Prognostic factors for polyp recurrence in chronic rhinosinusitis with nasal polyps

Clinical Practice Guideline: Surgical Management of Chronic Rhinosinusitis

OBJECTIVE

The purpose of this specialty-specific clinical practice guideline is to identify quality improvement opportunities and provide clinicians with trustworthy, evidence-based recommendations for the surgical management of chronic rhinosinusitis in adults. The target audience includes otolaryngologist-head and neck surgeons who manage adults with chronic rhinosinusitis, including candidacy and performance of endoscopic sinus surgery.

METHODS

This guideline was developed using the 55-page protocol published as the American Academy of Otolaryngology-Head and Neck Surgery Foundation's Clinical Practice Guideline Development Manual (3rd edition), which summarizes the methodology for assessments of current data, topic prioritization, development of key action statements (KASs), application of value judgments, and related procedures. The guideline group represented otolaryngologists, rhinologists, advanced practice nursing and physician assistants, and consumers who represented participating national professional organizations.

ACTION STATEMENTS

The Guideline Development Group made strong recommendations for the following KASs: Before considering surgery, the surgeon should verify an existing diagnosis of chronic rhinosinusitis to ensure established diagnostic criteria (signs and symptoms) from clinical practice guidelines are met, and the surgeon should assess candidacy for sinus surgery based on symptoms, disease characteristics, quality of life, and prior medical or surgical therapy (KASs 1A and 1B). The surgeon or their designee should not prescribe antibacterial therapy to an adult with chronic rhinosinusitis if significant or persistent purulent nasal discharge (anterior, posterior, or both) is absent on examination (KAS 3). The Guideline Development Group made recommendations for the following KASs: The surgeon should not endorse or require a predefined, one-size-fits-all regimen or duration of medical therapy (eg, antibiotics, steroids, antihistamines) as a prerequisite to sinus surgery for an adult with chronic rhinosinusitis (KAS 2). The surgeon should identify patients with chronic rhinosinusitis that would benefit most from surgery and are least likely to benefit from continued medical therapy alone, such as those with chronic rhinosinusitis subtypes that include, but are not limited to, chronic rhinosinusitis with polyps, polyps with bony erosion, eosinophilic mucin, or fungal balls (KAS 4). The surgeon or their designee should counsel patients before sinus surgery to establish realistic expectations, including the potential for chronicity or relapse, and the likelihood of long-term medical management, taking into account their chronic rhinosinusitis subtype (KAS 5). The surgeon should offer sinus surgery to an adult with chronic rhinosinusitis when the anticipated benefits exceed that of nonsurgical management alone, there is clarity regarding the anticipated outcomes, and the patient understands the expectation for long-term disease management following surgery (KAS 6). For an adult who is a candidate for sinus surgery, the surgeon or their designee should obtain a computed tomography (CT) scan with a fine-cut protocol, if not already available, to examine the paranasal sinuses for surgical planning (KAS 7). The surgeon should not plan the extent of sinus surgery (eg, which specific sinuses to operate on) solely based on arbitrary criteria regarding a minimal level of mucosal thickening, sinus opacification, or outflow obstruction on a CT scan (KAS 8). The surgeon or their designee should educate an adult with chronic rhinosinusitis who is scheduled for sinus surgery regarding anticipated postoperative care, specifically pain control, debridement, medical management, activity restrictions, return to work, duration and frequency of follow-up visits, and the potential for recurrent disease or revision surgery (KAS 9). When the sinus involves polyps, osteitis, bony erosion, or fungal disease in an adult with chronic rhinosinusitis who is scheduled for sinus surgery, the surgeon should perform sinus surgery that includes full exposure of the sinus cavity (lumen) and removal of diseased tissue, not just balloon or manual ostial dilation, or refer the patient to a surgeon who can perform this extent of surgery (KAS 10). The surgeon or their designee should routinely follow up to assess and document outcomes of sinus surgery for chronic rhinosinusitis, between 3 and 12 months after the procedure, through history (symptom relief, quality of life, complications, adherence to therapy, need for rescue medications, and ongoing care) and nasal endoscopy (KAS 11). There were no recommendations that were considered options from the Guideline Development Group.

Identifying Lactylation-related biomarkers and therapeutic drugs in ulcerative colitis: insights from machine learning and molecular docking

BACKGROUND

Ulcerative colitis (UC), a chronic relapsing-remitting inflammatory bowel disease. Recent studies have shown that lactylation modifications may be involved in metabolic-immune interactions in intestinal inflammation through epigenetic regulation, but their specific mechanisms in UC still require in-depth validation.

METHODS

We conducted comparative analyses of transcriptomic profiles, immune landscapes, and functional pathways between UC and normal cohorts. Lactylation-related differentially expressed genes were subjected to enrichment analysis to delineate their mechanistic roles in UC. Through machine learning algorithms, the diagnostic model was established. Further elucidating the mechanisms and regulatory network of the model gene in UC were GSVA, immunological correlation analysis, transcription factor prediction, immunofluorescence, and single-cell analysis. Lastly, the CMap database and molecular docking technology were used to investigate possible treatment drugs for UC.

RESULTS

Twenty-two lactylation-related differentially expressed genes were identified, predominantly enriched in actin cytoskeleton organization and JAK-STAT signaling. By utilizing machine learning methods, 3 model genes (S100A11, IFI16, and HSDL2) were identified. ROC curves from the train and test cohorts illustrate the superior diagnostic value of our model. Further comprehensive bioinformatics analyses revealed that these three core genes may be involved in the development of UC by regulating the metabolic and immune microenvironment. Finally, regorafenib and R-428 were considered as possible agents for the treatment of UC.

CONCLUSION

This study offers a novel strategy to early UC diagnosis and treatment by thoroughly characterizing lactylation modifications in UC.

Development of a nomogram for predicting the risk of carcinoma in chronic atrophic gastritis

OBJECTIVE

To construct a machine learning (ML) model to predict the progression of chronic atrophic gastritis (CAG) to gastric cancer (GC), given its precancerous significance.

METHODS

Using medical records from the Affiliated Hospital of Qingdao University, common laboratory indicators were extracted. LASSO regression identified 10 core risk factors, which were further analyzed using binary logistic regression to develop a nomogram model in R. The model's performance was evaluated using receiver operating characteristic (ROC) curves, the concordance index (C-index), calibration curves, and decision curve analysis (DCA).

RESULTS

The model showed excellent performance, with a C-index of 0.887. The key factors included sex, coagulation, blood cell indexes, and blood lipid levels. The ROC areas were 0.892 (quantitative) and 0.853 (qualitative), confirming model reliability.

CONCLUSION

A new nomogram model for assessing GC risk in CAG patients was successfully developed. However, due to data collection and time limitations, future studies should expand the sample size, perfect the validation process, and optimize the model to achieve more accurate risk prediction.

Investigation of PDE5 effect on NOS in nasal polyp pathophysiology

PURPOSE

Nasal polyps are masses resulting from chronic mucosal inflammation. Nitric oxide (NO) has recently attracted attention in nasal polyps as it plays an important role in both acute and chronic inflammation. One of the important mechanisms controlling NO production is phosphodiesterase (PDE) enzymes. The enzyme phosphodiesterase type 5 (PDE5) is an important regulator of cyclic guanosine 3'-5'-monophosphate (cGMP) signalling. PDE5 inhibitors increase intracellular cGMP concentration by inhibiting cGMP degradation and prolong NO signalling. NO is thought to cause nasal congestion because it increases microvascular permeability and causes mucosal oedema. The aim of our study was to investigate the role of PDE5, inducible nitric oxide synthase (iNOS), and endothelial nitric oxide synthase (eNOS) in the pathophysiology of nasal polyps with mucosal oedema in histopathology.

METHODS

Nasal mucosal tissues were obtained from 25 patients with nasal polyps who underwent endoscopic sinus surgery as the study group and 25 patients who underwent rhinoplasty as the control group. eNOS, iNOS and PDE5 levels were measured in nasal mucosal tissues.

RESULTS

The mean age was 47.40 ± 16.33 years in the nasal polyp group and 35.44 ± 12.47 years in the normal group, and 64.0% (n = 16) of both groups were male. ELISA measurements showed that PDE5 levels were significantly decreased and iNOS and eNOS levels were significantly increased in the nasal polyp group compared with the control group. CONCLUSıON: This study suggest that iNOS, eNOS, and PDE5 may play important roles in the pathophysiology of nasal polyps.

Clinical efficacy and mechanisms of biologics for chronic rhinosinusitis with nasal polyps

The management of chronic rhinosinusitis with nasal polyps (CRSwNP) can be challenging, particularly when standard treatments including intranasal corticosteroids and endoscopic sinus surgery do not result in adequate symptom control. CRSwNP is frequently characterized by a type 2 immune signature, and many patients have other comorbid type 2 conditions, including asthma. There are currently 3 biologic therapies approved for the treatment of CRSwNP-omalizumab, mepolizumab, and dupilumab-and there are promising therapies in development. Biologic therapies allow for improved patient quality of life in CRSwNP, reduction in need for systemic corticosteroid treatment and endoscopic sinus surgery, and improvement in treatment of comorbidities. Translational studies assessing how biologic therapies can modify inflammation in CRSwNP have allowed for a greater understanding of CRSwNP pathogenesis. We review CRSwNP clinical trial and real-world data on the effectiveness and safety of biologics, discuss their therapeutic mechanisms, assess outcomes of biologic therapy versus endoscopic sinus surgery, and discuss therapies in development and future directions.

Relevance of the LOEM Classification in Chronic Rhinosinusitis Management: A Retrospective Analysis of Surgical Outcomes

BACKGROUND

The lack of a standardized framework for defining endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) has led to ambiguity and inconsistency in surgical descriptions. This study evaluates the recently described lamella ostium extent mucosa (LOEM) classification's usefulness, aiming to solidify its role in enhancing clinical decision-making and the reproducibility of surgical studies.

METHODS

A nonrandomized retrospective study compared CRS patients who underwent ESS, categorized into four groups based on LOEM. Baseline characteristics, disease severity, and QoL were compared at baseline and 2 years postsurgery. Predictors of clinically meaningful improvements in QoL were assessed using linear and logistic regression models, analyzing changes in the Sinonasal Outcome Test (SNOT)-22. Additionally, a subgroup analysis evaluated QoL outcomes specific to different clinical phenotypes and the ESS type (t) performed.

RESULTS

305 patients were analyzed, with significant baseline differences across ESS groups, showing increasing disease severity and comorbidities from t1 to t4 surgeries. The t4 ESS showed the greatest postoperative improvements in SNOT-22, nasal polyp score, and Lund Mackay scale. Multivariate regression confirmed t4 ESS as a significant predictor of greater QoL improvements and higher responder rates (OR = 8.49, p = 0.036). Subgroup analyses found that prior ESS negatively impacted outcomes, while t4 ESS was more effective across CRS phenotypes, except in exclusive atopy, where t3 ESS proved superior.

CONCLUSIONS

The LOEM classification correlates surgical complexity with disease burden. The t4 ESS demonstrated superior clinical outcomes, particularly in CRS patients with poorly controlled asthma, severe N-ERD, or several prior ESS. These findings underscore the importance of personalized surgical planning and the potential utility of the LOEM system in optimizing patient outcomes.

The immunology of asthma and chronic rhinosinusitis

Asthma and chronic rhinosinusitis (CRS) are common chronic inflammatory diseases of the respiratory tract that have increased in prevalence over the past five decades. The clinical relationship between asthma and CRS has been well recognized, suggesting a common pathogenesis between these diseases. Both diseases are driven by complex airway epithelial cell and immune cell interactions that occur in response to environmental triggers such as allergens, microorganisms and irritants. Advances, including a growing understanding of the biology of the cells involved in the disease, the application of multiomics technologies and the performance of large-scale clinical studies, have led to a better understanding of the pathophysiology and heterogeneity of asthma and CRS. This research has promoted the concept that these diseases consist of several endotypes, in which airway epithelial cells, innate lymphoid cells, T cells, B cells, granulocytes and their mediators are distinctly involved in the immunopathology. Identification of the disease heterogeneity and immunological markers has also greatly improved the protocols for biologic therapies and the clinical outcomes in certain subsets of patients. However, many clinical and research questions remain. In this Review, we discuss recent advances in characterizing the immunological mechanisms of asthma and CRS, with a focus on the main cell types and molecules involved in these diseases.

Inflammatory and homeostatic roles of eosinophil subpopulations in chronic rhinosinusitis with nasal polyp pathogenesis

Chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) mainly expresses type-2 endotype, featuring eosinophils as a main player in the inflammatory process. Prolonged eosinophilia in the tissues of asthma and CRSwNP patients has been associated with structural changes, leading to fixed airflow obstruction in asthma and nasal polyposis in CRSwNP. This suggests that eosinophils may belong to different subgroups playing distinct roles in pathogenesis. Recent studies highlight the roles of inflammatory eosinophils (iEOS) in driving inflammation and tissue damage, whereas tissue-resident eosinophils (rEOS) maintain homeostasis and tissue repair in the airway. Therefore, understanding both roles of eosinophil subpopulations is crucial for better CRSwNP management, including enhancing the diagnosis accuracy, predicting recurrence, and optimizing treatment strategies.

Relevance of anatomical remnants for revision sinus surgery

OBJECTIVES

Review of the scientific literature dedicated to investigating how residual structures impact surgical outcomes in chronic rhinosinusitis (CRS) patients, providing information on the frequency of anatomical remnants after endoscopic sinus surgery (ESS).

MATERIAL AND METHODS

This review has been reported following the recommendations of the SWiM guideline. PubMed, Cochrane Library, Embase, and Web of Science were searched until April 2024. Studies selected for the systematic review were assessed about quality and risk of bias using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and STROBE. The findings were analyzed descriptively and qualitatively, aligning with EPOS and ICAR guidelines.

RESULTS

Fourteen relevant studies met the inclusion criteria for qualitative synthesis. Prospective and retrospective cross-sectional designs, focusing on revision ESS, were included. Four studies examined full-house functional ESS (FESS), three focused on frontal sinus surgery, four on conventional FESS and three did not specify the surgery type. The risk of bias was assessed, revealing significant variability in study quality and a low level of evidence. Wide variability was found in anatomical structures remaining after ESS, most notably in retained uncinate process (29.6-64%), agger nasi cell (4.5-83.33%) and frontoethmoidal cells (40.7-96.8%). Observations on concha bullosa, septal deviation and lateralization of the middle turbinate revealed distinct patterns among the included studies.

CONCLUSION

This systematic review underscores the persistent challenge of incomplete resection of anatomical structures in revision surgeries for CRS. The variability in the retention of key structures highlights the complexity of surgical outcomes and the need for further refinement in surgical techniques.

Development and Validation of an Explainable Prediction Model for Postoperative Recurrence in Pediatric Chronic Rhinosinusitis

OBJECTIVE

This study aims to develop an interpretable machine learning (ML) predictive model to assess its efficacy in predicting postoperative recurrence in pediatric chronic rhinosinusitis (CRS).

STUDY DESIGN

A decision analysis was performed with retrospective clinical data.

SETTING

Recurrent group and nonrecurrent group.

METHODS

This retrospective study included 148 pediatric CRS treated with functional endoscopic sinus surgery from January 2015 to January 2022. We collected demographic characteristics and peripheral blood inflammatory indices, and calculated inflammation indices. Models were trained with 3 ML algorithms and compared their predictive performance using the area under the receiver operating characteristic (AUC) curve. Shapley Additive Explanations and Ceteris Paribus profiles were used for model interpretation. The final model was transformed into a web for interactive visualization.

RESULTS

Among the 3 ML models, the Random Forest (RF) model demonstrated the best discriminative ability (AUC = 0.728). After reducing features based on importance and tuning parameters, the final RF model, including 4 features (systemic immune inflammation index (SII), pan-immune-inflammation value (PIV) and percentage of eosinophils (E%) and lymphocytes (L%)), showed good predictive performance in internal validation (AUC = 0.779). Global interpretation of the model suggested that L% and E% substantially contribute to the overall model. Local interpretation revealed a nonlinear relationship between the included features and model predictions. To enhance its clinical utility, the model was converted into a web (https://juice153.shinyapps.io/CRSRecurrencePrediction/).

CONCLUSION

Our ML model demonstrated promising accuracy in predicting postoperative recurrence in pediatric CRS, revealing a complex nonlinear relationship between postoperative recurrence and the features SII, PIV, L%, and E%.

GZMK-expressing CD8+ T cells promote recurrent airway inflammatory diseases

Inflammatory diseases are often chronic and recurrent, and current treatments do not typically remove underlying disease drivers1. T cells participate in a wide range of inflammatory diseases such as psoriasis2, Crohn's disease3, oesophagitis4 and multiple sclerosis5,6, and clonally expanded antigen-specific T cells may contribute to disease chronicity and recurrence, in part by forming persistent pathogenic memory. Chronic rhinosinusitis and asthma are inflammatory airway diseases that often present as comorbidities7. Chronic rhinosinusitis affects more than 10% of the general population8. Among these patients, 20-25% would develop nasal polyps, which often require repeated surgical resections owing to a high incidence of recurrence9. Whereas abundant T cells infiltrate the nasal polyps tissue10,11, T cell subsets that drive the disease pathology and promote recurrence are not fully understood. By comparing T cell repertoires in nasal polyp tissues obtained from consecutive surgeries, here we report that persistent CD8+ T cell clones carrying effector memory-like features colonize the mucosal tissue during disease recurrence, and these cells characteristically express the tryptase Granzyme K (GZMK). We find that GZMK cleaves many complement components, including C2, C3, C4 and C5, that collectively contribute to the activation of the complement cascade. GZMK-expressing CD8+ T cells participate in organized tertiary lymphoid structures, and tissue GZMK levels predict the disease severity and comorbidities better than well-established biomarkers such as eosinophilia and tissue interleukin-5. Using a mouse asthma model, we further show that GZMK-expressing CD8+ T cells exacerbate the disease in a manner dependent on the proteolytic activity of GZMK and complements. Genetic ablation or pharmacological inhibition of GZMK after the disease onset markedly alleviates tissue pathology and restores lung function. Our work identifies a pathogenic CD8+ memory T cell subset that promotes tissue inflammation and recurrent airway diseases by the effector molecule GZMK and suggests GZMK as a potential therapeutic target.

Long-term success and influencing factors of regenerative surgery for intra-bony defects: A retrospective cohort study

BACKGROUND

The composite outcome measure (COM) more comprehensively assesses the clinical efficacy of regenerative surgery than a single probing measurement. We aimed to assess long-term success defined by the COM (clinical attachment level [CAL] gain of ≥3 mm and postsurgery probing pocket depth [PPD] ≤ 4 mm) and influencing factors of regenerative surgery using bone substitutes and resorbable collagen membrane (RM) for intra-bony defects (IBDs).

METHODS

We retrospectively collected data from patients who underwent regenerative surgery using deproteinized bovine bone mineral (DBBM) and RM for IBDs. CAL and PPD values were compared at baseline (preoperative), 1 year (short-term), and at the last follow-up (5-10 years). Multivariate logistic regressions were performed to identify factors influencing COM-based long-term success.

RESULTS

Eighty-one defects in 75 teeth of 33 patients who completed follow-up (6.5 ± 1.4 years) were included. One tooth was lost. All defects with complete follow-up exhibited long-term average CAL gain (3.00 ± 2.00 mm, 95% confidence interval [CI]: 2.56-3.44 mm, p < 0.001) and PPD reduction (2.06 ± 1.91 mm, 95% CI: 1.64-2.49 mm, p < 0.001). Long-term success was achieved in 38.8% of IBDs. CAL and PPD values were comparable between 1 year and the last follow-up. Logistic regression analyses revealed that male sex (odds ratio [OR] = 0.23, 95% CI: 0.07-0.75) and bleeding on probing (BOP) during supportive periodontal therapy (OR = 0.96, 95% CI: 0.94-0.99) were risk factors for long-term success.

CONCLUSIONS

Regenerative surgery with DBBM and RM for IBDs can achieve some degree of long-term success defined by COM. However, within this study's limitations, male sex and higher BOP incidence postoperatively are negatively associated with optimal long-term success.

CLINICAL TRIAL NUMBER

ChiCTR2300069016.

A RESPONSE to antiIL-5 therapy in comorbid patients with chronic rhinosinusitis with nasal polyps and severe asthma: Study protocol

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) and severe asthma (SA) are 2 frequently coexisting conditions that are, in most cases, associated with eosinophilic inflammation. The concurrence of both diseases has a negative synergistic impact on disease severity and patients' health-related quality of life. Thus, a holistic, collaborative management of these patients is a critical unmet need. Mepolizumab, a systemic anti-IL-5 therapy, has been shown to be effective as an add-on treatment in both SA and CRSwNP, with more literature available on asthma outcomes than on CRSwNP.

Objectives

The primary objective of the study is to evaluate the real-world effectiveness of mepolizumab in improving the health-related quality of life of comorbid patients at 12 months using the SNOT-22 questionnaire. Secondary objectives include safety and efficacy outcomes of mepolizumab treatment in the 2 populations, which are expected to have variable severity of the respective comorbid conditions.

Methods

RESPONSE is a European real-world prospective cohort study designed to assess the effectiveness of mepolizumab in 2 cohorts of adult patients: one with SA as primary diagnosis with (secondary diagnosis) comorbid CRSwNP, and another with CRSwNP as primary diagnosis with (secondary diagnosis) comorbid asthma. Up to 350 patients receiving newly prescribed mepolizumab will be followed up for 12 months as per the investigators' standard of care.

Conclusion

This study will report the effects of anti-IL-5 therapy in both diseases investigated and the respective comorbidity, as well as the consequence of treating milder forms of asthma and CRSwNP with mepolizumab, supporting the emerging evidence on early treatment optimization.

In office sampling of eosinophil peroxidase to diagnose eosinophilic chronic rhinosinusitis

BACKGROUND

Practical biomarkers for endotypic characterization of chronic rhinosinusitis (CRS) remain elusive, hindering clinical utility. Eosinophil peroxidase (EPX) is an enzyme released by activated eosinophils. The objective of this study was to evaluate a clinic EPX assay as a marker of eosinophilic CRS.

METHODS

Subjects with and without CRS presenting to a tertiary care rhinology clinic were prospectively enrolled, and nasal cytology brushings were collected from the middle meatus during in-clinic nasal endoscopy. ELISA assay was used to quantify EPX levels, and a customized multiplex immunoassay was used to quantify inflammatory cytokine mediators. Findings were correlated with clinical data.

RESULTS

Forty-two subjects were enrolled, including 31 CRS subjects and 11 controls. Median EPX levels were 125.0 ng/mL (standard deviation [SD] 1745.8) and 6.5 ng/mL (SD 99.0) for CRS group and controls, respectively (p = 0.003). EPX levels were associated with history of asthma (p = 0.015), allergies (p = 0.028), polyps (p = 0.0006), smell loss (p = 0.006), and systemic eosinophilia or elevated immunoglobulin E (p ≤ 0.0001). Twenty-eight subjects from both the CRS and control groups had prior pathology for comparison, with histologic confirmation of local tissue eosinophilia (>10 eosinophils/hpf) in 11 subjects. This subgroup had a median EPX level of 967.5 ng/mL compared to 10.6 ng/mL in 17 subjects without local tissue eosinophilia (p = 0.0008). EPX levels were positively correlated to interleukin-5 levels (p = 0.0005).

CONCLUSION

EPX levels can be measured via well-tolerated in-clinic collection of nasal mucus. EPX levels are associated with clinical markers of type 2 inflammation and tissue eosinophilia and may provide a valuable diagnostic tool to delineate eosinophilic CRS.

The 7-Methylguanosine (m7G) methylation METTL1 acts as a potential biomarker of clear cell renal cell carcinoma progression

BACKGROUND

Clear cell renal cell carcinoma (ccRCC) is the most common subtype of renal cancer. 7-Methylguanosine (m7G), one of the most prevalent RNA modifications, has been reported to play an important role in ccRCC progression; however, the specific regulators of m7G modification that are involved in this function remain unclear. This study aimed to explore the correlation between regulators of m7G methylation and ccRCC progression using unsupervised machine learning methods.

METHODS

Transcriptome and clinical data of ccRCC were retrieved from The Cancer Genome Atlas (TCGA) database to identify differentially expressed m7G-related genes associated with the overall survival of patients with ccRCC. To construct and validate a prognostic risk model, TCGA dataset samples were divided into training and test sets. A multiple-gene risk signature was constructed using least absolute shrinkage and selection operator Cox regression analysis, and its prognostic significance was assessed using Cox regression and survival analyses. Finally, immunohistochemistry was performed to verify the prognostic significance of this signature.

RESULTS

In total, 537 patients with ccRCC were included in this study. We found that 26 m7G RNA methylation regulators that were significantly differentially expressed. Univariate and multifactorial Cox regression analyses revealed that METTL1 expression was associated with ccRCC progression.

CONCLUSIONS

METTL1 associated with m7G may serve as a potential biomarker for ccRCC prognosis and diagnosis. Moreover, it may affect the prognosis of ccRCC by regulating the tumor immune microenvironment, providing a potential therapeutic target for immunotherapy. These results provide a new perspective on the role of M7G-related RNAs in ccRCC pathogenesis.

Exploring the pathogenesis, biomarkers, and potential drugs for type 2 diabetes mellitus and acute pancreatitis through a comprehensive bioinformatic analysis

Background

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disease that accounts for > 90% of all diabetes cases. Acute pancreatitis (AP) can be triggered by various factors and is a potentially life-threatening condition. Although T2DM has been shown to have a close relationship with AP, the common mechanisms underlying the two conditions remain unclear.

Methods

We identified common differentially expressed genes (DEGs) in T2DM and AP and used functional enrichment analysis and Mendelian randomization to understand the underlying mechanisms. Subsequently, we used several machine learning algorithms to identify candidate biomarkers and construct a diagnostic nomogram for T2DM and AP. The diagnostic performance of the model was evaluated using ROC, calibration, and DCA curves. Furthermore, we investigated the potential roles of core genes in T2DM and AP using GSEA, xCell, and single-cell atlas and by constructing a ceRNA network. Finally, we identified potential small-molecule compounds with therapeutic effects on T2DM and AP using the CMap database and molecular docking.

Results

A total of 26 DEGs, with 14 upregulated and 12 downregulated genes, were common between T2DM and AP. According to functional and DisGeNET enrichment analysis, these DEGs were mainly enriched in immune effector processes, blood vessel development, dyslipidemia, and hyperlipidemia. Mendelian randomization analyses further suggested that lipids may be a potential link between AP and T2DM. Machine learning algorithms revealed ARHGEF9 and SLPI as common genes associated with the two diseases. ROC, calibration, and DCA curves showed that the two-gene model had good diagnostic efficacy. Additionally, the two genes were found to be closely associated with immune cell infiltration. Finally, imatinib was identified as a potential compound for the treatment of T2DM and AP.

Conclusion

This study suggests that abnormal lipid metabolism is a potential crosstalk mechanism between T2DM and AP. In addition, we established a two-gene model for the clinical diagnosis of T2DM and AP and identified imatinib as a potential therapeutic agent for both diseases.

Chronic rhinosinusitis with nasal polyps: predictors of recurrence 5 years after surgery

BACKGROUNDS

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a medical condition characterized by persistent inflammation of the nasal mucosa and sinuses, accompanied by the presence of nasal polyps. When medical treatments prove ineffective, endoscopic sinus surgery (ESS) is recommended, yielding variable outcomes and recurrence rates ranging from 5% to 60%.

AIMS/OBJECTIVES

The primary objectives of this study were to evaluate the outcomes of ESS and to identify independent predictors of recurrence and revision surgery.

MATERIAL AND METHODS

Retrospective cross-sectional study, focusing on patients diagnosed with CRSwNP who underwent ESS with a minimum follow-up period of 60 months. Various variables were collected. Multivariate and regression analyses were employed to assess the predictors associated with both recurrence and revision surgery.

RESULTS

The study analyzed 130 patients. The 5-year recurrence rate was 35.4%, and 17.7% of patients required revision surgery. These variables included asthma (p < 0.001), frontal sinus involvement (p < 0.001), Lund-Mackay score (p < 0.001), Endoscopic Nasal Polyps Score (p < 0.001), and eosinophilia in peripheral blood (p < 0.001). All the variables mentioned above were identified as predictors of recurrence and revision surgery.

CONCLUSIONS AND SIGNIFICANCE

Asthma, frontal sinus involvement, increased eosinophilia in peripheral blood, and a higher score on the LM system and NPS are poor prognostic factors in CRSwNP.

Factors for predicting the outcome of surgery for non-eosinophilic chronic rhinosinusitis with nasal polyps

BACKGROUND

Despite the large patient base in Asia, the prognostic factors of patients with non-eosinophilic chronic rhinosinusitis with nasal polyps (CRSwNPs) remain largely undetermined.

OBJECTIVE

To systematically investigate the predictive value of clinical and biological variables for non-eosinophilic CRSwNP.

METHODS

A total of 51 patients with non-eosinophilic CRSwNP who underwent functional endoscopic surgery were recruited. Clinical information and assessment were comprehensively collected before and after surgery. A broad spectrum of biomarkers was measured in tissue homogenates using multiple assays. A random forest algorithm and stepwise logistic regression were used to construct clinical, biological, and combined models.

RESULTS

A total of 41.2% patients with non-eosinophilic CRSwNP were uncontrolled more than 6 months after surgery. We identified 1 clinical variable (22-item Sino-Nasal Outcome Test score) and 4 biomarkers (programmed cell death ligand 1, platelet-derived growth factor subunit β [PDGF-β], macrophage inflammatory protein-3b, and PDGF-α) that were significantly predictive of the surgical outcome. The clinical, biological, and combined models had predictive ability with areas under the curve of 0.78, 0.83, and 0.89, respectively. PDGF-β and programmed cell death ligand 1 were identified as independent biomarkers for the prognosis of patients with CRSwNP without considerable eosinophilic infiltration.

CONCLUSION

This study reveals that clinical and biological factors, such as the 22-item Sino-Nasal Outcome Test score and PDGF-β, are predictive of the postfunctional endoscopic surgical prognosis of patients with non-eosinophilic CRSwNP.

Effect of Dupilumab on Radiological Remission in Patients with Chronic Rhinosinusitis with Nasal Polyp: A One Step Forward Toward Clinical Remission

Background and Objectives

 While achieving complete radiological improvement in patients with nasal polyps is often observed following surgical resection, the impact of biologic therapy, specifically dupilumab, on polyp size is an area of great interest. The objective of this study was to assess the effect of dupilumab in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) by assessing nasal polyps using the computed tomography (CT) staging system, Lund-Mackay score (LMS).

Methods

 A two-year prospective cohort study was conducted on 29 patients diagnosed with CRSwNP and asthma and eligible for dupilumab as an add-on therapy. The study involved comprehensive assessments of patients before biologic initiation and after the study. These assessments included clinical, laboratory, and radiological evaluations.

Results

Dupilumab treatment reduces LMS across sinuses (p<0.001) and improves nasal obstruction (p=0.001). Blood eosinophil count (BEC) predicts persistent sinus obstruction, doubling the likelihood per unit increase (odds ratio: 1.67, p=0.02). BEC levels identify persistent nasal obstruction (AUC: 76%, p=0.04), with a cutoff point above 255.5 cells per microliter, revealing a sensitivity of 100% and a specificity of 42%. The probability of persistent nasal obstruction at the 20th month is 55%, regardless of prior nasal polyp surgery (p=0.41).

Conclusion

Dupilumab led to significant radiological improvements in patients with CRSwNP, demonstrating a potential role of radiological remission, irrespective of prior nasal polyp surgery. Additionally, BEC levels may guide the likelihood of persistent nasal obstruction.

Utilizing radiomics techniques to isolate a single vertebral body from chest CT for opportunistic osteoporosis screening

PURPOSE

Opportunistic osteoporosis screening, conducted during routine medical examinations such as chest computed tomography (CT), presents a potential solution for early detection. This study aims to investigate the feasibility of utilizing radiomics technology based on chest CT images to screen for opportunistic osteoporosis.

METHODS

This Study is a Multicenter Retrospective Investigation. Relevant clinical data, including demographics and DXA results, would be collected for each participant. The radiomics analysis in this study focuses on the extraction of features from the 11th or 12th thoracic vertebral bodies from chest CT images. SVM machine learning models would be trained using these radiomic features, with DXA results as the ground truth for osteoporosis classification.

RESULTS

In the training group, Clinical models had an accuracy of 0.684 and an AUC of 0.744, Radiomics models had an accuracy of 0.828 and an AUC of 0.896, Nomogram models had an accuracy of 0.839 and an AUC of 0.901. In the internal validation group, Clinical models had an accuracy of 0.769 and an AUC of 0.829, Radiomics models had an accuracy of 0.832 and an AUC of 0.892, Nomogram models had an accuracy of 0.839 and an AUC of 0.918. In the external validation group, Clinical models had an accuracy of 0.715 and an AUC of 0.741, Radiomics models had an accuracy of 0.777 and an AUC of 0.796, Nomogram models had an accuracy of 0.785 and an AUC of 0.807. In all three datasets, the Nomogram model exhibited a statistically significant difference in screening effectiveness compared to the clinical models.

CONCLUSION

Our research demonstrates that by leveraging radiomics features extracted from a single thoracic spine using chest CT, and incorporating these features with patient basic information, opportunistic screening for osteoporosis can be achieved.

Mucosal LTE4, PGD2 and 15(S)-HETE as potential prognostic markers for polyp recurrence in chronic rhinosinusitis

BACKGROUND

Altered biosynthesis of eicosanoids is linked to type 2 inflammation in chronic rhinosinusitis with nasal polyps (CRSwNP), but their role in recalcitrant NPs is unclear.

OBJECTIVES

We sought to identify endotypes that are linked to recalcitrant CRSwNP, based on eicosanoids, their biosynthetic enzymes, and receptors as well as cytokines and the presence of eosinophils and mast cells in recurrent NPs.

METHODS

Mucosal tissue collected at the time of sinus surgery from 54 patients with CRSwNP and 12 non-CRS controls were analysed for leukotriene (LT) E4, prostaglandin (PG) D2, 15(S)-hydroxyeicosatetraenoic acid (15(S)-HETE) and 17 cytokines with ELISAs and Bio-Plex immunoassays. Patient subgroups were identified by cluster analysis and the probability of NP recurrence were tested with logistic regression analyses. Gene expressions were analysed with qPCR. Tryptase and eosinophil-derived neurotoxin (EDN) were measured with ELISAs as indications of the presence of mast cells and eosinophils, respectively.

RESULTS

Clustering of patients showed that an inflammatory signature characterised by elevated LTE4, PGD2, 15(S)-HETE and IL-13 was associated with NP recurrence. Previous NP surgery as well as aspirin-exacerbated respiratory disease were significantly more common among these patients. Expression of cyclooxygenase 1 was the only gene associated with NP recurrence. Levels of EDN, but not tryptase, were significantly higher in patients with recurrent NPs.

CONCLUSION

Distinguishing endotypes that include LTE4, PGD2, 15HETE and conventional biomarkers of type 2 inflammation could help predict recurrent nasal polyposis and thus identify cases of recalcitrant CRSwNP.

Significance as a Prognostic Factor of Eosinophil Count in Nasal Polyp Tissue in Patients with Chronic Rhinosinusitis Accompanied by Asthma

Background/Objectives: Patients with chronic rhinosinusitis (CRS) accompanied by asthma often show poor prognoses and require continuous management. This study aimed to assess the prognostic value of eosinophil counts in nasal polyp tissue for selecting individuals who would benefit from ongoing management in CRS patients with asthma. Methods: Patients with asthma who underwent endoscopic sinus surgery for CRS with nasal polyps were included in the study. Eosinophil counts in nasal polyp tissues were quantified, and retrospective data were collected from laboratory and clinical findings, including endoscopic examinations, CT scans, and Japan Endoscopic Sinus Surgery Rating and Evaluation Committee (JESREC) scores. Disease control status was evaluated through endoscopic examination 6 months post-surgery. Results: A total of 42 patients were divided into two groups based on their disease management status 6 months post-operation: the well-control group (24 patients, 57.14%) and the poor-control group (18 patients, 42.86%). Demographics and laboratory findings did not show significant differences between the groups. However, the JESREC score (p = 0.04) and tissue eosinophil count (p = 0.02) were significantly different. Multivariate analysis identified tissue eosinophil count as the only risk factor associated with prognosis, with a cut-off value of 90/HPF. Conclusions: In CRS patients with asthma, high tissue eosinophil counts in nasal polyps were associated with poor disease control, which is the most potent predictor of prognosis. The assessment of eosinophil counts in nasal polyp tissue could aid in identifying patients who would benefit from continuous management and tailored interventions for improved outcomes.

Increased autoreactivity and maturity of EBI2+ antibody-secreting cells from nasal polyps

Elevated numbers of antibody-secreting cells (ASCs) and anti-double-stranded DNA (anti-dsDNA) antibodies are found in nasal polyp (NP) tissue. The presence of anti-dsDNA IgG in tissue prospectively predicts recurrent NP but the characteristics of the source ASCs are unknown. Here, we investigated whether NP B cells expressing the extrafollicular marker EBI2 have increased propensity for autoantibody production and evaluated the molecular characteristics of NP ASCs. NPs showed increased frequencies of anti-dsDNA IgG and total IgG ASCs compared with tonsils, with more pronounced differences among EBI2+ cells. In NPs, EBI2+ cells were frequently double negative (IgD-CD27-) and ASCs. Single-cell RNA-Seq analysis of tonsils and NPs revealed substantial differences in B lineage composition, including differences in percentages of ASCs, germinal centers, proliferative cells, and non-ASCs. NPs exhibited higher expression of specific isotypes (IGHE, IGHA1, IGHA2, and IGHG4) and mature plasma genes, including SDC1 and XBP1, than tonsils. Gene Ontology biological processes indicated upregulated NF-κB and downregulated apoptosis pathways in NP ASCs. Together, these data indicate that NP EBI2+ ASCs secret increased total and anti-dsDNA IgG compared with those from tonsils and had molecular features of mature plasma cell differentiation.

Circulating Exosomal microRNA Profiles Associated with Risk of Postoperative Recurrence in Chronic Rhinosinusitis with Nasal Polyps

Background

Exosomes carry various types of transcripts and serve as promising biomarkers for inflammatory diseases. However, the role of serum exosomal microRNAs (miRNAs) in chronic rhinosinusitis with nasal polyps (CRSwNP) is poorly clarified.

Methods

A prospective exploratory cohort of 10 CRSwNP patients was conducted, and the serum exosome samples were subjected to miRNA sequencing. Two independent prospective cohorts, consisting of 40 and 54 patients respectively, were recruited from different medical centers for validation. These cohorts were monitored for over two years, with postoperative recurrence serving as the primary outcome measure. The top 3 differentially exosomal miRNAs were validated in the serum samples, and their predictive values for recurrence were assessed.

Results

Eight CRSwNP patients completed the follow-up, comprising 4 non-recurrent cases and 4 recurrent cases. Distinctive profiles of serum exosomal miRNAs were identified between the two groups. In the first validation cohort, reverse transcription-polymerase chain reaction results indicated elevated serum exosomal miR-3174 and miR-6750-5p expressions, along with reduced miR-192-3p levels in the recurrence group compared to the non-recurrence group. Receiver operating characteristic (ROC) curves and Kaplan-Meier survival analysis demonstrated significant correlations between expressions of exosomal miR-3174 and miR-192-3p and the risk of postoperative recurrence. These findings were further validated in the second cohort, confirming the elevation of both miRNAs in the recurrence group and their associations with recurrence risk. Additionally, serum exosomal miR-3174 levels increased in recurrent cases compared to their baseline levels.

Conclusion

Circulating exosomal microRNA signatures may influence the risk of postoperative recurrence in CRSwNP patients. Serum exosomal elevated exosomal miR-3174 and decreased miR-192-3p were correlated with CRSwNP recurrence risk.

Factors Contributing to the Recurrence of Chronic Rhinosinusitis With Nasal Polyps After Endoscopic Sinus Surgery: A Systematic Review

Chronic rhinosinusitis with nasal polyposis (CRSwNP) occurs due to the inflammation of sinonasal tissue. Cases of CRSwNP more commonly demand revision endoscopic sinus surgery (ESS) as compared to patients without polyposis. The recurrence rate varies widely depending on various factors, such as the extent of surgery, patient compliance with postoperative care, and the severity of the underlying disease. Studies conducted on chronic rhinosinusitis (CRS) patients showing recurrence or relapse of nasal polyps post endoscopic sinus surgery were included. We used the modified Newcastle-Ottawa scale (NOS) for cross-sectional studies and cohort studies. Only 15 articles met our inclusion and exclusion criteria after the full-text screening. The studies enrolled participants between 2009 and 2022, including 2,515 ESS patients. The mean age of the included subjects ranged between 37.1 and 57.57 years. In conclusion, CRSwNP is a chronic inflammatory disease that can impose a significant burden on patients, healthcare systems, and society. Asthma, aspirin intolerance, peripheral eosinophilia, interleukin-5 (IL-5) expression, T2 profile, and intense sinus opacification have been noted to be independent predictors of the condition in different studies. Recurrent polyposis in CRS signals a more aggressive disease course, requiring close follow-up and revision surgeries in the long run.

Increased SERPINB2 potentiates 15LO1 expression via STAT6 signalling in epithelial cells in eosinophilic chronic rhinosinusitis with nasal polyps

BACKGROUND

SERPINB2, a biomarker of Type-2 (T2) inflammatory processes, has been described in the context of asthma. Chronic rhinosinusitis with nasal polyps (CRSwNP) is also correlated with T2 inflammation and elevated 15LO1 induced by IL-4/13 in nasal epithelial cells. The aim of this study was to evaluate the expression and location of SERPINB2 in nasal epithelial cells (NECs) and determine whether SERPINB2 regulates 15LO1 and downstream T2 markers in NECs via STAT6 signalling.

METHODS

SERPINB2 gene expression in bulk and single-cell RNAseq database was analysed by bioinformatics analysis. SERPINB2, 15LO1 and other T2 markers were evaluated from CRSwNP and HCs NECs. The colocalization of SERPINB2 and 15LO1 was evaluated by immunofluorescence. Fresh NECs were cultured at an air-liquid interface with or without IL-13, SERPINB2 Dicer-substrate short interfering RNAs (DsiRNAs) transfection, exogenous SERPINB2, 15-HETE recombinant protein and pSTAT6 inhibitors. 15LO1, 15-HETE and downstream T2 markers were analysed by qRT-PCR, western blot and ELISA.

RESULTS

SERPINB2 expression was increased in eosinophilic nasal polyps compared with that in noneosinophilic nasal polyps and control tissues and positively correlated with 15LO1 and other downstream T2 markers. SERPINB2 was predominantly expressed by epithelial cells in NP tissue and was colocalized with 15LO1. In primary NECs in vitro, SERPINB2 expression was induced by IL-13. Knockdown or overexpression SERPINB2 decreased or enhanced expression of 15LO1 and 15-HETE in NECs, respectively, in a STAT6-dependent manner. SERPINB2 siRNA also inhibited the expression of the 15LO1 downstream genes, such as CCL26, POSTN and NOS2. STAT6 inhibition similarly decreased SERPINB2-induced 15LO1.

CONCLUSIONS

SERPINB2 is increased in NP epithelial cells of eosinophilic CRSwNP (eCRSwNP) and contributes to T2 inflammation via STAT6 signalling. SERPINB2 could be considered a novel therapeutic target for eCRSwNP.

Construction of oxidative phosphorylation-related prognostic risk score model in uveal melanoma

BACKGROUND

Uveal melanoma (UVM) is a malignant intraocular tumor in adults. Targeting genes related to oxidative phosphorylation (OXPHOS) may play a role in anti-tumor therapy. However, the clinical significance of oxidative phosphorylation in UVM is unclear.

METHOD

The 134 OXPHOS-related genes were obtained from the KEGG pathway, the TCGA UVM dataset contained 80 samples, served as the training set, while GSE22138 and GSE39717 was used as the validation set. LASSO regression was carried out to identify OXPHOS-related prognostic genes. The coefficients obtained from Cox multivariate regression analysis were used to calculate a risk score, which facilitated the construction of a prognostic model. Kaplan-Meier survival analysis, logrank test and ROC curve using the time "timeROC" package were conducted. The immune cell frequency in low- and high-risk group was analyzed through Cibersort tool. The specific genomic alterations were analyzed by "maftools" R package. The differential expressed genes between low- or high-risk group were analyzed and performed Gene Ontology (GO) and GSEA. Finally, we verified the function of CYC1 in UVM by gene silencing in vitro.

RESULTS

A total of 9 OXPHOS-related prognostic genes were identified, including NDUFB1, NDUFB8, ATP12A, NDUFA3, CYC1, COX6B1, ATP6V1G2, ATP4B and NDUFB4. The UVM prognostic risk model was constructed based on the 9 OXPHOS-related prognostic genes. The prognosis of patients in the high-risk group was poorer than low-risk group. Besides, the ROC curve demonstrated that the area under the curve of the model for predicting the 1 to 5-year survival rate of UVM patients were all more than 0.88. External validation in GSE22138 and GSE39717 dataset revealed that these 9 genes could also be utilized to evaluate and predict the overall survival of patients with UVM. The risk score levels related to immune cell frequency and specific genomic alterations. The DEGs between the low- and high- risk group were enriched in tumor OXPHOS and immune related pathway. In vitro experiments, CYC1 silencing significantly inhibited UVM cell proliferation and invasion, induced cell apoptosis.

CONCLUSION

In sum, a prognostic risk score model based on oxidative phosphorylation-related genes in UVM was developed to enhance understanding of the disease. This prognostic risk score model may help to find potential therapeutic targets for UVM patients. CYC1 acts as an oncogene role in UVM.

Computed Tomographic Evaluations in Patients with Empty Nose Syndrome

OBJECTIVE

We aimed to evaluate computed tomography (CT) images of patients with empty nose syndrome (ENS), investigate the impact of reconstruction surgery on sinus inflammation, and identify the optimal airspace diameter after surgery.

METHODS

We conducted a retrospective case series analysis, identifying and enrolling patients with ENS with perioperative CT findings. The clinical characteristics of the participants were collected, and the modified Lund-Mackay (mLM) CT scores were determined. The anterior airspace diameter was evaluated by measuring the distance between the septum and the lateral nasal wall on the coronal plane at the level of the nasolacrimal duct.

RESULTS

Twenty patients with ENS and perioperative CT images were enrolled. The mean total mLM CT score and all subsite scores showed no significant changes after surgery. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) score, Sino-nasal Outcome Test-25 (SNOT-25) score, sleep symptoms domain, psychological domain, and empty nose symptoms domain were significantly associated with anterior airspace diameter in the regression analysis.

CONCLUSION

There was no significant difference in sinus inflammation between preoperative and postoperative CT evaluations. The anterior airspace diameters were significantly associated with ENS6Q and SNOT-25 scores.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2105-2110, 2024.

IL-13 and IL-13-induced periostin levels are specifically decreased in patients following endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Type 2 (T2) inflammation plays a pathogenic role in chronic rhinosinusitis (CRS). The effects of endoscopic sinus surgery (ESS) on T2 inflammation are unknown.

OBJECTIVE

The aim of this study was to compare T2 inflammatory biomarkers from middle meatal (MM) mucus for distinguishing patients with CRS from CRS-free patients, identifying major phenotypes (CRS without nasal polyps [CRSsNP] and CRS with nasal polyps [CRSwNP]), assessing endotypic change, and establishing cross-sectional and longitudinal outcomes in patients undergoing ESS.

METHODS

MM mucus samples were collected from patients with CRSsNP and patients with CRSwNP before and 6 to 12 months after ESS and compared with samples from CRS-free control patients. T2 biomarkers were evaluated both continuously and using threshold-based definitions of T2 endotype to identify relationships with patient-reported (based on the 22-Item Sinonasal Outcomes Test and Chronic Rhinosinusitis Patient-Reported Outcomes Measure) and clinician-reported (radiographic and endoscopic) severity. Linear mixed models were developed to analyze clinical variables associated with T2 biomarker levels.

RESULTS

A total of 154 patients with CRS (89 with CRSsNP and 65 with CRSwNP) were enrolled, with a mean interval of 9 months between ESS and follow-up. An analysis of pre-ESS MM mucus samples revealed elevated levels of T2 mediators in patients with CRSwNP versus in patients with CRSsNP and CRS-free controls. Temporally stable correlations between levels of IL-13 and IL-5, levels of periostin and complement 5a, and levels of eosinophil cationic protein (ECP) and eotaxin-3 were observed. On this basis and on the basis of pathologic significance, levels of IL-13, periostin and ECP were further analyzed. After ESS, levels of IL-13 and periostin decreased significantly, whereas ECP levels remained unchanged. Across pre- and post-ESS evaluation, the T2 endotype was associated with radiographic severity but did not predict outcomes. CRSwNP status and African American race were associated with higher levels of IL-13 and periostin, whereas ECP level was higher in patients undergoing extensive surgery.

CONCLUSION

ESS decreased levels of IL-13 and periostin in the middle meatus. T2 inflammation after ESS was correlated with patient- and clinician-reported severity across phenotypes. Pre-ESS T2 inflammation did not predict post-ESS outcomes.

Hyperuricemia Increases the Risk of Postoperative Recurrence in Chinese Patients with Chronic Rhinosinusitis

Background

Elevated serum uric acid is crucial in the pathophysiology of chronic inflammatory diseases. However, its impact on chronic rhinosinusitis (CRS) recurrence risk is unknown. This study investigates the association between elevated serum uric acid and the risk of CRS recurrence.

Methods

A retrospective cohort study was conducted on 1004 CRS patients (including 638 males and 366 females) who received functional endoscopic sinus surgery. All patients were followed up for more than 2 years, and categorized into subgroups based on phenotype, gender, and postoperative recurrence. Cox regression analysis was performed to evaluate the associations between serum uric acid and the risk of CRS recurrence.

Results

After categorization, 104 males had hyperuricemia, and 54 females presented hyperuricemia. The rate of recurrent CRS in the hyperuricemia group was significantly higher compared to the non-hyperuricemia group in both males and females (P<0.05). In both male and female patients, the rate of hyperuricemia and uric acid levels were elevated in the recurrent CRS group in comparison with the non-recurrent CRS group (P<0.05). Unadjusted and adjusted Cox regression analysis demonstrated that serum uric acid was an independent risk factor for CRS recurrence (P<0.05). The receiver operator characteristic curve showed that serum uric acid was a potential biomarker for predicting the recurrence of CRS and its phenotypes in both genders (P<0.05).

Conclusion

There is a close relationship between elevated serum uric acid and the recurrence risk of CRS and its phenotypes, suggesting that serum uric acid may be a novel biomarker for predicting recurrent CRS.

Development and validation of a nomogram for predicting poor operative visibility during FESS in Chinese adult patients with CRS

Objective

The purpose of this study is to develop and evaluate a nomogram that is capable of predicting poor operative visibility during functional endoscopic sinus surgery.

Method

To identify potential risk factors, patients with chronic rhinosinusitis who underwent functional endoscopic sinus surgery (FESS) between January 2019 and December 2022 were selected from our hospital's electronic medical record system. Data on general patient information, clinical manifestations, clotting-related test indices, Lund-Machay score of sinuses CT scanning, Lund-kennedy score of nasal endoscopies, anesthesia methods, intraoperative blood pressure and heart rate, and Boezaart bleeding score were collected. Minimum absolute convergence and selection operator (LASSO) regression, as well as multivariate logistic regression, were used to determine the risk factors. A nomogram was developed in order to predict poor operating visibility during FESS, and its performance was evaluated utilizing both the training and verification datasets via various measures including receiver operating characteristic (ROC) curve analysis, area under the curve (AUC), Hosmer-Lemeshow goodness-of-fit test, calibration curve, and decision curve analysis.

Results

Of the 369 patients who met the inclusion criteria, 88 of them exhibited POV during FESS. By deploying LASSO and multivariate logistic regression analyses, six risk factors were identified and used to construct a nomogram for predicting POV during FESS. These factors include prothrombin time (PT), prothrombin activity (PTA), Lund-Mackay score (LMS), Lund-Kennedy score (LKS), anesthetic method, and intraoperative hypertension. The AUC of the training set was found to be 0.820 while that of the verification set was 0.852. The Hosmer-Lemeshow goodness-of-fit test and calibration curve analysis revealed good consistency between predicted and actual probabilities. Also, the decision curve demonstrated that the nomogram had a high degree of clinical usefulness and net benefit.

Conclusion

The constructed nomogram has a strong ability to predict the poor intraoperative field in patients with chronic rhinosinusitis, which can help preoperative judgment of high-risk patients and provide evidence for perioperative management and preoperative plan formulation.

Prognostic Value of Polypoid Changes of the Middle Turbinate in Relapsed Nasal Polypi after FESS: A Prospective Cohort Study

Introduction  Despite the high level of patient satisfaction with functional endoscopic sinus surgery (FESS) and the clinical improvement, polyp recurrence is observed in 23% to 87% of patients and requires reoperation. Objective  To assess the prognostic value of polypoid changes of the middle turbinate (PCMT) in relapse of paranasal sinus polyps in patients with chronic rhinosinusitis with nasal polyp (CRSwNP) after FESS and the effect of partial middle turbinectomy (PMT) on the outcome of surgery. Methods  We conducted a prospective clinical study on 60 patients with CRSwNP with and without PCMT. The patients were allocated into three groups: group I included twenty patients without PCMT; group II, twenty patients with PCMT; and group III included twenty patients with PCMT submitted to PMT. The patients were evaluated endoscopically according to the Lund-Kennedy endoscopic scoring system, radiologically according to the Lund-Mackay scoring system, and symptomatically through the 22-item Sinonasal Outcome Test (SNOT-22). Results  The total postoperative Lund-Kennedy score differed significantly among the 3 groups ( p  < 0.001), with a group II presenting a significantly higher total score compared to groups I and III. The Preoperative SNOT-22 score differed significantly among the three groups ( p  = 0.013), with group II presenting a significantly higher score compared to group I. There was a significant association involving the 3 groups and relapse at 12 months ( p  = 0.029); relapse was higher in group II (50.0%) than in groups I (20%) and III (15.0%). Conclusion  There was a significant association between PCMT and the relapse of nasal polyps. Also, nasal polyposis recurred at a lower rate in the group submitted to middle turbinate resection compared to the group in whom it was preserved.

[Difficult-to-treat chronic rhinosinusitis-when the standard treatment is not effective and biologics are not available]

BACKGROUND

In recent years, significant improvements have been made in the treatment options for uncontrolled chronic rhinosinusitis (CRS) refractory to standard medical and surgical therapy. This is the result of a better understanding of the pathophysiology and the resulting development of biologicals for CRS with nasal polyps (CRSwNP). However, biologics are not (yet) available for all patients in Europe.

OBJECTIVE

Based on the session "Difficult-to-treat CRS, when biologics are not available" at the 29th Congress of the European Rhinologic Society (ERS) 2023 in Sofia, Bulgaria, the treatment options for uncontrolled CRS with the exclusion of biologics will be discussed.

MATERIALS AND METHODS

The content of the presentations "Is there a place for antibiotics?" "Indications for revision surgery," "Novel systemic treatment options," "Novel local treatment options," and "Phototherapy for nasal polyps" are outlined and supported by a review of the literature.

RESULTS

Various treatment options are available for managing uncontrolled CRS, even if biologic treatments are unavailable. Treatment options for type‑2 (T2) CRS include steroid rinses, repeated short-term oral steroids, steroid-eluting stents, and extended sinus surgery. In the case of nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD), acetylsalicylic acid (ASA) desensitization can be considered. Non-T2 endotypes or CRS without nasal polyps (CRSsNP) may benefit from several weeks of macrolides and xylitol rinses.

CONCLUSION

To accurately assess the efficacy of second-line therapies for treatment of difficult-to-treat CRS within an endotype-specific framework, additional controlled clinical trials are needed that take into account the heterogeneity of CRS endotypes.

CD109 identified in circulating proteomics mitigates postoperative recurrence in chronic rhinosinusitis with nasal polyps by suppressing TGF-β1-induced epithelial-mesenchymal transition

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory disorder with a high rate of recurrence. This study aimed to explore biomarkers for identifying patients with recurrent CRSwNP (rCRSwNP).

METHODS

We recruited two independent cohorts. In the discovery cohort, rCRSwNP patients and non-recurrent CRSwNP (non-rCRSwNP) patients were recruited, and the serum proteomic profile was characterized. The top 5 upregulated and downregulated proteins were confirmed in the validation cohort by ELISA, WB, and qRT-PCR, and their predictive values for postoperative recurrence were assessed. In vitro, human nasal epithelial cells (HNEpCs) were employed to assess the ability of candidate proteins to induce epithelial-mesenchymal transition (EMT).

RESULTS

Serum proteomics identified 53 different proteins, including 30 increased and 23 decreased, between the rCRSwNP and non-rCRSwNP groups. ELISA results revealed that serum levels of CD163 and TGF-β1 were elevated, CD109 and PRDX2 were decreased in the rCRSwNP group compared to the non-rCRSwNP group, and serum CD163, TGF-β1, and CD109 levels were proved to be associated with the risk of postoperative recurrence. In addition, qRT-PCR and WB revealed that tissue CD163, TGF-β1, and CD109 expressions in rCRSwNP patients were enhanced compared to those non-rCRSwNP patients. Kaplan-Meier analysis showed that increased CD163 and TGF-β1 expression and decreased CD109 expression are associated with the risk of recurrence in CRSwNP patients. Receiver operating characteristic curves showed that TGF-β1 and CD109 had superior diagnostic performances for rCRSwNP. In vitro experiments showed that TGF-β1 promoted EMT in HNEpCs, and overexpression of CD109 reversed this effect. Functional recovery experiments confirmed that CD109 could attenuate EMT in HNEpCs by inhibiting the TGF-β1/Smad signaling pathway, attenuating EMT in epithelial cells.

CONCLUSION

Our data suggested that TGF-β1 and CD109 might serve as promising predictors of rCRSwNP. The TGF-β1/Smad pathway was implicated in fostering EMT in epithelial cells, particularly those exhibiting low expression of CD109. Consequently, the absence of CD109 expression in epithelial cells could be a potential mechanism underlying rCRSwNP.

Real-Life Study of Patient Preference for Dupilumab or Revision Surgery for Recurrent Chronic Rhinosinusitis with Nasal Polyps

(1) Background: Chronic rhinosinusitis with nasal polyps (CRSwNP) has a high rate of recurrence in patients, despite therapy with local corticosteroids and functional endoscopic sinus surgery. Dupilumab, a recombinant monoclonal human IgG4 antibody directed against the IL-4 receptor α that inhibits both IL-4 and IL-13 signal transduction, is available for symptomatic therapy. Patient preference between repeated surgery and injection therapy with Dupilumab is not known. (2) Methods: Patients who had experienced at least one surgical intervention for nasal polyps and were treated with Dupilumab for at least 3 months completed a retrospective patient questionnaire. (3) Results: In a cohort of 75 previously operated CRSwNP patients, 91.5% preferred therapy with Dupilumab to repeated surgery for nasal polyps. Preference for Dupilumab in the subgroups of patients with concomitant Non-steroidal Anti-inflammatory Drugs Exacerbated Respiratory Disease (N-ERD) (n = 32), patients with concomitant asthma (n = 25), and patients without concomitant disease (n = 18) was 100%, 96%, and 72%, respectively. (4) Conclusions: Patient preference for Dupilumab over repeat surgery is strongest in previously operated CRSwNP patients with concomitant asthma or N-ERD, but remains very high in patients without concomitant disease.

Long-Term Perspectives on Chronic Rhinosinusitis with Nasal Polyps: Evaluating Recurrence Rates after Functional Endoscopic Sinus Surgery in the Biologics Era-A 5-Year Follow-Up Study

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is an inflammatory disease with multifactorial etiopathogenesis. This study investigated the recurrence rate and risk factors predicting recurrence in patients subjected to Functional Endoscopic Sinus Surgery (FESS) for CRSwNP.

METHODS

Patients affected by CRSwNP who underwent FESS between January 2015 and March 2020 were enrolled. The recurrence rate and the influence of risk factors were assessed.

RESULTS

A total of 154 patients were included, 100 males and 54 females, aged 14-82 years (mean age 51.96 ± 16.27; median 52 years). Of 154 patients, 28 presented CRSwNP recurrence in a follow-up period ranging from 6 months to 69 months, with a recurrence rate of 18.2%. The recurrence rate was higher in patients aged between 31 and 50 years and between 51 and 70 years at the time of surgery than in those aged between 14 and 30 years and over 70 years. Furthermore, most patients with recurrence were men (61%), while 39% were women. A higher recurrence rate was observed between non-smokers (50%) and ex-smokers (36%), while only 14% declared themselves habitual smokers. Only four subjects (14%) had a positive family history of CRSwNP.

CONCLUSION

To date, no specific biomarkers have been identified in order to determine the appropriate therapy for the patients affected by CRSwNP. Based on our results, we suggest that it is necessary for an accurate assessment of the CRSwNP patients to identify which phenotype/endotype each subject manifests based on medical history, endoscopy, computed tomography, and a laboratory evaluation.

Effects of Metabolic Syndrome and its components on the postoperative recurrence in Chronic Rhinosinusitis with Nasal Polyps' patients

OBJECTIVES

Metabolic Syndrome (MetS) has been established as a significant factor in the pathogenesis of numerous chronic inflammatory conditions. However, its role in Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is unknown. This study aims to investigate the association between MetS, its components, and the risk of postoperative recurrence in Chinese patients with CRSwNP.

METHODS

A retrospective cohort study was conducted on CRSwNP patients who underwent endoscopic sinus surgery in our hospital. Patients were divided into MetS and non-MetS groups, and the clinical characteristics and recurrence rates were compared. All CRSwNP patients were followed up for more than 2-years and further categorized into non-recurrent and recurrent groups. Binary logistic regression analyses were performed to examine the effects of MetS and its components on the risk of postoperative recurrence.

RESULTS

A total of 555 CRSwNP patients were enrolled in the present study, 157 patients were included in the MetS group and 398 patients were categorized into the non-MetS group. The recurrence rate in the MetS group was significantly higher compared to the non-MetS group (p < 0.05). The rate of MetS, overweight or obesity, hyperglycemia and dyslipidemia were higher in the recurrent group in comparison with the non-recurrent group (p < 0.05). Multivariate logistic regression analysis suggested that MetS, overweight or obesity, hyperglycemia, dyslipidemia, and accompanying allergic rhinitis were associated with the risk of postoperative recurrence of CRSwNP (p < 0.05). Moreover, adjusted and unadjusted regression models showed that MetS was an independent risk factor for postoperative recurrence of CRSwNP, and the risk increased with more components of MetS included (p < 0.05).

CONCLUSION

Our findings revealed that MetS independently increased the risk of postoperative recurrence in patients with CRSwNP, with the risk escalating as the number of MetS components increased. Moreover, accompanying allergic rhinitis was also demonstrated to be a potential risk factor for CRSwNP recurrence.

LEVEL OF EVIDENCE

Level 4.

Metabolic syndrome facilitates histopathological changes and the risk of postoperative recurrence in chronic rhinosinusitis with nasal polyps

BACKGROUND

The relationship between metabolic syndrome (MS) and chronic rhinosinusitis with nasal polyps (CRSwNP) remains unclear. This study aimed to examine the effects of MS on histopathological features and postoperative recurrence in patients with CRSwNP.

METHODS

We recruited 529 patients with CRSwNP who underwent functional endoscopic sinus surgery. They were divided into MS and non-MS groups and followed up for 2 years to evaluate postoperative recurrence. Clinical characteristics, histopathological features, the immunoactivity of signature cytokines, and the risk of postoperative recurrence were compared between the two groups.

RESULTS

In total, 490 patients with CRSwNP were included in the study, 145 of whom experienced postoperative recurrence. The recurrence rate, tissue eosinophil count and percentage, and expression levels of IL-5 and IL-17A were significantly higher in the MS group compared to the non-MS group. Furthermore, within the MS group, patients who experienced recurrence exhibited higher tissue eosinophil counts and IL-5 and IL-17A levels than those in the non-MS group. Notably, the eosinophil count and IL-5 and IL-17A levels were higher in tissues collected during revision surgery than in those collected during primary surgery, particularly in patients with MS. Binary logistic regression analysis and Kaplan-Meier survival curves consistently indicated that MS independently increased the risk of postoperative recurrence in patients with CRSwNP. Furthermore, the risk increased with the number of MS components presented.

CONCLUSION

MS promoted tissue eosinophil infiltration, and IL-5 and IL-17A expression, and increased the risk of postoperative recurrence in patients with CRSwNP. MS was identified as an independent risk factor for postoperative recurrence, and the risk increased with an increase in the number of MS components.

[The correlation between preoperative neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio and postoperative recurrence of chronic rhinosinusitis]

Objective:Neutrophil-to-lymphocyte ratio （NLR） and platelet-to-lymphocyte ratio （PLR） play important roles in the poor prognosis of different inflammatory and neoplastic diseases, but their effects on postoperative recurrence of chronic rhinosinusitis（CRS） are unknown. The aim of this study was to investigate the correlation between preoperative NLR and PLR and the risk of postoperative recurrence in CRS. Methods:Clinical data were collected from patients with CRS who underwent initial functional endoscopic sinus surgery from October 2018 to February 2022 at our institution. Follow-up was until February 2023, and the study endpoint was defined as patient postoperative recurrence or follow-up time up to date. The optimal preoperative NLR and PLR threshold values were obtained based on subject work curve analysis, and they were divided into high and low level subgroups, respectively, and the clinical characteristics and postoperative recurrence rates of patients were compared between groups; patients were divided into non-recurrent CRS and recurrent CRS according to their postoperative recurrence, and Kaplan-Meier survival curves and logistic regression analysis were performed to explore the correlation between NLR and PLR and CRS The correlation between NLR and PLR and postoperative recurrence was investigated by Kaplan-Meier survival curve and logistic regression analysis. Results:A total of 630 patients with CRS were included, including 382 and 140 patients with high NLR and high PLR, respectively. The postoperative recurrence rates of CRS patients in the high NLR and high PLR groups were significantly higher than those in the low NLR and low PLR groups（P<0.05）. The recurrent CRS had higher NLR and PLR levels and higher proportion of high NLR and high PLR than the non-recurrent CRS（P<0.05）, and similarly the duration of recurrent CRS and the rate of allergic rhinitis with recurrence were significantly higher than the non-recurrent CRS（P<0.05）. Kaplan-Meier survival curves showed that postoperative CRS was significantly higher in the high NLR and high PLR groups compared with the low NLR and low PLR groups. recurrence was significantly higher（P<0.05）. In addition, logistic regression analysis showed that high NLR, high PLR, disease duration, and combined allergic rhinitis were significantly associated with an increased risk of postoperative recurrence of CRS（P<0.05）. Conclusion:Both high preoperative NLR and high PLR are independent risk factors for postoperative recurrence of CRS, and they are expected to be new indicators for postoperative prognostic assessment and risk stratification of CRS patients. In addition, disease duration and comorbid allergic rhinitis were significantly associated with the risk of postoperative recurrence of CRS.

Interaction of eosinophilic and neutrophilic inflammation in patients with chronic rhinosinusitis

PURPOSE OF REVIEW

In the past year, the endotype of chronic rhinosinusitis (CRS) has been studied from a new perspective. Eosinophilic and neutrophilic inflammation are not independent processes in the pathogenesis of CRS. In this review, we will focus on recent research on mixed eosinophilic-neutrophilic inflammation in CRS and discuss the mechanism and potential treatments.

RECENT FINDINGS

Traditionally, patients with eosinophilic CRS (ECRS) present with severe clinical manifestations, comorbidities, and a higher recurrence rate. Recent studies have found that approximately 40% of patients with ECRS present with neutrophilic infiltration, while patients with predominantly eosinophilic infiltration along with neutrophilic inflammation present with more complex inflammation, clinical manifestations and exhibit refractory characteristics.

SUMMARY

The complex inflammatory profile and refractory clinical characteristics of mixed eosinophilic-neutrophilic inflammation in CRS are current challenges for clinicians. We summarize the features of eosinophilic and neutrophilic inflammation and current studies on the mechanisms of mixed eosinophilic-neutrophilic inflammation and suggest potentially effective therapeutic methods. We hope that this review will help with determining precise treatment options for patients.

Endotypic heterogeneity and pathogenesis in chronic rhinosinusitis

PURPOSE OF REVIEW

This review aims to provide updates in realms of endotypic heterogeneity, pathogenesis at the molecular level, potential of biomarkers, and cutting-edge scope of biologics in CRS.

RECENT FINDINGS

High-dimensional analyses, such as transcriptomes, and machine learning, have significantly enhanced CRS endotyping, uncovering diverse pathogenetic mechanisms contributing to its heterogeneity. The dynamic process of epithelial remodeling in CRS pathogenesis has gained more clarity and support as exemplified by IL-13 and oncostatin M (OSM) that are shown intricately linked to epithelial barrier dysfunction. Moreover, anti-dsDNA autoantibody, BAFF, periostin, and cystatin SN show promise as potentials biomarkers, offering diagnostic and prognostic value for CRS.

SUMMARY

The identification of inflammatory molecules involved in endotype specific signaling pathways provides insights into the underlying mechanisms and verifiable biomarkers for diagnosis and prediction of disease severity. More comprehensive clinical studies should be conducted to facilitate biologics from bench to bedside in treating CRS.

Long-Term Clinical Outcomes in Patients with Chronic Rhinosinusitis with Nasal Polyps Associated with Expanded Types of Endoscopic Sinus Surgery

(1) Background: Surgical criteria for chronic rhinosinusitis with nasal polyps (CRSwNP) remain unresolved. This study addresses these discrepancies by comparing the clinical outcomes of expanded-functional endoscopic sinus surgeries (E-FESS) with more-limited FESS (L-FESS). (2) Methods: A database was analyzed retrospectively to compare surgical outcomes in CRSwNP patients who underwent E-FESS versus those subjected to L-FESS. Quality of life, endoscopic and radiological outcomes were compared at the baseline and two years after surgery. The clinical status of the responder was defined when a minimal clinically important difference of 12 points in SNOT-22 change was achieved. (3) Results: A total of 274 patients met the inclusion criteria and were analyzed; 111 underwent E-FESS and 163 were subjected to L-FESS. Both groups exhibited significant clinical improvements, although a greater magnitude of change in SNOT-22 (14.8 ± 4.8, p = 0.002) was shown after E-FESS. Higher significant improvements for endoscopic and radiological scores and lower surgical revision rates were also noted in the E-FESS group. (4) Conclusions: E-FESS provides better clinical outcomes and reduced revision surgery rates when compared to L-FESS in CRSwNP patients two years after surgery, irrespective of any comorbidity. Further randomized prospective studies are needed to comprehensively contrast these results.

IgE directly affects eosinophil migration in chronic rhinosinusitis with nasal polyps through CCR3 and predicts the efficacy of omalizumab

BACKGROUND

Whether IgE affects eosinophil migration in chronic rhinosinusitis with nasal polyps (CRSwNP) remains largely unclear. Moreover, our understanding of local IgE, eosinophils, and omalizumab efficacy in CRSwNP remains limited.

OBJECTIVE

We investigated whether IgE acts directly on eosinophils and determined its role in omalizumab therapy.

METHODS

Eosinophils and their surface receptors were detected by hematoxylin and eosin staining and flow cytometry. IgE and its receptors, eosinophil peroxidase (EPX), eosinophilic cationic protein, and CCR3 were detected by immunohistochemistry and immunofluorescence. Functional analyses were performed on blood eosinophils and polyp tissues. Logistic regression was performed to screen for risk factors. Receiver operating characteristic curve was generated to evaluate the accuracy.

RESULTS

Both FcεRI and CD23 were expressed on eosinophils. The expression of FcεRI and CD23 on eosinophil in nasal polyp tissue was higher than in peripheral blood (both P < .001). IgE and EPX colocalized in CRSwNP. IgE directly promoted eosinophil migration by upregulating CCR3 in CRSwNP but not in healthy controls. Omalizumab and lumiliximab were found to be effective in restraining this migration, indicating CD23 was involved in IgE-induced eosinophil migration. Both IgE+ and EPX+ cells were significantly reduced after omalizumab treatment in those who experienced response (IgE+ cells, P = .001; EPX+ cells, P = .016) but not in those with no response (IgE+ cells, P = .060; EPX+ cells, P = .151). Baseline IgE+ cell levels were higher in those with response compared to those without response (P = .024). The baseline local IgE+ cell count predicted omalizumab efficacy with an accuracy of 0.811.

CONCLUSIONS

IgE directly promotes eosinophil migration, and baseline local IgE+ cell counts are predictive of omalizumab efficacy in CRSwNP.

Chronic rhinosinusitis with nasal polyps: eosinophils versus B lymphocytes in disease pathogenesis

PURPOSE OF REVIEW

To highlight the current evidence that supports the view that eosinophils may not drive disease in chronic rhinosinusitis with nasal polyps (CRSwNP) and the emerging evidence for B cells as an important player in this disease.

RECENT FINDINGS

Eosinophil depletion studies in CRSwNP do not fully support a critical role for eosinophils in CRSwNP. Almost complete eosinophil depletion with dexpramipexole had no impact on polyp size reduction or clinical improvement. Anti-interleukin (IL)-5 and IL-5Rα inhibition were more effective though with less clinical impact when compared to anti-immunoglobulin E (IgE) or IL-4Rα inhibition strategies. As IL-5Rα is also expressed on CRSwNP derived IgE+ and IgG4+ plasma cells to the same extent as eosinophils, improvements in CRSwNP with IL-5 inhibition may suggest a role for B cells over eosinophils in CRSwNP. We review both eosinophils and B cells in the context of CRSwNP and highlight the current evidence that supports an emerging role for B cells.

SUMMARY

Despite many aspects of immunopathology in CRSwNP explainable by B cell dysfunction, B cells have so far been ignored in CRSwNP. Further work is needed, as targeting B cells may offer an exciting new therapeutic option in the future.

Assessment of eosinophilic rhinosinusitis cases that required secondary treatment (biologics or reoperation) during long-term postoperative courses

OBJECTIVE

Endoscopic sinus surgery (ESS) is selected as the primary treatment for eosinophilic chronic rhinosinusitis (ECRS). Biologics or reoperation are sometimes required as secondary treatment after ESS. The present study examined the long-term postoperative courses of ECRS cases treated according to the current treatment concept, the frequency of secondary treatment, and its predictive factors.

METHODS

Ninety-four patients with ECRS who underwent ESS and received continuous management for 1-5 years were retrospectively investigated. Patient characteristics, long-term changes in endoscopic scores and the results of olfactory function tests, and secondary treatment were evaluated.

RESULTS

Five patients underwent reoperation and 11 received dupilumab during the follow-up period (35.9±19.2 months). Sixteen patients (17%) required secondary treatment due to the deterioration of sinus conditions. These patients were significantly younger, had higher comorbidity rates of allergic rhinitis and bronchial asthma, and a higher preoperative CT score than those who did not require secondary treatment. Three months after surgery, CT scores, endoscopic scores (E-scores), and the self-administered odor questionnaire (SAOQ) were significantly worse in patients who required secondary treatment. A multivariate regression analysis identified age, preoperative CT scores, and 3-month E-scores as predictive factors for secondary treatment. Three-month E-scores showed higher sensitivity and specificity, and the odds ratio was 11.3 when the cut-off value was set at 10.

CONCLUSION

The early identification of patients for whom ESS may fail is important and additional treatments need to be provided at the appropriate timing where needed. Patients with the following factors need to be carefully followed up: a young age, high preoperative CT score, and high early postoperative E-score.

Identification of novel biomarkers based on lipid metabolism-related molecular subtypes for moderately severe and severe acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is an unpredictable and potentially fatal disorder. A derailed or unbalanced immune response may be the root of the disease's severe course. Disorders of lipid metabolism are highly correlated with the occurrence and severity of AP. We aimed to characterize the contribution and immunological characteristics of lipid metabolism-related genes (LMRGs) in non-mild acute pancreatitis (NMAP) and identify a robust subtype and biomarker for NMAP.

METHODS

The expression mode of LMRGs and immune characteristics in NMAP were examined. Then LMRG-derived subtypes were identified using consensus clustering. The weighted gene co-expression network analysis (WGCNA) was utilized to determine hub genes and perform functional enrichment analyses. Multiple machine learning methods were used to build the diagnostic model for NMAP patients. To validate the predictive effectiveness, nomograms, receiver operating characteristic (ROC), calibration, and decision curve analysis (DCA) were used. Using gene set variation analysis (GSVA) and single-cell analysis to study the biological roles of model genes.

RESULTS

Dysregulated LMRGs and immunological responses were identified between NMAP and normal individuals. NMAP individuals were divided into two LMRG-related subtypes with significant differences in biological function. The cluster-specific genes are primarily engaged in the regulation of defense response, T cell activation, and positive regulation of cytokine production. Moreover, we constructed a two-gene prediction model with good performance. The expression of CARD16 and MSGT1 was significantly increased in NMAP samples and positively correlated with neutrophil and mast cell infiltration. GSVA results showed that they are mainly upregulated in the T cell receptor complex, immunoglobulin complex circulating, and some immune-related routes. Single-cell analysis indicated that CARD16 was mainly distributed in mixed immune cells and macrophages, and MGST1 was mainly distributed in exocrine glandular cells.

CONCLUSIONS

This study presents a novel approach to categorizing NMAP into different clusters based on LMRGs and developing a reliable two-gene biomarker for NMAP.

Application of roc-analysis to assess the quality of predicting the risk of chronic rhinosinusitis recurrence

OBJECTIVE

Aim: To propose a new, original approach to assessing the quality of a multivariate regression model for predicting the risk of recurrence in patients with chronic rhinosinusitis based on ROC analysis with the construction of appropriate curves, estimating the area under them, as well as calculating the sensitivity, accuracy, specificity, and predictive value of a positive and negative classification results, the likelihood ratio of positive and negative patient detection results.

PATIENTS AND METHODS

Materials and Methods: 204 patients aged with a diagnosis of chronic rhinosinusitis were examined.

RESULTS

Results: To build a multivariate regression model 14 probable factors of chronic rhinosinusitis occurrence were selected to determine the diagnostic value of the proposed model we calculate the sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), the likelihood ratio of a positive test (LR+), the likelihood ratio of a negative test (LR-) and prediction accuracy % of the proposed mathematical model. In order to determine the prognostic value of the risk ratio of CRS recurrence model, ROC- analysis was performed, ROC curves were obtained.

CONCLUSION

Conclusions: The multivariate regression model makes it possible to predict potential complications and the possibility of disease recurrence. The construction of ROC-curves allows us to assert the excellent classification quality of chronic rhinosinusitis recurrence.

Tissue Interleukin-33: A Novel Potential Regulator of Innate Immunity and Biomarker of Disease Severity in Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a disease of real interest for researchers due to its heterogenicity and complex pathophysiological mechanisms. Identification of the factors that ensure success after treatment represents one of the main challenges in CRSwNP research. No consensus in this direction has been reached so far. Biomarkers for poor outcomes have been noted, but nonetheless, their prognostic value has not been extensively investigated, and needs to be sought. We aimed to evaluate the correlation between potential prognostic predictors for recalcitrant disease in patients with CRSwNP.

METHODS

The study group consisted of CRSwNP patients who underwent surgical treatment and nasal polyp (NP) tissue sampling. The preoperative workup included Lund-Mackay assessment, nasal endoscopy, eosinophil blood count, asthma, and environmental allergy questionnaire. Postoperatively, in subjects with poor outcomes, imagistic osteitis severity was evaluated, and IL-33 expression was measured.

RESULTS

IL-33 expression in NP was positively and significantly correlated with postoperative osteitis on CT scans (p = 0.01). Furthermore, high osteitis CT scores were related to high blood eosinophilia (p = 0.01). A positive strong correlation was found between postoperative osteitis and the Lund-Mackay preoperative score (p = 0.01), as well as the nasal endoscopy score (p = 0.01).

CONCLUSIONS

Our research analyzed the levels of polyp IL-33, relative to blood eosinophilia, overall disease severity score, and osteitis severity, in patients with CRSwNP. These variables are prognostic predictors for poor outcomes and recalcitrant disease. Considering the importance of bone involvement in CRSwNP, this research aims to provide a better insight into the correlations of osteitis with clinical and biological factors.

Endoscopic Extended Sinus Surgery for Patients with Severe Chronic Rhinosinusitis with Nasal Polyps, the Choice of Mucoplasty: A Systematic Review

PURPOSE OF REVIEW

The advances in the knowledge of the molecular basis of the inflammatory response in chronic rhinosinusitis with nasal polyps (CRSwNP) have led the management of these patients towards personalized and precision medicine. Surgery has been positioned as a suitable alternative in patients who do not achieve control with appropriate medical treatment, but polypoid recurrences remain a constraint. The emergence of new surgical approaches based on patient phenotyping and the poor disease control associated with type 2 inflammatory phenotype makes it necessary to review the role of personalized and precision surgery in managing the disease.

RECENT FINDINGS

Surgical approaches based on wide resection of bony sinus structures and the treatment of mucosa lining the sinonasal cavity have been analyzed and compared with other techniques and seem to offer more favorable surgical outcomes and improved quality of life (QoL), in addition to lower relapse rates. The innovations with new complementary surgical techniques, such as reboot surgery adding an extended autologous mucosal graft from the nasal floor (mucoplasty), may benefit endoscopic and QoL outcomes in the most severe CRSwNP patients with type 2 phenotype. Using bilateral endonasal mucoplasty as a complementary technique to reboot surgery is a suitable technical choice that has improved short- and medium-term QoL and endoscopic outcomes for patients with severe CRSwNP. These results are likely due to a combination of the extension of reboot and the inherent inflammatory and healing properties of mucoplasty. We propose this technique as a valuable surgical resource, although more robust clinical studies are needed to evaluate its long-term benefits comprehensively.