Consensus panel on role of potentially ototoxic antibiotics for topical middle ear use: Introduction, methodology, and recommendations.
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Administration, Topical↗
Biomedical subjects
Michael G Stewart
Publications and source records attributed to Michael G Stewart.
Chronic sinusitis: symptoms versus CT scan findings.
PURPOSE OF REVIEW: The association between symptoms of chronic rhinosinusitis and findings on a sinus CT scan remains controversial. Although the 1997 Task Force on Rhinosinusitis definition of chronic rhinosinusitis includes only symptoms and signs, many clinicians use CT scans for diagnosis and assessment of disease severity. RECENT FINDINGS: Two prospective studies evaluated associations between symptoms and CT scan findings. One study compared the diagnosis of chronic sinusitis with findings using a validated CT staging system; the CT findings were poorly predictive of the presence or absence of chronic sinusitis. The other study used a nonvalidated assessment of symptoms and several measurements from CT scans and identified a few significant associations. SUMMARY: There are few recent studies explicitly addressing symptom severity and CT scan findings in chronic sinusitis. Most studies conclude that there is little correlation between CT findings and symptoms but that both are important in the evaluation of sinusitis.
Chronic Disease↗
Long-term synaptic morphometry changes after induction of long-term potentiation and long-term depression in the dentate gyrus of awake rats are not simply mirror phenomena.
Mechanisms of expression of long-term synaptic plasticity are believed to involve morphological changes of the activated synapses and remodelling of connectivity. Here, we investigated changes in synaptic and neuronal parameters in the dentate gyrus 24 h after induction of long-term potentiation (LTP) and long-term depression (LTD) in awake rats. In dentate granule cells, tetanization of the medial or lateral perforant paths induces LTP in specific synaptic bands along the dendrites in the middle and outer molecular layers, respectively, and tetanization of the lateral path induces robust LTD heterosynaptically in the middle molecular layer. This functional segregation allowed us to assess morphological changes associated with LTP and LTD in each pathway in the same population of neurons. Electron microscopy and unbiased counting methods were used to estimate neuronal density, axospinous, axodendritic and perforated synapse density, multiple synapse bouton density and postsynaptic density (PSD) area. Whereas there was no change in neuronal density, PSD area and multiple synapse boutons 24 h after either LTP or LTD, there was a noninput-specific increase in unperforated axospinous synapses after both LTP and LTD. However, we found that LTP of the medial, but not lateral, perforant path is associated with a specific increase in perforated axospinous synapses in the potentiated area. We also show that heterosynaptic LTD is associated with an input-specific increase in axodendritic synapse density. These results suggest that each perforant pathway may differ with respect to the nature of LTP-induced long-term changes and show that morphologically LTD is not simply the converse of LTP.
Animals↗
Benign paroxysmal positional vertigo and comorbid conditions.
PURPOSE: To determine the prevalence of comorbid disease in patients with benign paroxysmal positional vertigo (BPPV) and the relationship of comorbid disease to symptoms of vertigo, disequilibrium, and anxiety. PROCEDURES: Patients who had posterior semicircular canal BPPV and who had been referred for vestibular rehabilitation at a tertiary care center completed a health status questionnaire and the Vertigo Symptom Scale, answered questions about level of vertigo, and were tested on computerized dynamic posturography. RESULTS: Subjects had high rates of diabetes, mild head trauma, and probable sinus disease. Balance was generally impaired, worse in diabetics and subjects with significant vestibular weakness. Subjects who smoked or had had mild head trauma had higher levels of anxiety. CONCLUSIONS: Comorbid conditions, particularly diabetes, mild head trauma, and sinus disease, are unusually prevalent in BPPV patients. Message: Patients with comorbid disease are at risk for having increased vertigo, anxiety, and disequilibrium compared to other patients.
Adult↗
Arytenoid adduction combined with medialization thyroplasty: an evidence-based review.
OBJECTIVE: Medialization thyroplasty (MT) and arytenoid adduction (AA) are effective treatments for medializing the paralyzed vocal cord, but indications and benefits of each procedure are controversial. We performed a formal evidence-based review to answer this question: In patients with unilateral vocal cord paralysis, does AA combined with MT significantly improve subjective and objective voice outcomes compared with MT alone?Study design We performed a MEDLINE literature search using specific search terms to identify pertinent articles, which were reviewed and graded according to the evidence quality. RESULTS: We identified 219 potentially pertinent articles; detailed review yielded 10 studies for further analysis. Only 3 studies directly compared MT with AA plus MT: overall, there was no clear benefit in subjective or objective outcomes for AA plus MT. CONCLUSIONS: Very limited grade C evidence indicates no clear benefit, or lack of benefit, in subjective or objective outcomes if AA is added to MT, compared with MT alone.
Arytenoid Cartilage↗
Morphological changes in hippocampal dentate gyrus synapses following spatial learning in rats are transient.
The hippocampus is believed to play a crucial role in the formation of memory for spatial tasks. In the present study quantitative electron microscopy was used to investigate morphological changes in the hippocampal dentate gyrus of 3-month-old male rats at 3, 9 and 24 h after training to find a hidden platform in a Morris water maze. Average escape latency (time taken to reach the platform) in all trained groups decreased progressively with increased training but data from a probe trial (quadrant analysis test) at the end of training indicated that only animals in the 9- and 24-h groups, not the 3-h group, displayed significant retention of platform location. Unbiased stereological methods were used to estimate synapse and neuronal density at each time point after training. The majority of synapses had unperforated postsynaptic densities, were localized on small dendritic spines and were classed as axo-spinous. In comparison to age-matched untrained rats, significant but transient increases were observed in axo-spinous synapse density and synapse-to-neuron ratio 9 h after the start of training, but not at earlier (3 h) or later (24 h) times. These changes at 9 h post-training were accompanied by transient decreases in both mean synaptic height and area of postsynaptic density. No such changes were observed in an exercise-matched control group of rats, indicating that the transient synaptic changes in the dentate gyrus are most likely to be specifically related to processes involved in memory formation for the spatial learning task.
Animals↗
Rapid reversal of stress induced loss of synapses in CA3 of rat hippocampus following water maze training.
The impact was examined of exposing rats to two life experiences of a very different nature (stress and learning) on synaptic structures in hippocampal area CA3. Rats were subjected to either (i) chronic restraint stress for 21 days, and/or (ii) spatial training in a Morris water maze. At the behavioural level, restraint stress induced an impairment of acquisition of the spatial response. Moreover, restraint stress and water maze training had contrasting impacts on CA3 synaptic morphometry. Chronic stress induced a loss of simple asymmetric synapses [those with an unperforated postsynaptic density (PSD)], whilst water maze learning reversed this effect, promoting a rapid recovery of stress-induced synaptic loss within 2-3 days following stress. In addition, in unstressed animals a correlation was found between learning efficiency and the density of synapses with an unperforated PSD: the better the performance in the water maze, the lower the synaptic density. Water maze training increased the number of perforated synapses (those with a segmented PSD) in CA3, both in stressed and, more notably, in unstressed rats. The distinct effects of stress and learning on CA3 synapses reported here provide a neuroanatomical basis for the reported divergent effects of these experiences on hippocampal synaptic activity, i.e. stress as a suppressor and learning as a promoter of synaptic plasticity.
Animals↗
An evidence-based review of the treatment of peritonsillar abscess.
OBJECTIVE: Peritonsillar abscess (PTA) is commonly seen but still controversial. We performed an evidence-based review to answer 3 questions: Are steroids beneficial? Which is the best technique for acute surgical management? When is tonsillectomy indicated? STUDY DESIGN: We performed a MEDLINE search of the published literature using appropriate search terms to identify pertinent articles, which were reviewed and graded according to the evidence quality. RESULTS: Forty-two articles were analyzed. There are no published studies on steroids in PTA. There were 5 level I clinical studies on surgical technique, which indicated that needle aspiration, incision and drainage, and quinsy tonsillectomy are all effective for initial management. The overall PTA recurrence rate is 10% to 15%. CONCLUSIONS: Overall, grade C evidence indicates that several methods of initial surgical drainage are equally effective, and the recurrence rate is low. The literature does not specifically address different treatments for children and adults.
Drainage↗
Searching the medical literature on the Internet.
The volume of new information being added to the medical literature is expanding quickly. Hence, computer-assisted literature searches frequently are used to assist in patient care and clinical problem solving, including choosing the most appropriate diagnostic tests, properly diagnosing medical conditions, and developing and implementing suitable treatment plans. This article describes techniques for performing more efficient medical literature searches using the PubMed interface of MEDLINE.
Databases, Bibliographic↗
Outcomes research and facial plastic surgery.
Outcomes research examines the delivery of medical care from the patient's perspective, using unique instruments and methodologies. Outcome studies can measure the effectiveness of treatments or interventions in individual patients or in large populations, using prospective observational research designs. The steps in performing outcomes research are as follows: identify and define the disease or procedure of interest, create a staging system for disease severity, identify important co-morbid conditions, choose or design an outcomes instrument to measure treatment outcomes, and design a study to assess outcomes prospectively. Although there is currently a dearth of outcomes instruments available for use in facial plastic and reconstructive surgery, some new instruments are being developed, and even using existing tools outcomes research should prove to be a valuable research tool for facial plastic surgeons to demonstrate improved quality of life and functional status in their patients.
Comorbidity↗
Facial nerve monitoring in chronic ear surgery: US practice patterns.
OBJECTIVE: The use of intraoperative facial nerve monitoring (IOFNM) improves facial nerve outcomes in acoustic neuroma surgery, but the role of IOFNM in chronic ear surgery (CES) is poorly defined. This study was performed to identify IOFNM practice patterns in the United States for CES. METHODS: A 10-item survey was mailed to a random sample of 500 active members of the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: The overall response rate was 45.2%. Of the respondents, 75% had access to IOFNM, and of this group, 66% used IOFNM at least some of the time. Otolaryngologists trained in the 1990s (P < 0.0001), those in an academic setting (P = 0.02), and those who perform more otologic than other types of surgery (P = 0.004) were more likely to use IOFNM. Although most respondents had access to IOFNM, only 32% thought that IOFNM should be required for CES. CONCLUSIONS: The majority of otolaryngologists who perform CES have access to IOFNM and will use it at least some of the time. IOFNM use is especially prevalent in otolaryngologists who have trained recently and in more experienced otologic surgeons. However, there are strong feelings against requiring IOFNM for CES.
Facial Nerve↗
Tutorials in clinical research: part V: outcomes research.
OBJECTIVES: This is the fifth in a series of sequential "Tutorials in Clinical Research." The objective of the present report is to give the reader a broad overview of the field of outcomes research. This summary is intended to enable the reader to understand outcomes research methodology and to start the design of an outcomes research study. STUDY DESIGN: Tutorial. METHODS: The authors developed the report from available materials and refined it to be concise but complete for use by the practicing clinician. RESULTS: We describe the basic steps of record-based and patient-based outcomes research, including development of a staging system, identification of comorbid conditions, and creation or identification of an outcomes instrument. CONCLUSION: Outcomes research is a unique methodology that uses patient-based outcomes to assess the effectiveness of medical treatment.
Evidence-Based Medicine↗
Tutorials in clinical research, part VI: descriptive statistics.
OBJECTIVES: This is the sixth in a series of Tutorials in Clinical Research. The objectives of this tutorial are to produce a brief, step-by-step, user-friendly atlas with clinical scenarios and illustrative examples to serve as ready references and, it is hoped, to open an inviting door to understanding statistics. STUDY DESIGN: Tutorial. METHODS: The authors met weekly for 6 months discussing clinical research articles and the applied statistics. Liberal use of reference texts and discussion focused on constructing a tutorial that is factual as well as easy to read and understand. RESULTS: The tutorial is organized into five sections: Overview, Key to Descriptive Summaries, Steps in Summarizing Descriptive Data, Understanding the Summaries of Specific Data Types, and Understanding Scope or Dispersion of Data. CONCLUSIONS: Assessing the validity of medical studies requires a working knowledge of statistics; however, obtaining this knowledge need not be beyond the ability of the busy surgeon. Desire is the only limiting factor. We have tried to construct an accurate, basic, easy-to-read-and-apply introduction to the task of summarizing the characteristics of a single variable. This is known as descriptive statistics.
Data Interpretation, Statistical↗
Outcomes research: an overview.
Outcomes research is increasingly important in contemporary medicine. Outcomes research differs from traditional clinical research in that outcomes are typically measured from the patient's perspective, and expanded measures of outcome are used, such as quality of life and cost-effectiveness. In this introduction to the special journal edition, the author will discuss the background behind outcomes research and describe several of its important aspects. Outcomes research consists of the clinical study of expanded, patient-based outcomes, as well as the study of populations, databases, and the delivery of health care. Outcomes research also includes the development of validated instruments to assess patient-based outcomes, development of disease severity staging systems, identification of comorbid conditions, and meta-analysis.
Attitude to Health↗
Outcomes research in pediatric otolaryngology.
There are several validated outcomes instruments available for use in the pediatric otolaryngology population. These include instruments for otitis media, rhinosinusitis, tonsil and adenoid disease; sleep-disordered breathing, voice disorders and tracheotomy. In addition, several prospective outcomes studies have been performed on common pediatric otolaryngology conditions. These studies have typically indicated that the quality of life impact of diseases such as otitis media and recurrent tonsillitis is quite high, and that surgical treatments (such as tympanostomy tube placement and adenotonsillectomy) result in significant improvements in quality of life and disease-specific health status. In addition, cost-effectiveness studies of cochlear implantation have indicated that implantation is a very cost-effective intervention when performed in children.
Child↗
Objective versus subjective outcomes assessment in rhinology.
BACKGROUND: Prior studies on the relationship between computed tomography scan findings and patient-based quality of life in chronic rhinosinusitis (CRS) have found very low correlations. Whereas surprising, similarfindings have been noted in other diseases. METHODS: We performed a cross-sectional analysis of the association between objective and subjective findings in nasal septal deformity and a systematic review and synthesis of the literature on CRS and other diseases. RESULTS: We found no association between objective anatomic findings and subjective symptoms in nasal obstruction (R = 0.03; Kruskal-Wallis test, p = 0.97). Multiple studies in CRS and other diseases-sleep apnea, hearing loss, asthma, etc.- have found similarly low correlations between objective and subjective testing. CONCLUSION: For nasal septal deviation and CRS, the patient's subjective perception of disease severity has, at best, a very weak association with objective assessment of severity. Patient-based outcomes assessment remains important; these instruments apparently quantify an aspect of disease not detected by objective testing.
Humans↗
Medical management and diagnosis of chronic rhinosinusitis: A survey of treatment patterns by United States otolaryngologists.
BACKGROUND: This study was performed to identify current patterns of diagnostic criteria and medical treatment for chronic rhinosinusitis (CRS) by otolaryngologists in the United States. METHODS: A 15-item survey was mailed to a random sample of 200 members of the American Academy of Otolaryngology-Head and Neck Surgery; statistical analysis was performed. RESULTS: The overall response rate was 40.0%. Of respondents, 73% defined CRS as lasting >12 weeks. Seventy-three percent also believed radiological imaging was necessary for definitive diagnosis, but only 30% believed nasal endoscopy was necessary. Regarding treatment, respondents reported use of oral antibiotics (94%) and nasal corticosteroids (94%) as part of maximum medical management; oral decongestants, oral mucoevacuants, and allergy testing were used only by about one-half of the respondents, and less frequently topical decongestants (38%), oral corticosteroids (36%), and oral antihistamines (27%) were used. Oral corticosteroids were more likely to be used by specialists that self-classified as rhinologists than by other otolaryngologists (p = 0.005), but rhinologists were less likely to use radiological imaging (p = 0.04) as a diagnostic criterion. Pediatric otolaryngologists used allergy testing in medical management more frequently than other otolaryngologists (p < 0.001). Overall, the basis for choice of maximal medical management was personal clinical experience (74%), rather than clinical research results or expert recommendations. CONCLUSION: We had a fairly small sample of returned surveys; therefore, our findings may not be generalizable to the entire population of U.S. otolaryngologists. Nevertheless, in our survey, U.S. otolaryngologists agree on the use of oral antibiotics and nasal corticosteroids as part of maximal medical management for CRS but do not agree on other adjuvant therapies or on the use of endoscopy as a diagnostic criterion.
Adrenal Cortex Hormones↗