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Hornung CM, Ganti A, Lunos S, Tyler MA. Characterizing Trends in Diagnosis and Management of Sinusitis in a Large Health Care System: From Primary Care to Otolaryngology. Ann Otol Rhinol Laryngol 2024; 133:476-484. [PMID: 38345045 DOI: 10.1177/00034894241230365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
OBJECTIVES Variations in management of sinusitis in primary care settings can be associated with inappropriate antibiotic prescriptions and delays in treatment. The objective of this study was to identify patient and provider characteristics associated with possible inaccurate diagnosis and management of sinusitis. METHODS We performed a cross-sectional retrospective analysis using an established regional healthcare database of patients who received a diagnosis of sinusitis between 2011 and 2022 from a non-otolaryngologist provider. Patient's comorbidities, insurance status, chronicity of sinusitis, and prescriptions were included. We noted if patients were referred to an otolaryngology practice and if they received a diagnosis of sinusitis from an otolaryngologist. RESULTS We analyzed 99 581 unique patients and 168 137 unique encounters. The mean age was 41.5 (±20.4 years) and 35.7% were male. Most patients had private insurance (88.5%), acute sinusitis (81.2%), and were seen at a primary care office (97.8%). Approximately 30% of patients were referred to an otolaryngology practice for sinusitis. Of referred patients, 50.6% did not receive a diagnosis of sinusitis from an otolaryngology practice. Patients without a sinusitis diagnosis by an otolaryngology practice received significantly more mean courses of antibiotics (5.04 vs 2.39, P < .0001) and oral steroids (3.53 vs 2.08, P < .0001). CONCLUSIONS Over half of the patients referred to an otolaryngology practice from primary care for sinusitis did not receive a diagnosis of sinusitis from an otolaryngology practice. Further research should investigate implications for increased healthcare costs and inappropriate prescription trends associated with the management of sinusitis.
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Affiliation(s)
- Christopher M Hornung
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Ashwin Ganti
- Department of Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Scott Lunos
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Matthew A Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
- Center for Skull Base and Pituitary Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
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Gokani SA, Clark A, Javer A, Philpott C. Prevalence and Associated Factors of Medication Non-Adherence in CRS Patients following Endoscopic Sinus Surgery. J Clin Med 2023; 12:5381. [PMID: 37629424 PMCID: PMC10455742 DOI: 10.3390/jcm12165381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
This study aimed to evaluate factors that may predispose patients to not adhere to prescribed medication after endoscopic sinus surgery (ESS) and to compare SNOT-22 scores at 0-12 months post-operatively between adherent and non-adherent patients. CRS patients who underwent ESS between 2012 and 2016 were recruited to this retrospective cohort study. Adherence was assessed through a questionnaire and review of medical notes. Ninety-four participants were included (61% male, mean age 60). Of those, 66% did not adhere to their prescribed post-operative CRS medication timing or dosage. The most common reason for non-adherence was improvement of symptoms (17%), followed by deterioration of symptoms (11%) and side effects (10%). Post-operative SNOT-22 scores were lowest for non-intentionally non-adherent (NINA) participants with a mean of 10.5 [95% CI: 7.47-13.5], compared to 25.0 for intentionally non-adherent (INA) [95% CI: 17.6-32.4] and 17.7 for adherent patients [95% CI: 13.7-21.7], p = 0.01. This study identifies that almost two-thirds of patients are not compliant with CRS medications after ESS. NINA participants reported lower post-operative SNOT-22 scores compared to INA and adherent participants. Future studies should focus on educating patients to continue with medications post-operatively despite an initial improvement in symptoms.
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Affiliation(s)
- Shyam Ajay Gokani
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; (S.A.G.); (A.C.)
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; (S.A.G.); (A.C.)
| | - Amin Javer
- St Paul’s Sinus Centre, Vancouver, BC V6Z 1Y6, Canada;
| | - Carl Philpott
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; (S.A.G.); (A.C.)
- James Paget University Hospital NHS Foundation Trust, Gorleston-on-Sea, Great Yarmouth NR31 6LA, UK
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Roberts E. Oral Corticosteroids for Patients with Eosinophilic Diseases: An Expert Panel View on Use, Overuse, and Strategies to Reduce Use. EUROPEAN MEDICAL JOURNAL 2023. [DOI: 10.33590/emj/10303904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Severe asthma (SA), chronic rhinosinusitis with nasal polyps (CRSwNP), and eosinophilic granulomatosis with polyangiitis (EGPA) are three conditions driven by IL-5 and eosinophilic inflammation. As these conditions have high use of healthcare services, as well as lifestyle and psychological burdens, safe treatment to achieve optimal control is key. In all three conditions, as for many other eosinophilic diseases (ED), oral corticosteroids (OCS) are often used for both acute and maintenance treatment where disease activity is high. While, in general, OCS are very effective, their use is limited by a well-recognised high potential for adverse effects (AE). Moreover, cumulative exposure to OCS may not be acknowledged in many patients, especially for those predominantly treated in primary care, exposing patients to potentially damaging long-term OCS-related AEs. To discuss the use of OCS for these eosinophilic diseases, as well as to provide guidance on how to help limit their use, a board of European experts within each field was gathered. The experts completed questionnaires regarding treatment and referral pathways for patients with SA, CRSwNP, or EGPA; then, in an online meeting, discussed a number of issues in regard to OCS use. Here, the authors present the key recommendations from the expert advisory panel alongside some background to these conditions regarding treatment with OCS.
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Williamson S, Dennison L, Greenwell K, Denison-Day J, Mowbray F, Richards-Hall S, Smith D, Bradbury K, Ainsworth B, Little P, Geraghty AWA, Yardley L. Using nasal sprays to prevent respiratory tract infections: a qualitative study of online consumer reviews and primary care patient interviews. BMJ Open 2022; 12:e059661. [PMID: 35772824 PMCID: PMC9247325 DOI: 10.1136/bmjopen-2021-059661] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/09/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Nasal sprays could be a promising approach to preventing respiratory tract infections (RTIs). This study explored lay people's perceptions and experiences of using nasal sprays to prevent RTIs to identify barriers and facilitators to their adoption and continued use. DESIGN Qualitative research. Study 1 thematically analysed online consumer reviews of an RTI prevention nasal spray. Study 2 interviewed patients about their reactions to and experiences of a digital intervention that promotes and supports nasal spray use for RTI prevention (reactively: at 'first signs' of infection and preventatively: following possible/probable exposure to infection). Interview transcripts were analysed using thematic analysis. SETTING Primary care, UK. PARTICIPANTS 407 online customer reviews. 13 purposively recruited primary care patients who had experienced recurrent infections and/or had risk factors for severe infections. RESULTS Both studies identified various factors that might influence nasal spray use including: high motivation to avoid RTIs, particularly during the COVID-19 pandemic; fatalistic views about RTIs; beliefs about alternative prevention methods; the importance of personal recommendation; perceived complexity and familiarity of nasal sprays; personal experiences of spray success or failure; tolerable and off-putting side effects; concerns about medicines; and the nose as unpleasant and unhygienic. CONCLUSIONS People who suffer disruptive, frequent or severe RTIs or who are vulnerable to RTIs are interested in using a nasal spray for prevention. They also have doubts and concerns and may encounter problems. Some of these may be reduced or eliminated by providing nasal spray users with information and advice that addresses these concerns or helps people overcome difficulties.
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Affiliation(s)
- Sian Williamson
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Laura Dennison
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Kate Greenwell
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - James Denison-Day
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Fiona Mowbray
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Samantha Richards-Hall
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Deb Smith
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Katherine Bradbury
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Ben Ainsworth
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Department of Psychology, University of Bath, Bath, UK
| | - Paul Little
- Primary Care and Population Science, University of Southampton, Southampton, UK
| | - Adam W A Geraghty
- Primary Care and Population Science, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- School of Health Sciences, University of Bristol, Bristol, UK
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Kim IA, Nosulya EV, Ragimova DR. [Features of adherence to treatment of patients with chronic rhinosinusitis with nasal polyps]. Vestn Otorinolaringol 2022; 87:81-86. [PMID: 35274897 DOI: 10.17116/otorino20228701181] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic polypous rhinosinusitis (CPR) is characterized by refractory to drug therapy and a high potential for recurrence after surgical treatment. One of the important factors limiting the effectiveness of drug therapy of CPR, in particular intranasal glucocorticosteroids (inGCSs), is the insufficient level of adherence to treatment of patients with CPR. OBJECTIVE Generalization of data on the significance and ways to increase adherence to treatment of patients with CPR. MATERIAL AND METHODS Materials of scientific publications included in the Cochrane Library, Russian Science Citation Index, MEDLINE, PubMed information bases were used as a data source. The material was selected based on the following keywords: "chronic rhinosinusitis", "nasal polyps", "intranasal glucocorticosteroids", "adherence to treatment". RESULTS Despite the fact that inGCSs are one of the main pathogenetically justified methods of treating CPR, their use is limited by many factors, one of which is the level of patient compliance with the treatment regimen. CONCLUSION Improving adherence to treatment is one of the important reserves for increasing the effectiveness of drug therapy for chronic polypous rhinosinusitis.
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Affiliation(s)
- I A Kim
- National Medical Research Center for Otorhinolaryngology, Moscow, Russia
| | - E V Nosulya
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - D R Ragimova
- Pirogov Russian National Research Medical University, Moscow, Russia
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Bachert C, Sousa AR, Han JK, Schlosser RJ, Sowerby LJ, Hopkins C, Maspero JF, Smith SG, Kante O, Karidi-Andrioti DE, Mayer B, Chan RH, Yancey SW, Chaker AM. Mepolizumab for chronic rhinosinusitis with nasal polyps: treatment efficacy by comorbidity and blood eosinophil count. J Allergy Clin Immunol 2022; 149:1711-1721.e6. [PMID: 35007624 DOI: 10.1016/j.jaci.2021.10.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/12/2021] [Accepted: 10/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND In the Phase III SYNAPSE study, mepolizumab reduced nasal polyp (NP) size and nasal obstruction in chronic rhinosinusitis with NP (CRSwNP). OBJECTIVE To assess the efficacy of mepolizumab in patients from SYNAPSE grouped by comorbid asthma, aspirin-exacerbated respiratory disease (AERD), and baseline blood eosinophil count (BEC). METHODS SYNAPSE, a randomized, double-blind, 52-week study (NCT03085797), included patients with severe bilateral CRSwNP eligible for surgery despite intranasal corticosteroid treatment. Patients received 4-weekly subcutaneous mepolizumab 100 mg or placebo plus standard of care for 52 weeks. Co-primary endpoints were change in total endoscopic NP score (Week 52) and nasal obstruction visual analog scale (VAS) score (Weeks 49-52). Subgroup analyses by comorbid asthma and AERD status, and post hoc by BEC, were exploratory. RESULTS Analyses included 407 patients (289 with asthma; 108 with AERD; 371 and 278 with BEC counts ≥150 or ≥300 cells/μL, respectively). The proportion of patients with ≥1-point improvement from baseline in NP score was higher with mepolizumab versus placebo across comorbid diseases (asthma: 52.9% vs 29.5%; AERD: 51.1% vs 20.6%) and baseline BEC subgroups (<150 cells/μL: 55.0% vs 31.3%; ≥150 cells/μL: 49.5% vs 28.1%; <300 cells/μL: 50.7% vs 29.0%; ≥300 cells/μL: 50.4% vs 28.1%). A similar trend was observed in patients without comorbid asthma or AERD. More patients had >3-point improvement in nasal obstruction VAS score with mepolizumab versus placebo across comorbid subgroups. CONCLUSION Mepolizumab reduced polyp size and nasal obstruction in CRSwNP regardless of the presence of comorbid asthma or AERD. CLINICAL IMPLICATION Mepolizumab should be considered for the treatment of CRSwNP, particularly in patients with comorbid asthma or AERD.
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Affiliation(s)
- Claus Bachert
- Upper Airways Research Laboratory and Department of Oto-Rhino-Laryngology, Ghent University and Ghent University Hospital, Ghent, Belgium; Division of ENT Diseases, CLINTEC, Karolinska Institute, University of Stockholm, Stockholm, Sweden; First Affiliated Hospital, Sun Yat-sen University, International Airway Research Center, Guangzhou, China
| | - Ana R Sousa
- Clinical Sciences, GSK R&D, Brentford, Middlesex, UK
| | - Joseph K Han
- Department of Otolaryngology, Head & Neck Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Leigh J Sowerby
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, ON, Canada
| | - Claire Hopkins
- ENT Department, Guys and St Thomas's Hospital, and King's College, London, UK
| | - Jorge F Maspero
- Allergy and Respiratory Research Unit, Fundación CIDEA, Buenos Aires, Argentina
| | - Steven G Smith
- Respiratory Therapeutic Area Unit, GSK, Research Triangle Park, NC, USA
| | - Oliver Kante
- Global Clinical Sciences and Delivery, GSK Munich, Germany
| | | | | | - Robert H Chan
- Clinical Sciences, GSK R&D, Brentford, Middlesex, UK
| | | | - Adam M Chaker
- Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Department of Otolaryngology and Center for Allergy and Environment, Munich, Germany.
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Burrowes SAB, Barlam TF, Skinner A, Berger R, Ni P, Drainoni ML. Provider views on rapid diagnostic tests and antibiotic prescribing for respiratory tract infections: A mixed methods study. PLoS One 2021; 16:e0260598. [PMID: 34843599 PMCID: PMC8629209 DOI: 10.1371/journal.pone.0260598] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 11/12/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Respiratory tract infections (RTIs) are often inappropriately treated with antibiotics. Rapid diagnostic tests (RDTs) have been developed with the aim of improving antibiotic prescribing but uptake remains low. The aim of this study was to examine provider knowledge, attitudes and behaviors regarding RDT use and their relationship to antibiotic prescribing decisions across multiple clinical departments in an urban safety-net hospital. METHODS We conducted a mixed methods sequential explanatory study. Providers with prescribing authority (attending physicians, nurse practitioners and physician assistants) who had at least 20 RTI encounters from January 1, 2016 to December 31, 2018. Eighty-five providers completed surveys and 16 participated in interviews. We conducted electronic surveys via RedCap from April to July 2019, followed by semi-structured individual interviews from October to December 2019, to ascertain knowledge, attitudes and behaviors related to RDT use and antibiotic prescribing. RESULTS Survey findings indicated that providers felt knowledgeable about antibiotic prescribing guidelines. They reported high familiarity with the rapid streptococcus and rapid influenza tests. Familiarity with comprehensive respiratory panel PCR (RPP-respiratory panel PCR) and procalcitonin differed by clinical department. Qualitative interviews identified four main themes: providers trust their clinical judgment more than rapid test results; patient-provider relationships play an important role in prescribing decisions; there is patient demand for antibiotics and providers employ different strategies to address the demand and providers do not believe RDTs are implemented with sufficient education or evidence for clinical practice. CONCLUSION Prescribers are knowledgeable about prescribing guidelines but often rely on clinical judgement to make final decisions. The utility of RDTs is specific to the type of RDT and the clinical department. Given the low familiarity and clinical utility of RPP and procalcitonin, providers may require additional education and these tests may need to be implemented differently based on clinical department.
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Affiliation(s)
- Shana A. B. Burrowes
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, United States of America
- * E-mail:
| | - Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
| | - Alexandra Skinner
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, United States of America
| | - Rebecca Berger
- Massachusetts Department of Public Health, Boston, MA, United States of America
| | - Pengsheng Ni
- Biostatistics and Epidemiology Data Analytics Center (BEDAC) Boston University School of Public Health, Boston, MA, United States of America
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, United States of America
- Evans Center for Implementation and Improvement Sciences (CIIS), Boston University School of Medicine, Boston, MA, United States of America
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Beegun I, Koenis DS, Alusi G, Dalli J. Dysregulated Maresin Concentrations in Plasma and Nasal Secretions From Patients With Chronic Rhinosinusitis. Front Immunol 2021; 12:733019. [PMID: 34531873 PMCID: PMC8438229 DOI: 10.3389/fimmu.2021.733019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/09/2021] [Indexed: 01/01/2023] Open
Abstract
The mechanisms that lead to disease onset and propagation in patients with chronic rhinosinusitis (CRS) are not fully elucidated. Maresins (MaR) are a family of essential fatty acid-derived lipid mediators that play a central role in the regulation of inflammation with several studies demonstrating that these mediators display protective activities in airway inflammation. Therefore, in the present studies we evaluated whether concentrations of these mediators were altered in both peripheral blood and nasal secretions from CRS patients. Herein, we focused on patients with CRS that also develop nasal polyps (CRSwNP), given that therapeutic options for the treatment of these patients are limited. Thereby, insights into disease mechanisms in these patients may help design more effective treatments. For this purpose, we compared maresin concentrations from CRSwNP patients with those found in healthy volunteers or patients with an upper respiratory tract infection (URTI), as a self-resolving inflammatory condition. Using liquid chromatography tandem mass spectrometry, we found that MaR concentrations were significantly decreased in plasma from patients with CRSwNP when compared to healthy volunteers. MaR concentrations were observed to be significantly upregulated in nasal secretions from patients with CRSwNP when compared with both healthy volunteers and URTI subjects. Concentration of these mediators in both plasma and nasal secretions from CRSwNP patients were positively correlated with quality-of-life scores in these patients. Assessment of the concentrations of other pro-resolving and pro-inflammatory lipid mediators (LM) demonstrated that there was a general shift in LM levels in both plasma and nasal secretions from CRSwNP when compared with healthy volunteers and URTI subjects. Of note, incubation of peripheral blood cells from CRSwNP patients with MaR1 downregulated the expression of activation markers on peripheral blood phagocytes, including CD41 and CD62P, markers of platelet-leukocyte heterotypic aggregates. Together these findings demonstrate that both local and systemic LM concentrations, in particularly those of the MaR family, become altered in patients with CRSwNP. They also suggest that therapeutics designed around MaR1 may be useful in regulating the activation of phagocytes in patients with CRSwNP thereby potentially also limiting the local inflammatory response in these patients.
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Affiliation(s)
- Issa Beegun
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Duco S Koenis
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Ghassan Alusi
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Jesmond Dalli
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.,Centre for Inflammation and Therapeutic Innovation, Queen Mary University of London, London, United Kingdom
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Saydy N, Moubayed SP, Desrosiers M. Patient perspectives on endoscopic sinus surgery for chronic rhinosinusitis. J Otolaryngol Head Neck Surg 2021; 50:34. [PMID: 34130732 PMCID: PMC8207753 DOI: 10.1186/s40463-021-00515-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 05/10/2021] [Indexed: 12/22/2022] Open
Abstract
Background Through shared decision-making, physicians and patients can elect endoscopic sinus surgery (ESS) when maximal medical therapy fails in patients with chronic rhinosinusitis (CRS). In this study, we aim to explore the most important themes with regards to patients’ perspectives on ESS. Our objective was to define the patient experience and ensure that we have congruent physician and patient goals for obtaining success. Methods Semi-structured face-to-face interviews were conducted with 22 patients at a tertiary-care institution in Montreal. Three themes were established a priori: living with CRS, objectives and expectations and criteria for success. This thematic approach allowed the identification, analysis and reporting of patterns found across the data set. A phenomenological methodological orientation was used. Interviews were audio-recorded and transcribed verbatim for continuous analysis. These were coded by hand by a single coder who read the transcripts multiple times and relistened to the recordings. Results Exploration of themes on patients’ perspectives on ESS for CRS yielded multiple anecdotal findings, and some recurring patterns. There is a tendency for patients to focus on one principal symptom that drives their decrease in QoL. Headaches and nasal congestion seemed to impact patients’ QoL the most amongst rhinologic symptoms. Hyposmia was rarely spontaneously by patients but was often a significant source of distress when prompted during interviews. Objectives and expectations seemed to be inversely proportional to number of previous surgeries and severity of symptoms preoperatively. There was a clear association between preoperative expectations and postoperative satisfaction. There was no clear pattern in the improvement magnitude or time improved postoperatively for patients to consider the surgery a success. Conclusions Patients’ level of satisfaction postoperatively and with their care in general is multifactorial. We believe the topic of goals and expectations regarding ESS should be discussed preoperatively for every patient with CRS. This includes patients with seemingly minor disease and patients naive to surgery, as can sometimes have exceedingly high expectations. Preoperative counselling must also include an assessment of what symptom is the most cumbersome to that particular patient, as patients tend to focus a lot on one or two symptoms. Postoperatively, we encourage clinicians to be attentive to the change in each patient’s principal complaints within the context of a personalized approach and to refer back to patients’ preoperative goals in their assessment of operative success. Graphical abstract ![]()
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Affiliation(s)
- Nadim Saydy
- Division of Otolaryngology - Head & Neck Surgery, Centre Hospitalier de l'Université de Montréal, University of Montreal, 1051 Sanguinet Street, Montreal, QC, H2X 3E4, Canada
| | - Sami Pierre Moubayed
- Division of Otolaryngology - Head & Neck Surgery, Sacré-Coeur Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Martin Desrosiers
- Division of Otolaryngology - Head & Neck Surgery, Centre Hospitalier de l'Université de Montréal, University of Montreal, 1051 Sanguinet Street, Montreal, QC, H2X 3E4, Canada.
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Han JK, Bachert C, Fokkens W, Desrosiers M, Wagenmann M, Lee SE, Smith SG, Martin N, Mayer B, Yancey SW, Sousa AR, Chan R, Hopkins C. Mepolizumab for chronic rhinosinusitis with nasal polyps (SYNAPSE): a randomised, double-blind, placebo-controlled, phase 3 trial. THE LANCET RESPIRATORY MEDICINE 2021; 9:1141-1153. [PMID: 33872587 DOI: 10.1016/s2213-2600(21)00097-7] [Citation(s) in RCA: 258] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/29/2021] [Accepted: 02/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyps affects approximately 2-4% of the general population, and long-term use of systemic corticosteroids is associated with adverse effects. The aim of this study was to assess the efficacy and safety of mepolizumab in adults with recurrent, refractory severe bilateral chronic rhinosinusitis with nasal polyps. METHODS SYNAPSE was a randomised, double-blind, placebo-controlled, parallel-group, phase 3 trial done at 93 centres, mainly hospitals, in 11 countries. Eligible patients were aged 18 years or older with recurrent, refractory, severe, bilateral nasal polyp symptoms (nasal obstruction symptom visual analogue scale [VAS] score of >5), were eligible for repeat nasal surgery (overall symptoms VAS score >7 and endoscopic nasal polyps score of ≥5, with a minimum score of 2 in each nasal cavity) despite standard of care treatment, and had to have at least one nasal surgery in the past 10 years. Patients were randomly assigned (1:1), using permuted block design, to receive either 100 mg mepolizumab subcutaneously or placebo once every 4 weeks, in addition to standard of care (mometasone furoate intranasal spray for at least 8 weeks before screening and during the study, saline nasal irrigations, systemic corticosteroids or antibiotics, or both), as required, for 52 weeks. Site staff, the central study team, and patients were masked to study treatment and absolute blood eosinophil counts. The coprimary endpoints were change from baseline in total endoscopic nasal polyp score at week 52 and in mean nasal obstruction VAS score during weeks 49-52, assessed in the intention-to-treat population (ITT). This study is registered with ClinicalTrials.gov, NCT03085797. FINDINGS From May 25, 2017, to Dec 12, 2018, 854 patients were screened for eligibility. 414 patients were randomly assigned with 407 included in the ITT population; 206 received mepolizumab and 201 received placebo. Total endoscopic nasal polyp score significantly improved at week 52 from baseline with mepolizumab versus placebo (adjusted difference in medians -0·73, 95% CI -1·11 to -0·34; p<0·0001) and nasal obstruction VAS score during weeks 49-52 also significantly improved (-3·14, -4·09 to -2·18; p<0·0001). Adverse events considered related to study treatment were reported in 30 (15%) of 206 patients receiving mepolizumab and 19 (9%) of 201 receiving placebo. On-treatment serious adverse events occurred in 12 (6%) patients receiving mepolizumab and 13 (6%) receiving placebo; none were considered related to treatment in those receiving mepolizumab. One death was reported in the placebo group (myocardial infarction; death occurred 99 days after the last dose) and was considered unrelated to the treatment. INTERPRETATION Mepolizumab treatment improved nasal polyp size and nasal obstruction compared with placebo, with no new safety indications, in patients with recurrent, refractory severe chronic rhinosinusitis with nasal polyps. These findings suggest that mepolizumab provides an effective add-on treatment option to standard of care in this population. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Joseph K Han
- Department of Otolaryngology, Eastern Virginia Medical School, Norfolk, VA, USA.
| | - Claus Bachert
- Department of Oto-Rhino-Laryngology, Upper Airways Research Laboratory, Ghent University Hospital, Ghent University, Ghent, Belgium; Division of ENT Diseases, CLINTEC, Karolinska Institutet, University of Stockholm, Stockholm, Sweden
| | - Wytske Fokkens
- Department of Otolaryngology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Martin Desrosiers
- Division of Otolaryngology-Head and Neck Surgery, Centre Hospitalier de l'University de Montreal, Montreal, QC, Canada
| | - Martin Wagenmann
- Department of Otorhinolaryngology, HNO-Klinik, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Stella E Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Steven G Smith
- Respiratory Therapeutic Area Unit, GlaxoSmithKline, Research Triangle Park, NC, USA
| | | | | | - Steven W Yancey
- Respiratory Therapeutic Area Unit, GlaxoSmithKline, Research Triangle Park, NC, USA
| | | | | | - Claire Hopkins
- Department of ENT, Guy's Hospital, London, UK; St Thomas' Hospital, King's College London, London, UK
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11
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Ryu G, Baek BJ. A Survey on the Management of Chronic Rhinosinusitis in the Korean Rhinologic Society. JOURNAL OF RHINOLOGY 2021. [DOI: 10.18787/jr.2020.00343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background and Objectives: There are several diagnostic and therapeutic modalities for chronic rhinosinusitis (CRS), but specific guidelines have not been developed for Koreans. This study sought to evaluate and report CRS practice patterns of members of the Korean Rhinologic Society.Materials and Method: An anonymous survey including 32 items was conducted from August to September 2015. The survey items were categorized into three parts: general information, diagnosis and treatment of CRS, and endoscopic sinus surgery.Results: A total of 267 members participated in this survey. Almost half of the respondents (41.9%) were in their 40s and 42.7% had 10-20 years of experience. A total of 61.8% were private practitioners, while the rest worked in hospitals (38.2%). The prevalence rate of acute rhinosinusitis was higher in private clinics compared to hospitals (p<0.001). Intranasal steroids and saline irrigation were more commonly prescribed among hospital doctors compared to private practitioners (p<0.001). Amoxicillin/clavulanic acid was the drug of choice for adult and pediatric CRS patients among private practitioners. However, hospital doctors preferred macrolides for adult CRS patients and third-generation cephalosporins for pediatric CRS patients. Most private clinics performed surgery under local anesthesia (90.8%), while those in a hospital setting preferred general anesthesia (78.4%). Revision surgery rates were higher in hospitals compared to private clinics (p<0.001).Conclusion: There were significant variations in CRS practice patterns between private clinics and hospitals. For effective and standardized diagnosis and management of CRS, appropriate local guidelines are needed.
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Wu D, Yan B, Wang Y, Wang C, Zhang L. Prognostic and pharmacologic value of cystatin SN for chronic rhinosinusitis with nasal polyps. J Allergy Clin Immunol 2021; 148:450-460. [PMID: 33675819 DOI: 10.1016/j.jaci.2021.01.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/17/2021] [Accepted: 01/22/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Integrated care pathways improve the management of patients with chronic rhinosinusitis with nasal polyps (CRSwNP). The application of integrated care pathways requires development of endotype-based biomarkers to stratify patients. The value of cytokines and markers induced by cytokines for the management of CRSwNP is largely unknown. OBJECTIVES Our aim was to determine the prognostic and pharmacologic value of type 2, non-type 2 cytokines, and markers associated with type 2 inflammation, including CCL26, periostin, and cystatin SN, in nasal secretions for CRSwNP. METHODS This retrospective study assigned 151 patients with CRSwNP to the discovery and validation phases. Concentrations of cytokines, CCL26, periostin, and cystatin SN in nasal secretions were determined by using Luminex and ELISA. Predictive significance was assessed with receiver-operating characteristic curves. Survival analysis was performed by using Kaplan-Meier curves and Cox regression models. RESULTS Cystatin SN was an independent predictor of the uncontrolled status of CRSwNP over a 2-year follow-up after adjustment for other risk factors (hazard ratio = 1.168 and 1.132 in the discovery and validation phases, respectively; both P < .001). Patients with high cystatin SN concentrations presented with a faster onset and higher rate of uncontrolled status than did those with low levels (P < .001). Enhanced medical treatment for patients with high cystatin SN levels postponed the uncontrolled status in the discovery (P = .016) and validation (P = .002) phases but did not completely abolish it by the end of the follow-up. CONCLUSION Cystatin SN levels in nasal secretions hold strong prognostic value and can facilitate medical instructions for managing CRSwNP.
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Affiliation(s)
- Di Wu
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Bing Yan
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China; Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China; Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Chengshuo Wang
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China; Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China.
| | - Luo Zhang
- Department of Otolaryngology, Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China; Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China; Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, China.
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13
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McDermott C, Vennik J, Philpott C, le Conte S, Thomas M, Eyles C, Little P, Blackshaw H, Schilder A, Hopkins C. Maximising recruitment to a randomised controlled trial for chronic rhinosinusitis using qualitative research methods: the MACRO conversation study. Trials 2021; 22:54. [PMID: 33436031 PMCID: PMC7805190 DOI: 10.1186/s13063-020-04993-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Randomised controlled trials (RCTs) are considered the ‘gold standard’ of medical evidence; however, recruitment can be challenging. The MACRO trial is a NIHR-funded RCT for chronic rhinosinusitis (CRS) addressing the challenge of comparing surgery, antibiotics and placebo. The embedded MACRO conversation study (MCS) used qualitative research techniques pioneered by the University of Bristol QuinteT team to explore recruitment issues during the pilot phase, to maximise recruitment in the main trial. Methods Setting: Five outpatient Ear Nose and Throat (ENT) departments recruiting for the pilot phase of the MACRO trial (ISRCTN Number: 36962030, prospectively registered 17 October 2018). We conducted a thematic analysis of telephone interviews with 18 recruiters and 19 patients and 61 audio-recordings of recruitment conversations. We reviewed screening and recruitment data and mapped patient pathways at participating sites. We presented preliminary findings to individual site teams. Group discussions enabled further exploration of issues, evolving strategies and potential solutions. Findings were reported back to the funder and used together with recruitment data to justify progression to the main trial. Results Recruitment in the MACRO pilot trial began slowly but accelerated in time to progress successfully to the main trial. Research nurse involvement was pivotal to successful recruitment. Engaging the wider network of clinical colleagues emerged as an important factor, ensuring the patient pathway through primary and secondary care did not inadvertently affect trial eligibility. The most common reason for patients declining participation was treatment preference. Good patient-clinician relationships engendered trust and supported patient decision-making. Overall, trial involvement appeared clearly presented by recruiters, possibly influenced by pre-trial training. The weakest area of understanding for patients appeared to be trial medications. A clear presentation of medical and surgical treatment options, together with checking patient understanding, had the potential to allay patient concerns. Conclusion The MACRO conversation study contributed to the learning process of optimising recruitment by helping to identify and address recruitment issues. Although some issues were trial-specific, others have applicability to many clinical trial situations. Using qualitative research techniques to identify/explore barriers and facilitators to recruitment may be valuable during the pilot phase of many RCTs including those with complex designs.
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Affiliation(s)
- Clare McDermott
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jane Vennik
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Carl Philpott
- Norwich Medical School, University of East Anglia, Norwich, UK.,James Paget University Hospital NHS Foundation Trust, Great Yarmouth, UK
| | - Steffi le Conte
- Surgical Interventional Trials Unit, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Caroline Eyles
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen Blackshaw
- evidENT, Ear Institute, University College London, London, UK
| | - Anne Schilder
- evidENT, Ear Institute, University College London, London, UK
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14
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Speth MM, Phillips KM, Hoehle LP, Caradonna DS, Gray ST, Sedaghat AR. Appropriate medical management of chronic rhinosinusitis reduces use of antibiotics and oral corticosteroids. Laryngoscope 2019; 130:E709-E714. [DOI: 10.1002/lary.28390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/10/2019] [Accepted: 10/15/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Marlene M. Speth
- Klinik für Hals‐, Nasen‐, Ohren‐ Krankheiten, Hals‐und Gesichtschirurgie Kantonsspital Aarau, Switzerland
| | - Katie M. Phillips
- Department of Otolaryngology–Head and Neck Surgery Stanford University Stanford California U.S.A
| | - Lloyd P. Hoehle
- Edward Via College of Osteopathic Medicine–Carolinas Spartanburg South Carolina U.S.A
| | - David S. Caradonna
- Department of Otolaryngology Harvard Medical School Boston Massachusetts U.S.A
- Division of Otolaryngology Beth Israel Deaconess Medical Center Boston Massachusetts U.S.A
| | - Stacey T. Gray
- Department of Otolaryngology Harvard Medical School Boston Massachusetts U.S.A
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Ahmad R. Sedaghat
- Department of Otolaryngology–Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati Ohio U.S.A
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15
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Walker A, Philpott C, Hopkins C. What is the most appropriate treatment for chronic rhinosinusitis? Postgrad Med J 2019; 95:493-496. [DOI: 10.1136/postgradmedj-2019-136519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/22/2019] [Indexed: 12/13/2022]
Abstract
Chronic rhinosinusitis (CRS) is a common, treatable disease that affects approximately 11% of British adults. It places an enormous burden on patients, with significant detriment to their quality of life, and the health service as it consumes vast numbers of both primary and secondary care resources. However, there is considerable variability in treatment strategies and prescribing practices. This review summarises the key recommendations from landmark guidelines in the treatment of CRS and critically appraises the evidence for treatment.
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16
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Philpott C, le Conte S, Beard D, Cook J, Sones W, Morris S, Clarke CS, Thomas M, Little P, Vennik J, Lund V, Blackshaw H, Schilder A, Durham S, Denaxas S, Carpenter J, Boardman J, Hopkins C. Clarithromycin and endoscopic sinus surgery for adults with chronic rhinosinusitis with and without nasal polyps: study protocol for the MACRO randomised controlled trial. Trials 2019; 20:246. [PMID: 31036048 PMCID: PMC6489242 DOI: 10.1186/s13063-019-3314-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/21/2019] [Indexed: 01/12/2023] Open
Abstract
Background Chronic rhinosinusitis (CRS) is a common source of ill health; 11% of UK adults reported CRS symptoms in a worldwide population study. Guidelines are conflicting regarding whether antibiotics should be included in primary medical management, reflecting the lack of evidence in systematic reviews. Insufficient evidence to inform the role of surgery contributes to a fivefold variation in UK intervention rates. The objective of this trial is to establish the comparative effectiveness of endoscopic sinus surgery (ESS) or a prolonged course of antibiotics (clarithromycin) in adult patients with CRS in terms of symptomatic improvement and costs to the National Health Service compared with standard medical care (intranasal medication) at 6 months. Methods/design A three-arm parallel-group trial will be conducted with patients who remain symptomatic after receiving appropriate medical therapy (either in primary or secondary care). They will be randomised to receive: (1) intranasal medication plus ESS, (2) intranasal medication plus clarithromycin (250 mg) or (3) intranasal medication plus a placebo. Intranasal medication (current standard medical care) is defined as a spray or drops of intranasal corticosteroids and saline irrigations. The primary outcome measure is the SNOT-22 questionnaire, which assesses disease-specific health-related quality of life. The study sample size is 600. Principal analyses will be according to the randomised groups irrespective of compliance. The trial will be conducted in at least 16 secondary or tertiary care centres with an internal pilot at six sites for 6 months. Discussion The potential cardiovascular side effects of macrolide antibiotics have been recently highlighted. The effectiveness of antibiotics will be established through this trial, which may help to reduce unnecessary usage and potential morbidity. If ESS is shown to be clinically effective and cost-effective, the trial may encourage earlier intervention. In contrast, if it is shown to be ineffective, then there should be a significant reduction in surgery rates. The trial results will feed into the other components of the MACRO research programme to establish best practice for the management of adults with CRS and design the ideal patient pathway across primary and secondary care. Trial registration ISRCTN36962030. Registered on 17 October 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3314-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carl Philpott
- Norwich Medical School, Chancellor's Drive, University of East Anglia, Norwich, UK. .,ENT Department, James Paget University Hospital NHS Foundation Trust, Great Yarmouth, UK.
| | | | | | | | | | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK
| | | | | | | | - Valerie Lund
- UCL Ear Institute, University College London, London, UK
| | - Helen Blackshaw
- evidENT, UCL Ear Institute, University College London, London, UK
| | - Anne Schilder
- evidENT, UCL Ear Institute, University College London, London, UK
| | - Stephen Durham
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
| | - James Carpenter
- London School of Hygiene and Tropical Medicine, University College London, London, UK
| | - James Boardman
- Fifth Sense, Sanderum House, 38 Oakley Road, Chinnor, Oxfordshire, OX39 4TW, UK
| | - Claire Hopkins
- ENT Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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17
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Blackshaw H, Vennik J, Philpott C, Thomas M, Eyles C, Carpenter J, Clarke CS, Morris S, Schilder A, Lund V, Little P, Durham S, Denaxas S, Williamson E, Beard D, Cook J, Le Conte S, Airey K, Boardman J, Hopkins C. Expert panel process to optimise the design of a randomised controlled trial in chronic rhinosinusitis (the MACRO programme). Trials 2019; 20:230. [PMID: 31014344 PMCID: PMC6480653 DOI: 10.1186/s13063-019-3318-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/21/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND MACRO (Defining best Management for Adults with Chronic RhinOsinusitis) is an NIHR-funded programme of work designed to establish best practice for adults with chronic rhinosinusitis (CRS). The 7-year programme comprises three consecutive workstreams, designed to explore NHS care pathways through analysis of primary and secondary data sources, and to undertake a randomised controlled trial to evaluate a longer-term course of macrolide antibiotics and endoscopic sinus surgery for patients with CRS. A number of outstanding elements still required clarification at the funding stage. This paper reports an expert panel review process designed to agree and finalise the MACRO trial design, ensuring relevance to patients and clinicians whilst maximising trial recruitment and retention. METHODS An expert panel, consisting of the MACRO Programme Management Group, independent advisors, and patient contributors, was convened to review current evidence and the mixed-method data collected as part of the programme, and reach agreement on MACRO trial design. Specifically, agreement was sought for selection of macrolide antibiotic, use of orally administered steroids, inclusion of CRS phenotypes (with/without nasal polyps), and overall trial design. RESULTS A 12-week course of clarithromycin was agreed as the main trial comparator due to its increasing use as a first- and second-line treatment for patients with CRS, and the perceived need to establish its role in CRS management. Orally administered steroids will be used as a rescue medication during the trial, rather than routinely either pre or post trial randomisation, to limit any potential effects on surgical outcomes and better reflect current UK prescribing habits. Both CRS phenotypes will be included in a single trial to ensure that the MACRO trial is both pragmatic and generalisable to primary care. A modified, three-arm trial design was agreed after intense discussions and further exploratory work. Inclusion criteria were amended to ensure that the patients recruited would be considered eligible for the treatment offered in the trial due to having already received appropriate medical therapy as deemed suitable by their ENT surgeon. A proposed 6-week run-in period prior to randomisation was removed due to the new criteria prior to randomisation. CONCLUSION The expert panel review process resulted in agreement on key elements and an optimal design for the MACRO trial, considered most likely to be successful in terms of both recruitment potential and ability to establish best management of patients with CRS.
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Affiliation(s)
- Helen Blackshaw
- evidENT, Ear Institute, University College London, London, UK
| | - Jane Vennik
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Carl Philpott
- Norwich Medical School, University of East Anglia, Norwich, UK
- James Paget University Hospital NHS Foundation Trust, Norwich, UK
| | - Mike Thomas
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Caroline Eyles
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Caroline S. Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Anne Schilder
- evidENT, Ear Institute, University College London, London, UK
| | - Valerie Lund
- evidENT, Ear Institute, University College London, London, UK
| | - Paul Little
- James Paget University Hospital NHS Foundation Trust, Norwich, UK
| | - Stephen Durham
- Faculty of Medicine, Imperial College London, London, UK
| | | | | | - David Beard
- Surgical Interventional Trials Unit, University of Oxford, Oxford, UK
| | - Jonathan Cook
- Surgical Interventional Trials Unit, University of Oxford, Oxford, UK
| | - Steffi Le Conte
- Surgical Interventional Trials Unit, University of Oxford, Oxford, UK
| | - Kim Airey
- evidENT, Ear Institute, University College London, London, UK
| | - Jim Boardman
- Fifth Sense, Sanderum House, 38 Oakley Road, Chinnor, Oxfordshire OX39 4TW UK
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18
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Vennik J, Eyles C, Thomas M, Hopkins C, Little P, Blackshaw H, Schilder A, Savage I, Philpott CM. Chronic rhinosinusitis: a qualitative study of patient views and experiences of current management in primary and secondary care. BMJ Open 2019; 9:e022644. [PMID: 31015263 PMCID: PMC6501991 DOI: 10.1136/bmjopen-2018-022644] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To explore patient views and perspectives of current management of chronic rhinosinusitis (CRS) in primary and secondary care. DESIGN Semistructured qualitative telephone interviews as part of the MACRO programme (Defining best Management for Adults with Chronic RhinOsinusitis). SETTING Primary care and secondary care ear, nose and throat outpatient clinics in the UK. PARTICIPANTS Twenty-five patients consented to in-depth telephone interviews. Transcribed recordings were managed using NVivo software and analysed using inductive thematic analysis. RESULTS CRS has a significant impact on patients' quality of life, affecting their ability to work effectively, their social interactions and daily living. Patients seek help when symptoms become unmanageable, but can become frustrated with the primary care system with difficulties obtaining an appointment, and lack of continuity of care. Patients perceive that general practitioners can be dismissive of CRS symptoms, and patients often prioritise other concerns when they consult. Health system barriers and poor communication can result in delays in accessing appropriate treatment and referral. Adherence to intranasal steroids is a problem and patients are uncertain about correct technique. Nasal irrigation can be time-consuming and difficult for patients to use. Secondary care consultations can appear rushed, and patients would like specialists to take a more 'holistic' approach to their management. Surgery is often considered a temporary solution, appropriate when medical options have been explored. CONCLUSIONS Patients are frustrated with the management of their CRS, and poor communication can result in delays in receiving appropriate treatment and timely referral. Patients seek better understanding of their condition and guidance to support treatments decisions in light of uncertainties around the different medical and surgical options. Better coordinated care between general practice and specialist settings and consistency of advice has the potential to increase patient satisfaction and improve outcomes.
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Affiliation(s)
- Jane Vennik
- Primary Care and Population Sciences, University of Southamption, Southampton, UK
| | - Caroline Eyles
- Primary Care and Population Sciences, University of Southamption, Southampton, UK
| | - Mike Thomas
- Primary Care and Population Sciences, University of Southamption, Southampton, UK
| | | | - Paul Little
- Primary Care and Population Sciences, University of Southamption, Southampton, UK
| | - Helen Blackshaw
- EvidENT, University College London Ear Institute, London, UK
| | - Anne Schilder
- EvidENT, University College London Ear Institute, London, UK
| | - Imogen Savage
- EvidENT Patient Panel, University College London Ear Institute, London, UK
| | - Carl M Philpott
- Norwich Medical School, University of East Anglia, Norwich, UK
- Ear, Nose and Throat, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
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