appropriately they performed coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy. Ninety percent of 913 sampled physicians (n = 819) consented to a review of up to 20 of their 1981 Medicare patients' records. These physicians represented seven different specialties and subspecialties and performed 4988 procedures, 92% of the desired sample. Only three of 230 hospitals did not participate. We attribute our method's success primarily to the formation of a network to connect the branches of the profession, respect for office and hospital practice routine, confidentiality, and the development of carefully designed medical record abstraction systems. We conclude that, with effort, cooperative research among disparate segments of the medical community can become a reality even if the topic studied is relatively sensitive.