Reliability and Confidence of Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) Rating Among Research and Clinical Speech Pathologists Before and After Implementation of a Training Manual: A Multi-site Study.

DIGEST is a validated, open-source method to grade the severity of pharyngeal dysphagia from the modified barium swallow (MBS) study. Dissemination and implementation of DIGEST is rising, making it critical to understand reliability and facilitators of accurate implementation among users. The aim was to assess reliability of the tool among speech-language pathology (SLP) raters practicing at multiple sites before and after review of a DIGEST training manual and evaluate confidence of DIGEST use pre-and post-training. Thirty-two SLPs from 5 sites participated in a blinded longitudinal DIGEST rating study. Raters were provided a standardized training set of MBS (n = 19). Initial SLP ratings (round 1, R1) were followed by a 2-4 week break before raters rated a re-keyed MBS set (round 2, R2). A minimum 4-8 week wash-out period then preceded self-study of the DIGEST training manual which was followed by a final rating (round 3, R3) and a post-manual survey afterwards. Baseline reliability (R1) of overall DIGEST was on average k = 0.70, reflecting agreement in the substantial range. Seventy-five percent of raters (24/32) demonstrated reliability ≥ 0.61 in the substantial to almost perfect range prior to training. Inter-rater reliability significantly improved from R1 to R3 after review of the DIGEST manual, with the largest change in DIGEST-Efficiency (mean change: DIGEST k = .04, p = .009, DIGEST-Safety k = .07, p = 0.03, and DIGEST-Efficiency k = .14, p = 0.009). Although DIGEST reliability at baseline was adequate in the majority of raters, self-study of the DIGEST training manual significantly improved inter-rater reliability and rater confidence using the DIGEST method, particularly when assigning DIGEST-Efficiency grade. These early data show promise that provider training may be useful to aid in fidelity of DIGEST implementation among SLP clinical users with varying DIGEST experience.

Exploring patient experiences with a telehealth approach for the PRO-ACTIVE trial intervention in head and neck cancer patients.

INTRODUCTION: Following the COVID-19 directive to cease non-essential services, a rapid shift was made in the delivery of Speech Language Pathology (SLP) dysphagia management in the 3-arm, randomized PRO-ACTIVE trial. To inform future programs, this study explored patients' experiences with telehealth when the planned in-person SLP intervention was moved to a telehealth modality. METHODS: A theory-guided qualitative descriptive approach was used. Willing participants who had received at least one telehealth swallowing therapy session participated in a one-time semi-structured interview. Interview transcripts were subjected to a standard qualitative content/theme analysis. Researchers reviewed all transcripts and used a multi-step analysis process to build a coding framework through consensus discussion. Summaries and key messages were generated for each code. RESULTS: Eleven participants recounted their telehealth experiences and reported feeling satisfied, comfortable and confident with the session(s). They identified that previous experience with teleconferencing, access to optimal technical equipment, clinician skill, and caregiver assistance facilitated their telehealth participation. Participants highlighted that telehealth was beneficial as it reduced commuting time, COVID-19 exposure and fatigue from travel; and also allowed caregiver participation particularly during COVID. In comparing their in-person SLP sessions to telehealth sessions, limitations were also identified, including: lack of previous experience with and/or poor access to technology, and less opportunity for personalization. Participants indicated that use of phone alone was less preferred than an audio/video platform. DISCUSSION: Patients reported that overall, telehealth sessions did not compromise their learning experience when compared to in-person sessions. Patients benefited from use of telehealth in several ways despite some limitations of the use of technology. Patient feedback about telehealth provides an important perspective that may be critical to inform best practices for care delivery.

Addressing an unmet need in oncology patients: rehabilitation of upper aerodigestive tract function.

BACKGROUND: Laryngeal dysfunction in the oncology population is common and may detract from quality of life (QoL) due to vocal restriction and aspiration. Therapies to address this complex issue have not been explored to date. We examined the outcomes among oncology patients treated with a minimally invasive office-based surgical approach for the rehabilitation of laryngeal dysfunction. PATIENTS AND METHODS: A retrospective analysis was carried out of oncology patients referred for laryngeal dysfunction. Patients who underwent minimally invasive injection laryngoplasty (IL) were selected. Subjective outcome measures, objective voice analysis parameters, and swallowing studies were annotated. RESULTS: Sixty-one patients underwent IL for the management of laryngeal dysfunction. Lung cancer was the most common cancer diagnosis (39.3%), and 52% of patients had thoracic malignancies. All patients had a self-reported improvement in vocal function with a single injection, and 55 patients (90%) reported lasting effects at 3 months. In patients with pre- and postoperative voice analysis, phonatory function increased from 5.0 to 10.5 s, more than twofold improvement compared with baseline functioning. Seventy-one percent of patients who aspirated before injection no longer required a modified diet. There were no major complications. CONCLUSIONS: Interventions to improve the QoL in oncology patients continue to evolve. We report significant improvements in both subjective and objective measures of laryngeal function after IL for vocal fold dysfunction that are both immediate and sustained. We conclude that IL is a safe and efficacious procedure for the treatment of laryngeal dysfunction in oncology patients, resulting in palliation and improved QoL.

Left ventricular wall motion analysis using real-time three-dimensional ultrasound.

This study tested the ability of real-time 3-D (RT 3-D) echocardiography to detect and delineate regions of abnormal contraction (akinesia or dyskinesia) in a canine model of regional myocardial injury and to develop methods to simplify injury assessments. Closed chest RT 3-D scans were obtained and regional left ventricular (LV) contractile function was assessed in nine animals at baseline and after myocardial cryoinjury with a 1-cm cryoprobe. Evaluation of contractile function was based on radial shortening of LV chamber cross-sections at multiple levels. Radial length changes were analyzed using color-coded circumferential maps of the LV. Seven sets of motion maps demonstrated new areas of poorly contracting myocardium in the cryoinjured region relative to baseline. Two sets of data were excluded due to insufficient LV visualization. Motion maps derived from RT 3-D echo have the ability to detect and localize regions of abnormal LV wall motion.

Weaning children with accommodative esotropia out of spectacles: a pilot study.

BACKGROUND/AIM: Many children with accommodative esotropia must continue spectacle use throughout life. This study was undertaken to determine which factors are predictive of successfully weaning children with accommodative esotropia out of spectacles. METHODS: A retrospective review of 10 children with accommodative esotropia, who were gradually weaned from their hyperopic correction, and three age matched controls was performed. The main outcome measure was resolution or non-resolution of esotropia following weaning and eventual discontinuation of spectacles. Secondary outcome measures were final refractive error and the final esotropic or esophoric angle without correction. RESULTS: Six patients were successfully weaned from spectacles. At the completion of the weaning period one child was orthophoric and the other five children had well controlled esophorias. The other four patients remained spectacle dependent because of persistent esotropia or decreased vision without spectacles. The baseline and final refractive errors were significantly lower in the children successfully weaned from spectacles (p = 0.014). While the children who were successfully weaned from spectacles were older when initially diagnosed with accommodative esotropia (4.6 v 2.5 years), this difference was not statistically significant (p = 0.09). CONCLUSION: Some children with accommodative esotropia may be weaned out of spectacles during the grade school years with resolution of their esotropia. It is likely that gradual reduction of the hyperopic correction increases divergence amplitudes, but it is unclear whether this facilitates emmetropisation.

Activation of MEF2 by muscle activity is mediated through a calcineurin-dependent pathway.

Gene expression in skeletal muscles of adult vertebrates is altered profoundly by changing patterns of contractile work. Here we observed that the functional activity of MEF2 transcription factors is stimulated by sustained periods of endurance exercise or motor nerve pacing, as assessed by expression in trans genic mice of a MEF2-dependent reporter gene (desMEF2-lacZ). This response is accompanied by transformation of specialized myofiber subtypes, and is blocked either by cyclosporin A, a specific chemical inhibitor of calcineurin, or by forced expression of the endogenous calcineurin inhibitory protein, myocyte-enriched calcineurin interacting protein 1. Calcineurin removes phosphate groups from MEF2, and augments the potency of the transcriptional activation domain of MEF2 fused to a heterologous DNA binding domain. Across a broad range, the enzymatic activity of calcineurin correlates directly with expression of endogenous genes that are transcriptionally activated by muscle contractions. These results delineate a molecular pathway in which calcineurin and MEF2 participate in the adaptive mechanisms by which skeletal myofibers acquire specialized contractile and metabolic properties as a function of changing patterns of muscle contraction.

Costs of counterdefenses to host resistance in a parasitoid of Drosophila.

The ability of a parasitoid to evolve enhanced counterdefenses against host resistance and its possible costs were studied in a Drosophila-parasitoid system. We reared Asobara tabida (Braconidae, Hymenoptera) exclusively on D. melanogaster to impose artificial selection for improved counterdefenses against cellular encapsulation, the main host defense against parasitism. Controls were reared on D. subobscura, the main host of the population of wasps from which the laboratory culture was derived and a species that never encapsulates parasitoids. We observed improved survival and avoidance of encapsulation in all five selection lines compared to their paired control lines, although there was unexpected variation among pairs. Improved survival was associated with parasitoid eggs becoming embedded in host tissue, where they were protected from circulating haemocytes. There were no differences among lines in average adult size, fat content, egg load, or performance on D. subobscura. However, the duration of the egg stage in selection lines was longer than that of control lines, probably because of reduced nutrient and/or oxygen supply when eggs are embedded in host tissue. We suggest that this delay in hatching reduces the probability of parasitoid survival if another parasitoid egg is laid in the same host (superparasitism or multiparasitism) and hence is a cost of enhanced counterdefenses against host resistance.

Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma. METHODS: A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI. RESULTS: One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound. CONCLUSIONS: In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.

Comparison of benefits on myocardial performance of cellular cardiomyoplasty with skeletal myoblasts and fibroblasts.

Cellular cardiomyoplasty (CCM), or introduction of immature cells into terminally injured heart, can mediate repair of chronically injured myocardium. Several different cell types, ranging from embryonic stem cells to autologous skeletal myoblasts, have been successfully propagated within damaged heart and shown to improve myocardial performance. However, it is unclear if the functional advantages associated with CCM depend upon the use of myogenic cells or if similar results can be seen with other cell types. Thus, we compared indices of regional contractile (systolic) and diastolic myocardial performance following transplantation of either autologous skeletal myoblasts (Mb) or dermal fibroblasts (Fb) into chronically injured rabbit heart. In vivo left ventricular (LV) pressure (P) and regional segment length (SL) were determined in 15 rabbits by micromanometry and sonomicrometry 1 week following LV cryoinjury (CRYO) and again 3 weeks after autologous skeletal Mb or dermal Fb transplantation. Quantification of systolic performance was based on the linear regression of regional stroke work and end-diastolic (ED) SL. Regional diastolic properties were assessed using the curvilinear relationships between LVEDP and strain (epsilon) as well as LVEDP and EDSL. At study termination, cellular engraftment was characterized histologically in a blinded fashion. Indices of diastolic performance were improved following CCM with either Mb or Fb. However, only Mb transplantation improved systolic performance; Fb transfer actually resulted in a significant decline in systolic performance. These data suggest that both contractile and noncontractile cells can improve regional material properties or structural integrity of terminally injured heart, as reflected by improvements in diastolic performance. However, only Mb improved systolic performance in the damaged region, supporting the role of myogenic cells in augmenting contraction. Further studies are needed to define the mechanism by which these effects occur and to evaluate the long-term safety and efficacy of CCM with any cell type.

Good visual function in posterior microphthalmos.

Posterior microphthalmos is a rare condition in which the anterior segment is normal in size and configuration, but the posterior segment is reduced in size; this results in axial hyperopia and retinal folding. Patients have decreased vision that is caused by posterior segment abnormalities, high refractive error, and amblyopia. We present a case of posterior microphthalmos in which retinal function was relatively intact and visual loss was believed to be primarily caused by refractive error and amblyopia. After treatment, the child's visual acuity and school performance improved. This case emphasizes the need for careful examination, refraction, and follow-up for these children because their visual potential may be reasonably good.

Myogenic cell transplantation improves in vivo regional performance in infarcted rabbit myocardium.

BACKGROUND: Although cardiac transplantation is an ideal treatment for end-stage heart disease, inadequate donor availability has stimulated efforts to manage terminally injured myocardium by other innovative methods. Autologous skeletal myoblast transplantation, or cellular cardiomyoplasty, is one method to potentially mediate myocardial repair within chronically injured hearts. However, few investigators have documented the ability of myogenic cells to alter load-insensitive indices of systolic and diastolic performance in vivo. In this study, both systolic and diastolic regional myocardial function were evaluated following left ventricular cryoinjury and compared with function after myogenic cell transplantation. METHODS: Left ventricular pressure and segment length were determined in 9 rabbits by micromanometry and sonomicrometry 1 week following cryoinjury and 3 weeks after myoblast transplantation. At study termination, the extent of myoblast engraftment was determined by histologic analysis. Systolic performance was based on the linear regression of stroke work and end-diastolic segment length. Diastolic properties were evaluated by the curvilinear relationships between left ventricular pressure and strain, and left ventricular pressure and end-diastolic segment length. RESULTS: Although mean indices of systolic performance were unchanged after cell transplantation, systolic performance improved in 3 animals. In contrast, myoblast engraftment was associated with significantly improved diastolic properties (strain and dynamic stiffness) in all animals. CONCLUSIONS: These data quantify temporal changes in regional myocardial performance and suggest that cellular cardiomyoplasty improves diastolic compliance prior to affecting systolic performance. Cellular cardiomyoplasty, a potential therapeutic option for ischemic heart disease, appears to reverse diastolic creep and thus may represent a clinical alternative to transplantation in the near future.

Periocular abscess and cellulitis from Pasteurella multocida in a healthy child.

PURPOSE: To examine an unusual cause of periorbital cellulitis, Pasteurella multocida. METHODS: Case report, review of the literature. RESULTS: We treated a 13-year-old previously healthy child who developed Pasteurella preseptal cellulitis secondary to a cat bite and cat scratch. After receiving a dose of intravenous antibiotics and starting oral antibiotics, the child had delayed onset of several abscesses around the right eye, with marked pain and erythema. After incision and drainage, he improved. CONCLUSION: Pasteurella multocida is a rare but potentially serious cause of ocular infection. All cases of potential exposure should be treated promptly and followed until complete resolution of infection.

Anterior hyaloid face opacification after pediatric Nd:YAG laser capsulotomy.

PURPOSE: The purpose of this study was to examine the clarity of the visual axis after Nd:YAG laser capsulotomy following cataract extraction and primary intraocular lens implantation in a pediatric population. METHODS: A retrospective review was performed of all cases of cataract extraction and primary intraocular lens implantation over a period of 5 years. A group of children who had been treated by primary surgical posterior capsulotomy and anterior vitrectomy (Group 1) was used as the "gold standard," with whom the children treated with Nd:YAG laser capsulotomy (Group 2) were compared. The groups were studied for the incidence of opacification of the visual axis after the primary procedure. RESULTS: Data on 78 eyes were reviewed, and 56 eyes met inclusion criteria. Of these, 33 eyes were treated with primary posterior capsulotomy and anterior vitrectomy (Group 1) and 23 eyes were treated with Nd:YAG laser capsulotomy (Group 2). One eye (3%) of Group 1 experienced postoperative visual axis reopacification. Thirteen (57%) of 23 eyes in Group 2 experienced reopacification, requiring retreatment. Four eyes (17%) treated with Nd:YAG laser required a third treatment. CONCLUSIONS: In our series, 57% of patients treated with Nd:YAG laser capsulotomy experienced reopacification across the anterior hyaloid face. With the removal of the anterior vitreous at the time of cataract extraction, the scaffolding for cell migration is removed and reopacification of the visual axis is rarely seen. For patients in whom slit-lamp capsulotomy is not possible, especially if there is no Nd:YAG laser available for use in the operating room or when loss to follow-up may be an issue, primary posterior capsulotomy and anterior vitrectomy should be strongly considered.

Cellular cardiomyoplasty improves diastolic properties of injured heart.

BACKGROUND: Acute myocardial infarction leads to loss of functional myocytes and structural integrity that often decreases diastolic compliance and increases resting myocardial segment length (diastolic creep). Successfully engrafting autologous skeletal myoblasts could improve compliance and potentially reverse creep. Thus, we transplanted myoblasts into cryoinjured rabbit heart (n = 15, CRYO) and measured regional diastolic properties in the presence (n = 9, +ENG) or absence (n = 6, -ENG) of engraftment. MATERIALS AND METHODS: Left ventricular (LV) pressures (P) and myocardial segment lengths (SL) were measured in vivo by micromanometry and sonomicrometry after cryoinjury (CRYO) and again 3 weeks following transplantation of myoblasts. Performance was estimated from the relationships between end-diastolic (ED) P and strain (epsilon) or between EDP and EDSL. Compliance was characterized by strain (epsilon(8)) and dynamic stiffness (dP/dL(8)) at 8 mm Hg. Creep was characterized by resting myocardial segment length (EDSL(0)) and static stiffness at 8 mm Hg (m(stat8)). RESULTS: Successful myoblast engraftment was determined via histologic examination. In nine +ENG animals, diastolic properties improved. Regional strain (epsilon(8)) increased (0.06 +/- 0.02 CRYO vs 0.10 +/- 0.04 +ENG; P = 0.0009) while dynamic stiffness (dP/dL(8)) decreased (43 +/- 23 mm Hg/mm CRYO vs 23 +/- 14 mm Hg/mm +ENG; P = 0.009). Static stiffness (m(stat8)) was unaffected (0.78 +/- 0.2 mm Hg/mm CRYO vs 0.72 +/- 0. 1 mm Hg/mm +ENG; P = 0.08), and creep did not occur (EDSL(0) = 10.3 +/- 2.8 CRYO vs 10.4 +/- 2.3 +ENG; P = 0.74). In the absence of myoblast engraftment (n = 6, -ENG), strain decreased (epsilon(8) = 0. 06 +/- 0.02 CRYO vs 0.05 +/- 0.02 -ENG; P = 0.048), but dynamic stiffness (dP/dL(8)) did not (36 +/- 19 mm Hg/mm CRYO vs 28 +/- 12 mm Hg/mm -ENG; P = 0.20). Furthermore, static stiffness decreased (0. 78 +/- 0.3 mm Hg/mm CRYO vs 0.65 +/- 0.2 mm Hg/mm -ENG; P = 0.05) and creep was obvious (EDSL(0) = 10.8 +/- 3.6 mm CRYO vs 13.0 +/- 4. 4 mm -ENG, P = 0.04). CONCLUSIONS: Myoblast engraftment may partially overcome the loss of myocytes and structural integrity that often follow chronic myocardial ischemia. Improved compliance and reversal of diastolic creep suggest regeneration of viable muscle within once infarcted myocardium.

Intracardiac transplantation of skeletal myoblasts yields two populations of striated cells in situ.

BACKGROUND: Adult heart lacks stem cells and cannot effectively regenerate. In contrast, skeletal muscle is constantly undergoing repair. We proposed to transplant immature skeletal myoblasts into injured myocardium. METHODS: Approximately 7x10(6) soleus skeletal myoblasts were expanded in vitro from adult New Zealand White rabbits (n = 23) whose posterior left ventricle was cryoinjured to create a transmural lesion. Autologous myoblasts (n = 18) or saline (n = 5) was transplanted into the central cryolesion at the time of injury (n = 6) or 1 week later (n = 12). Hearts were harvested 2 weeks after injection. RESULTS: Myoblast transfer did not incur further morbidity. After cryolesion, grossly, a 1.6-cm epicardial hemorrhagic lesion could be seen. Histologically, the transmural lesion contained inflammatory cells and active scarring but no viable cardiomyocytes. Electron microscopy demonstrated a predominance of collagen and fibroblasts. Nine hearts contained multinucleated cells within the cryolesion that covered approximately 75% of the central cryolesion in 17% of animals. Immunohistochemical analysis confirmed their skeletal muscle origin. At the periphery of the lesion, isolated clusters of nonskeletal muscle cells could be visualized (n = 12) that resembled immature cardiocytes. CONCLUSIONS: Autologous skeletal myoblasts can regenerate viable striated tissue within damaged myocardium. Myoblast transfer warrants further investigation as a new method for improving myocardial performance within infarcted myocardium.

A load-independent in vivo model for evaluating therapeutic interventions in injured myocardium.

Although cardiomyocyte damage is normally irreversible, gene therapy and somatic cell transfer offer potential for improving function in damaged regions of the heart. However, in ischemic models of injury, variability in depth, size, and location of damage compromises statistical evaluation of in vivo function. We have adapted cryoablation to create a reproducible, posterior, transmural lesion within rabbit myocardium in which small changes in function are measurable in vivo. Before and at 2 and 6 wk postinjury, in vivo left ventricular intracavitary pressure and myocardial segment length were measured. Regional indexes of performance, segmental stroke work (SW), and percent systolic shortening (SS) were significantly decreased (P < 0.001) postcryoinjury as was the slope (Mw) of the linear preload recruitable SW relationship between SW and end-diastolic segment length (P = 0.0001). Decreased SW, SS, and Mw correlated with wall thinning, loss of myocytes, presence of fibroblasts, and transmural scar formation. Reproducible changes in regional myocardial performance in vivo postcryoinjury suggest that this is a reasonable model for evaluating novel therapies for cardiovascular disease.

Regenerating functional myocardium: improved performance after skeletal myoblast transplantation.

The adult heart lacks reserve cardiocytes and cannot regenerate. Therefore, a large acute myocardial infarction often develops into congestive heart failure. To attempt to prevent this progression, we transplanted skeletal myoblasts into cryoinfarcted myocardium of the same rabbits (autologous transfer), monitored cardiac function in vivo for two to six weeks and examined serial sections of the hearts by light and electron microscopy. Islands of different sizes comprising elongated, striated cells that retained characteristics of both skeletal and cardiac cells were found in the cryoinfarct. In rabbits in which myoblasts were incorporated, myocardial performance was improved. The ability to regenerate functioning muscle after autologous myoblast transplantation could have a important effect on patients after acute myocardial infarction.

Cyclic esotropia after a traumatic sixth nerve palsy in a child.

Cyclic esotropia is a rare phenomenon in which esotropia and orthophoria alternate over a period of 48 to 96 hours. The mechanism that underlies the phenomenon is unknown. Cyclic esotropia often occurs after a fusion-disrupting event. We report an unusual case of cycling esotropia with onset after a traumatic sixth nerve palsy. The cyclic phase persisted for 2 years, following a 48-hour alternate-day pattern. After strabismus surgery for the esotropic angle, the deviation disappeared and the patient remained orthotropic, with 1 year of follow-up to date.

Balloon dilatation for treatment of resistant nasolacrimal duct obstruction.

PURPOSE: Our purpose was to report our experience with balloon catheter dilatation for resistant nasolacrimal duct obstruction. METHODS: Patients enrolled had symptoms of nasolacrimal duct obstruction and (1) had failed previous probing or (2) were more than 2 years old. Balloon dilatation was performed with a LacriCATH lacrimal catheter (Atrion Medical Products, Birmingham, Ala.). A subset of patients had Silastic silicone rubber (Dow Corning, Midland, Mich.) intubation after balloon dilatation. Success was determined by clinical examination a minimum of 6 weeks later. RESULTS: Twenty-one lacrimal systems of 12 patients were treated (age range 4 months to 7 years). Of the patient subset treated with a LacriCATH lacrimal catheter alone, 9 of 18 systems demonstrated complete resolution of symptoms. Three of the 12 patients underwent balloon dilatation intraoperatively after attempts at Silastic silicone rubber intubation were unsuccessful. In two of these patients, who were younger, Silastic silicone rubber tubes passed easily after balloon treatment; however, in an older patient, age 5 years, intubation still could not be accomplished. CONCLUSION: Common clinical strategy for treatment of resistant nasolacrimal obstruction includes repeat probing, intubation of the nasolacrimal system with Silastic silicone rubber tubes, or dacryocystorhinostomy. Balloon catheter dilatation is an alternative or adjunct to consider. Factors that may affect the success of treatment include the age of the patient, the complexity of the nasolacrimal anatomy, and use of adjunctive systemic antibiotics and steroids.

Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism.

The operative management of patients with hyperparathyroidism is controversial. Higher rates for persistent hypercalcemia and postoperative hypoparathyroidism are seen in multiple-gland hyperplasia and in bilateral neck exploration. Hyperparathyroid patients undergoing unilateral neck exploration with removal of a single parathyroid adenoma have a rapid clearance of parathyroid hormone (PTH) that declines to undetectable levels within hours after successful parathyroid surgery. We have taken advantage of a sensitive immunoradiometric assay (IRMA) for the secreted biologically active, intact PTH-(1-84) molecule and demonstrated a decline of PTH to less than 40% of baseline values 15 minutes after successful parathyroid adenomectomy in 12 patients. Intraoperative measurement of PTH by modification of this IRMA may complement surgical skill and histopathologic information and has the potential for providing guidance regarding the extent of neck exploration necessary for determining surgical care of hyperparathyroidism.