Endoscopic dacryocystorhinostomy as an option for symptomatic epiphora in isolated monocanalicular obstruction.

Epiphora from monocanalicular obstruction is commonly treated with canaliculoplasty, with or without dacryocystorhinostomy, or with conjunctivodacryocystorhinostomy with Jones tube placement. We describe two patients with epiphora due to isolated monocanalicular obstruction without concurrent nasolacrimal duct obstruction who underwent endoscopic dacryocystorhinostomy; both cases had previously failed canaliculoplasty, and both reported significant improvement in epiphora postoperatively. We hypothesize this is due to decreased resistance through the lacrimal drainage system allowing for increased flow through the patent canaliculus and shortened lacrimal apparatus. In patients presenting with epiphora secondary to isolated monocanalicular obstruction, endoscopic dacryocystorhinostomy may be considered in the absence of nasolacrimal duct obstruction before proceeding to conjunctivodacryocystorhinostomy and Jones tube placement.

Effect of EnChroma glasses on color vision screening using Ishihara and Farnsworth D-15 color vision tests.

BACKGROUND: The prevalence of color vision deficiency (CVD) is about 0.5% in females and 8% in males. Although there is no cure for CVD, specially filtered glasses are purported to improve color contrast. One recent development is the EnChroma filter. The purpose of this study was to assess the effect of the EnChroma filter on color vision screening (CVS) using Ishihara and Farnsworth D-15 color vision tests. METHODS: The medical records of patients with CVD were reviewed retrospectively. Responses to color vision testing with and without the EnChroma filter were evaluated using Ishihara and Farnsworth D-15 tests, and the overall scores were analyzed. RESULTS: A total of 38 eyes of 19 patients were included. Mean error scores of no filter compared to EnChroma were significantly reduced in 17 eyes using the Ishihara test (0.88 ± 0.03 vs 0.85 ± 0.03, P = 0.017). The error score significantly reduced only in deutans (P = 0.022), not in protans (P = 0.44). The confusion index of no filter to the EnChroma filter was significantly reduced in 20 eyes using the Farnsworth test (3.30 ± 0.15 vs 2.98 ± 0.17; P = 0.01). The confusion index significantly reduced only in protans (P = 0.01), not in deutans (P = 0.19). CONCLUSIONS: In this study cohort, the EnChroma filter significantly reduced overall error scores using the Ishihara and Farnsworth tests; error scores on Ishihara testing reduced only in deutans. Conversely, the confusion index using Farnsworth reduced only in protans. The majority of patients reported subjective increase in color perception.

Orbital Myxofibrosarcoma: Case Report and Review of Literature.

Myxofibrosarcoma is rarely found in the orbit, let alone as a primary orbital tumor. With this having only been previously reported 5 times in the literature, there is a very limited understanding of its presentation and course. Typical management involves surgical excision with or without postoperative radiotherapy. Low-grade malignancy, although rare to metastasize, still has a high rate of local recurrence and with each recurrence increases the risk of metastatic potential. With this in mind, analysis of each case is critical in better understanding the disease, and this case adds to the current literature.

Are Traditional Radiographic Methods Accurate Predictors of Pedicle Morphology?

STUDY DESIGN: Cadaveric in vitro computed tomography (CT) imaging study. OBJECTIVE: To examine minimum pedicle diameter from transverse and coronal CT reconstructions of thoracolumbar spine specimens and compare their degree of disparity, if any. Pedicle angulation in coronal and transverse planes was measured and their contribution to the disparity in minimum pedicle diameter was assessed. SUMMARY OF BACKGROUND DATA: Spinal minimum pedicle diameter can be obtained from both transverse and coronal CT reconstructions; however, the degree of disparity in these measurements has not been described previously. Angulation of the pedicle in transverse and coronal planes may contribute to a disparity in minimum pedicle diameter acquired from reconstructions. This also has not been described previously. This study examined whether the disparity could be predicted by spinal level, as pedicle angulations vary in both coronal and transverse planes. METHODS: Five thoracolumbar specimens (T1-L5, age 48-59 yrs, male) were CT scanned utilizing clinical protocols. Minimum pedicle diameters and pedicle angulations were acquired in transverse and coronal reconstructions. Disparities between minimum pedicle diameters were measured and the correlation between this disparity and spinal level was characterized. RESULTS: A significant difference (P < 0.001) in minimum pedicle diameter existed between measures from coronal and transverse reconstructions. There was a significant correlation (P < 0.001) between the difference in minimal pedicle diameter and the transverse pedicle angle as well as the coronal pedicle angle. CONCLUSION: An overestimation of minimum pedicle diameter in the transverse reconstruction occurs when the coronal pedicle angulation increases, and in the coronal reconstruction when the transverse pedicle angulation increases. Therefore, pedicle angle should be determined using both coronal and transverse reconstructions and utilized to reduce the risk of overestimation of the true pedicle diameter. LEVEL OF EVIDENCE: NA.

What does Medicare pay rhinologists? An analysis of Medicare payment data.

BACKGROUND: Information about charges and payments for physician services continues to be scrutinized. Recently, the Centers for Medicare and Medicaid Services (CMS) released data regarding Medicare charges and payments to all physicians for calendar year 2012. The purpose of this study was to investigate the variability and patterns in Medicare charges and payments among a large sample of rhinologists. METHODS: Charge and payment data were obtained from publicly available CMS datasets (http://www.cms.gov). Data for all otolaryngologists and rhinology subsets were extracted. Charges, payments, fee multipliers, and total submitted claims were compared. Unequal variance 2-tailed t tests were used for analysis. RESULTS: Mean submitted charges for rhinologists were $291,464 compared to $211,209 for all otolaryngologists (p = 0.0014). Mean payments to rhinologists were $70,172 compared to $77,275 for all otolaryngologists (p = 0.24). Fees for services ranged from 1.33 to 14.29 times Medicare reimbursement rates (mean = 4.47). The fee multiplier was significantly higher for operating room-based codes compared to office-based codes (9.43 vs 3.44, p < 0.001). Academic rhinologists submitted fewer claims and had a higher fee multiplier than private rhinologists (p < 0.001). Academic and private rhinologists had no difference in submitted charges (p = 0.28). CONCLUSION: The wide availability of Medicare payment information makes it important for physicians to understand how their individual data compares to that of their colleagues. Medicare payments to rhinologists were comparable to otolaryngologists as a whole. Charges for services commonly performed by rhinologists vary widely. Academic rhinologists submitted fewer claims than their private colleagues, but overall charges and payments were comparable between the 2 groups.

Sacral insufficiency fracture after partial sacrectomy.

A 66-year-old woman presented with severe lower back pain. Magnetic resonance imaging (MRI) revealed a large, soft-tissue mass-a chordoma-at the S3-S4 level, eroding most of the S3 vertebral body and extending into S4. The mass extended beyond the involved sacrococcygeal segments and dorsally beyond normal cortical margins of the sacrum and coccyx. The patient underwent a noninstrumented sacrectomy distal to the S2 foramen, lumbar laminectomy L5, S1 and S2, and thecal sac transaction at the S3 nerve roots. At the third postoperative month, she noted onset of extreme pain in her groin and left thigh. MRI showed increased signal on short tau inversion recovery sequences, and T2-weighted images revealed a left sacral ala stress fracture with a vertically oriented fracture line. Over the next 3 months, the patient had a resolution of her pain and, at 2-year follow-up, the patient remained disease-free. Surgeons contemplating performing partial sacrectomies should bear in mind, even with preservation of the S1 body, that the potential for fracture exists as evidenced by our patient. It is our opinion that this patient did not require instrumentation but a more gradual rehabilitation program.

N-acetylcysteine reduces disease activity by blocking mammalian target of rapamycin in T cells from systemic lupus erythematosus patients: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: Systemic lupus erythematosus (SLE) patients exhibit T cell dysfunction, which can be regulated through mitochondrial transmembrane potential (Δψm) and mammalian target of rapamycin (mTOR) by glutathione (GSH). This randomized, double-blind, placebo-controlled study was undertaken to examine the safety, tolerance, and efficacy of the GSH precursor N-acetylcysteine (NAC). METHODS: A total of 36 SLE patients received either daily placebo or 1.2 gm, 2.4 gm, or 4.8 gm of NAC. Disease activity was evaluated monthly by the British Isles Lupus Assessment Group (BILAG) index, the SLE Disease Activity Index (SLEDAI), and the Fatigue Assessment Scale (FAS) before, during, and after a 3-month treatment period. Mitochondrial transmembrane potential and mTOR were assessed by flow cytometry. Forty-two healthy subjects matched to patients for age, sex, and ethnicity were studied as controls. RESULTS: NAC up to 2.4 gm/day was tolerated by all patients, while 33% of those receiving 4.8 gm/day had reversible nausea. Placebo or NAC 1.2 gm/day did not influence disease activity. Considered together, 2.4 gm and 4.8 gm NAC reduced the SLEDAI score after 1 month (P = 0.0007), 2 months (P = 0.0009), 3 months (P = 0.0030), and 4 months (P = 0.0046); the BILAG score after 1 month (P = 0.029) and 3 months (P = 0.009); and the FAS score after 2 months (P = 0.0006) and 3 months (P = 0.005). NAC increased Δψm (P = 0.0001) in all T cells, profoundly reduced mTOR activity (P = 0.0009), enhanced apoptosis (P = 0.0004), reversed expansion of CD4-CD8- T cells (mean ± SEM 1.35 ± 0.12-fold change; P = 0.008), stimulated FoxP3 expression in CD4+CD25+ T cells (P = 0.045), and reduced anti-DNA production (P = 0.049). CONCLUSION: This pilot study suggests that NAC safely improves lupus disease activity by blocking mTOR in T lymphocytes.