Elisabeth H. Ference

The Clinical Presentation and Surgical Management of Adnexal Torsion in the Pediatric and Adolescent Population

STUDY OBJECTIVE To determine the history, clinical presentation, physical exam, and laboratory findings of ovarian and/or tubal torsion in the pediatric and adolescent population and to examine the surgical management of adnexal torsion. DESIGN Descriptive, retrospective chart review. SETTING Academic childrens hospital. PARTICIPANTS Children and adolescents, aged 3-21 years, with the surgical diagnosis of ovarian and/or tubal torsion. MAIN OUTCOME MEASURES Pain, physical exam, and laboratory characteristics and surgical outcomes. RESULTS Of the 82 cases, there was a higher rate of right-sided adnexal torsion (64%). The most commonly reported duration of pain was 24 hours. Most (91%) stated the pain has sudden onset and 69% qualified the pain as severe. Eighty-three percent complained of nausea and 67% had vomiting. There was a higher rate of tachycardia in younger patients (P = 0.003). On exam, 91% of subjects presented with tenderness, usually in the right lower quadrant (61%). A longer duration of pain was associated with a higher rate of oophorectomy and/or salpingectomy. There was no difference in the rates of the removal of adnexal structures between gynecologists and pediatric surgeons. CONCLUSIONS Most pediatric or adolescent patients with adnexal torsion present with acute onset of severe, intermittent pain lasting for 24 hours. Nausea and vomiting, as well as abdominal tenderness were common. Our findings will facilitate the accurate diagnosis of adnexal torsion and may contribute to more expedient surgical management.

Combination Treatments for Psoriasis: A Systematic Review and Meta-analysis

OBJECTIVE To summarize the current state of evidence for combination topical and systemic therapies for mild to severe psoriasis. DATA SOURCES We performed a systematic search for all entries in PubMed, CINAHL, Cochrane Review, and EMBASE related to combination treatments for psoriasis through July 2010. STUDY SELECTION We included randomized controlled trials that reported proportion of disease clearance or mean change in clinical severity score (or provided these data through communication with study authors) for efficacy of a combination treatment for psoriasis compared with 1 or more corresponding monotherapies. DATA EXTRACTION Study data were extracted by 3 independent investigators, with disagreement resolved by consensus. The proportion of patients who achieved clearance, definition of clearance, means and standard deviations for baseline disease symptom score and final disease symptom score, and major design characteristics were extracted for each study. DATA SYNTHESIS Combination treatments consisting of vitamin D derivative and corticosteroid, vitamin D derivative and UV-B, vitamin A derivative and psoralen-UV-A, vitamin A derivative and corticosteroid, vitamin A derivative and UV-B, corticosteroid and hydrocolloid occlusion dressings, UV-B and alefacept, and vitamins A and D derivatives were more effective than 1 or more monotherapies using the likelihood of clearance as the outcome. Blinding status and potency of the corticosteroid treatment used were significant sources of heterogeneity between studies. CONCLUSIONS The results demonstrate the need for additional long-term trials with standardized outcome measures to evaluate the efficacy and adverse effects of combination therapies for psoriasis and highlight the possible effects of trial design characteristics on results.

The prevalence of bacterial infection in acute rhinosinusitis: A systematic review and meta-analysis

To systematically assess the prevalence of bacterial infection in adults with acute rhinosinusitis (ARS).

Operative utilization of balloon versus traditional endoscopic sinus surgery

To study the utilization of balloon catheter dilation (BCD) compared to traditional endoscopic sinus surgery (ESS)

Surgical anatomy and variations of the infraorbital nerve.

To assess relevant variations in the anatomical course of the infraorbital nerve (ION). This understanding may reduce the risk of surgical injury.

Commentary on gender differences in prevalence, treatment, and quality of life of patients with chronic rhinosinusitis

Objective To examine the existing evidence on gender differences in the prevalence, treatment, and quality of life of patients with chronic rhinosinusitis (CRS). Methods Review of the literature and expert opinion. Results From a sociologic standpoint, women have historically been considered more likely to report symptoms, seek medical care, and give poorer self-evaluation of health, which may bias data toward increased prevalence and a greater effect of CRS on quality of life in women. However, the influence of gender seems to be restricted primarily to the evaluation of general quality of life, whereas the disease-specific health-related quality of life is not different between genders. Furthermore, migraine headaches, which are more common among women, may be misdiagnosed as CRS, which contributes to gender differences in the prevalence of CRS. The degree to which reported differences in prevalence and health utilization represent biologic or physiologic differences between genders is not known; however, differences in anatomic size, tobacco susceptibility, and hormonal factors have been speculated to increase the overall susceptibility to CRS in women compared with men. Conclusions Focused research that examines the effect of gender on the development, treatment, and outcomes of CRS is warranted.

Current Utilization of Balloon Dilation versus Endoscopic Techniques in Pediatric Sinus Surgery

Objectives To study the utilization of balloon catheter dilation (BCD) compared to traditional endoscopic surgery (ESS) in pediatric patients. Study Design Cross-sectional analysis. Setting Hospital and freestanding ambulatory surgery centers in California, Florida, Maryland, and New York Subjects Patients less than 18 years who underwent BCD(316) or ESS(2346), as identified by CPT codes from the State Ambulatory Surgery Databases 2011. Methods Patient and facility demographics, mean charges, and operating room time were examined using bivariate and multivariate analyses. Results A total of 2662 children underwent surgery, with BCD used in 10.6% of maxillary, 8.4% of sphenoid, and 11.8% of frontal procedures. Adjusted analysis found that children with asthma, allergic rhinitis (AR), GERD, or concomitant adenoidectomy were more likely to have BCD compared to patients without these comorbidities, asthma odds ratio (OR) = 1.94 (95% CI, 1.84-3.41), AR OR = 1.77 (95% CI, 1.03-3.07), GERD OR = 2.79 (95% CI, .59-4.90), or without adenoidectomy OR = 2.50 (95% CI, 1.84-3.41). Patients with cystic fibrosis were less likely to have BCD, OR = 0.33 (95% CI, 0.11-0.95). Median charges for patients undergoing maxillary antrostomy alone by BCD (P = .042) or with adenoidectomy (P < .001) were approximately

National Trends in Retropharyngeal Abscess among Adult Inpatients with Peritonsillar Abscess

2100 and

Measurement and comparison of health utility assessments in chronic rhinosinusitis

4200 greater than the median of patients undergoing those procedures with ESS. However, operating room time was similar (P = .81) between patients undergoing maxillary antrostomy, regardless of whether BCD was used, but was longer (P < .001) in those undergoing maxillary antrostomy and adenoidectomy when BCD was utilized. Conclusions BCD was used in 11.9% of pediatric sinus surgery and had higher average charges with no decrease in OR time compared to procedures that only utilized ESS. Future research is necessary to evaluate whether BCD may lead to improved outcomes and eventually decreased operating room time for pediatric patients with chronic rhinosinusitis.

Antibiotic Prescribing by Physicians Versus Nurse Practitioners for Pediatric Upper Respiratory Infections

Objectives To describe national trends in retropharyngeal abscess (RPA) complicating peritonsillar abscess (PTA) and to determine factors associated with RPA in patients with PTA. Study Design Cross-sectional analysis. Setting Nationwide Inpatient Sample, 2003-2010. Subjects and Methods PTA patients ≥18 years old, with or without RPA, were extracted according to ICD-9-CM codes. The cohort was analyzed with descriptive statistics and multivariate regression modeling to identify factors associated with RPA. Results Of the 91,647 (95% CI: 86,433-95,449) patients identified with PTA, 885 (1.0%) also had a concurrently coded RPA. The annual rate of concomitant RPA increased from 0.5% (95% CI: 0.3%-0.8%) to 1.4% (95% CI: 1.0%-2.0%) between 2003 and 2010 (P < .001). PTA patients with RPA more frequently underwent tonsillectomy (23.5% vs 11.1%), endotracheal intubation (7.1% vs 1.5%), and mechanical ventilation (13.2% vs 2.0%) than those without RPA (all P < .001). PTA patients with RPA were significantly older (41 vs 34 years old), had a longer hospital stay (6.4 vs 2.5 days), and had more procedures (2.5 vs 0.9) when compared to patients without RPA (all P < .001). Upon multivariate regression analysis, factors associated with RPA included the age groups of 40 to 64 years (odds ratio, 2.256; P < .001) and 65 and older (odds ratio, 2.086; P = .045). Median total charges for PTA inpatients with concomitant RPA were approximately