The personal financial burden of chronic rhinosinusitis: A Canadian perspective

The cyclooxygenase-2 upregulation mediates production of PGE2 autacoid to positively regulate interleukin-6 secretion in chronic rhinosinusitis with nasal polyps and polyp-derived fibroblasts

Chronic rhinosinusitis (CRS) can be traditionally classified as CRSwNP [with nasal polyps (NPs)] and CRSsNP (without NPs) based on the clinical phenotypes but recently suggested to be classified by the endotypes. We have identified overexpression of the cyclooxygenase-2 (COX-2) gene in NP tissues of Taiwanese CRSwNP patients. Therefore, in this study, we sought to investigate its protein expression/location/distribution in NP specimens and explore its roles in nasal polyposis. The COX-2 protein and mRNA expression was found higher in NPs than that in the control and CRSsNP patients' nasal tissues, mainly located at the epithelium and subepithelial stroma. Consistently, the CRS-related peptidoglycan (PGN) and bradykinin provoked COX-2 mRNA and protein upregulation in the human NP-derived fibroblasts and caused PGE2, thromboxane A2 (TXA2), and interleukin (IL-6) secretion in culture medium. Further analysis revealed that the PI3K/Akt activation and COX-2 induction were necessarily required for PGN-induced IL-6 production/secretion and the induced PGE2, but not TXA2, was speculated to affect IL-6 protein trafficking and production. Finally, the IL-6 increase observed in vitro could also be detected in NP tissues. Collectively, we demonstrated here that COX-2 protein and IL-6 are overexpressed in human NP tissues. In response to PGN challenge, the PI3K/Akt activation and COX-2-mediated PGE2 autacoid correlates with extracellular IL-6 protein trafficking/production in NP-derived fibroblasts, which can additionally contribute to the production of Th17-related cytokines such as IL-17 and TNF-α. This study also suggests COX-2 as a special biomarker for CRSwNP endotyping and may highlight the importance of COX-2 inhibitors in treating CRSwNP.

Direct economic burden 1 year postoperation in Chinese adult patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) remains a common and challenging clinical entity, and its economic burden has not been well described in China thus far.

METHODS

A total of 101 CRSwNP patients who underwent endoscopic sinus surgery were included to investigate direct costs in the first year post-surgery. Costs for outpatient visits, medication use, and examination costs were obtained from the Hospital Information System, and differences were compared between subgroups. Multiple linear regression analysis was adopted to investigate the main influencing factors on annual total direct costs for CRSwNP patients.

RESULTS

Ninety-two subjects completed the study. The individual mean total direct cost for a CRSwNP patient 1 year post-surgery was $742.4. The largest contributors were pharmacy costs ($580.2), followed by examination costs ($108.1) and outpatient visits ($54.1). Total direct costs were higher in subgroups of patients with uncontrolled clinical status, asthma comorbidity, and eosinophilic CRSwNP compared to their counterparts. The main influencing factors were clinical control status (P = 0.016) and asthma comorbidity (P = 0.035).

CONCLUSIONS

The individual mean total direct cost of CRSwNP in 1-year post-surgery was $742.4. Clinical control status and asthma comorbidity influence these costs and are therefore important in guiding health resources allocation for CRSwNP management.

Acupuncture for the Treatment of Chronic Rhinosinusitis: A PRISMA-Compliant Systematic Review and Meta-Analysis

Background. Chronic rhinosinusitis (CRS) is a highly prevalent disease associated with poor quality of life. In this paper, we appraised the role of acupuncture in the treatment of CRS. Methods. Electronic databases were searched for randomized controlled clinical trials (RCTs) that examined the role of acupuncture in CRS. The primary outcome measures included posttreatment CRS severity, as measured by the Visual Analogue Scale (VAS) and Total Effective Rate (TER). The risk of bias and quality of evidence were evaluated according to the Cochrane Collaboration’s risk-of-bias tool and GRADE tool, respectively. Results. Evidence from the RCTs (n = 10) suggested that acupuncture as a monotherapy or adjunctive therapy to conventional treatment was associated with significant improvements in VAS, TER, and quality of life when compared with conventional treatments for CRS. However, there was a similar incidence of adverse events. The risk of bias was unclear and the quality of evidence for each finding was generally moderate to low. Conclusions. Acupuncture as a stand-alone or adjunctive treatment for CRS was associated with clinical symptom improvement and better quality of life, without any risk for serious adverse events. However, the high clinical heterogeneity of the included RCTs and overall moderate-to-low quality of evidence necessitates rigorous, well-designed trials to confirm these findings. Trial Registrations. This trial is registered with PROSPERO (no. CRD42021292135).

Bromelain, a Group of Pineapple Proteolytic Complex Enzymes (Ananas comosus) and Their Possible Therapeutic and Clinical Effects. A Summary

Bromelain is a complex combination of multiple endopeptidases of thiol and other compounds derived from the pineapple fruit, stem and/or root. Fruit bromelain and stem bromelain are produced completely distinctly and comprise unique compounds of enzymes, and the descriptor “Bromelain” originally referred in actuality to stem bromelain. Due to the efficacy of oral administration in the body, as a safe phytotherapeutic medication, bromelain was commonly suited for patients due to lack of compromise in its peptidase efficacy and the absence of undesired side effects. Various in vivo and in vitro studies have shown that they are anti-edematous, anti-inflammatory, anti-cancerous, anti-thrombotic, fibrinolytic, and facilitate the death of apoptotic cells. The pharmacological properties of bromelain are, in part, related to its arachidonate cascade modulation, inhibition of platelet aggregation, such as interference with malignant cell growth; anti-inflammatory action; fibrinolytic activity; skin debridement properties, and reduction of the severe effects of SARS-Cov-2. In this paper, we concentrated primarily on the potential of bromelain’s important characteristics and meditative and therapeutic effects, along with the possible mechanism of action.

Stakeholder point of view on prescription drug affordability - a systematic literature review and content analysis

OBJECTIVES

The objectives of this research were to: 1) understand perspectives on affordability of pharmaceutical drugs from the point of view of stakeholders as reported in published peer-reviewed journals and conferences; 2) evaluate if (and how) perspectives on affordability overlapped across stakeholders.

METHODS

The systematic literature review followed Cochrane and PRISMA guidelines. Content analysis with iterative and systematic coding of text was conducted, to identify themes.

RESULTS

A total of 7,372 unique citations were eligible, and 126 articles included for final synthesis. For patients, 6 core themes emerged: financial barriers, adherence, access, patient-provider communication, financial distress, and factors that impact affordability. For payers, 5 core themes: financing schemes, cost-effectiveness, budget impact, private vs. public preferences, and ethics. For providers, 3 themes: patient-provider communication, physician prescribing behavior, and finding alternatives to support patient access. For policymakers, 2 themes: measuring affordability and the role of government. Limited articles representing the manufacturer perspective were identified. Perspectives of decision makers (payers, policymakers) did not overlap with those affected by affordability (patients, providers).

CONCLUSIONS

This research highlights the multi-dimensionality of drug "affordability." Multiple factors beyond cost influence patient affordability implying interventions can help alleviate affordability issues for some patients. The lack of overlap highlights potential hazards that decisions related to out-of-pocket spending, insurance coverage, reimbursement, and rationing occur without explicitly considering patient and provider perspectives.

Impact of the 13-valent pneumococcal conjugate vaccine on acute otitis media and acute sinusitis epidemiology in British Columbia, Canada

BACKGROUND

Numerous studies have characterized the 13-valent pneumococcal conjugate vaccine (PCV13) programme's beneficial effects on acute otitis media (AOM) and acute sinusitis (AS) rates in children; however, few studies have examined the impact on adults.

OBJECTIVES

This retrospective cohort study evaluates the overall effect of the PCV13 immunization programme on the incidence of AOM and AS at the population level.

METHODS

Health administrative databases were linked to assess outpatient visits, hospitalizations and antibiotic utilization from 2000 to 2018. Multivariable Poisson regression was used to evaluate the impact of the PCV13 vaccine programme (2011-18) compared with the pre-PCV13 era (2000-10), overall and by age.

RESULTS

From 2000 to 2018, the incidence of AOM decreased by 50% (62 to 31 per 1000 population) while sinusitis decreased by 18% (33 to 27 per 1000 population). In the PCV13 era, the incidence of AOM declined [incidence rate ratio (IRR): 0.70; 95% CI: 0.70-0.70], in parallel with decreased incidence of antibiotic utilization (IRR: 0.65; 95% CI: 0.64-0.65). A reduction was also observed in the incidence of AS during the PCV13 era compared with the pre-PCV13 era (IRR: 0.88; 95% CI: 0.88-0.88), mainly driven by declines among those younger than 65 years of age. In contrast, an increase in AS incidence was noted in individuals aged ≥65 years (IRR: 1.03; 95% CI: 1.02-1.03). A decrease in antibiotic prescription rates for sinusitis was observed for those under 65 years of age.

CONCLUSIONS

The PCV13 immunization programme is associated with a reduction in the incidence of AOM and AS. Moreover, the associated use of antibiotics for these diagnoses has comparably decreased across paediatric, as well as adult populations.

Perceived Financial Insecurity Impacts Healthcare Decision-Making Among Patients With Sinusitis

OBJECTIVES/HYPOTHESIS

The economic burden of sinusitis is significant, and socioeconomic factors can impact patient decision-making. The purpose of this study was to examine the impact of perceived financial insecurity on healthcare decision-making and treatment compliance among sinusitis patients.

STUDY DESIGN

Cross-sectional study using the 2018 National Health Interview Survey.

METHODS

Survey responses to nine questions regarding financial stressors and nine questions regarding cost-saving healthcare actions were recorded, which included seeking lower cost medication, medication noncompliance, and avoiding care visits due to costs.

RESULTS

There was a total weighted sample size of 28.9 million patients who self-reported a diagnosis of sinusitis (12% of the U.S. population). Sinusitis patients who reported cost-saving actions had an increased severity of perceived financial insecurity than those without cost-saving actions (P < .001). Sinusitis patients with perceived financial insecurity had the highest odds of at least one cost-saving action (odds ratio [OR] = 5.94, 95% CI = 5.911-5.970, P < .001), followed by lack of health insurance (OR = 5.13, 95% CI = 5.107-5.159, P < .001), and poor self-reported health status (OR = 2.81, 95% CI = 2.792-2.822, P < .001). Increasing the number of financial stressors increased the odds of at least one cost-saving action (P < .001). Across all financial stressors, the most commonly performed cost-saving action was asking for lower cost medication.

CONCLUSIONS

Perceived financial insecurity is associated with cost-saving healthcare actions among sinusitis patients, including treatment noncompliance. Interventions to assess financial insecurity among sinusitis patients may facilitate shared decision-making for optimal, individualized treatment plans that may lead to improved outcomes and quality of life.

LEVEL OF EVIDENCE

NA. Laryngoscope, 2021.

The role of house dust mite immunotherapy in Indonesian children with chronic rhinosinusitis allergy: A randomized control trial

Background

Chronic rhinosinusitis allergy (CRA) is a disease that is commonly found in children and is mostly caused by allergy to house dust mites (HDM). The use of HDM immunotherapy can be considered in children with allergies.

Objectives

Analyzing the impact of mite immunotherapy on disease burden in Indonesian children with CRA.

Methods

A randomized control trial study was conducted to participants in 2 groups, namely the immunotherapy group (n = 25) and the non-immunotherapy group (n = 25). Participants were given HDM immunotherapy for 14 weeks, which was given once per week. Participants during therapy were evaluated for rhinosinusitis symptoms and measured their immunity status (specific IgE), sleep quality (SDSC), quality of life (SN5), and family coping (F-COPES) pre-post therapy. Statistical analysis used in this study included paired t-test, Wilcoxon test, independent t-test, or Mann Whitney test with p < 0.05.

Results

The value of specific IgE in the immunotherapy group was 4.12 ± 7.75 kU/l (pre-test) and 1.52 ± 2.42 kU/l (post-test; p < 0.001), while in the non-immunotherapy group was 1.47 ± 3.28 kU/l (pre-test) and 1.18 ± 2.81 kU/l (post-test; p = 0.317). The SDSC value in the immunotherapy group was 42.16 ± 2.75 (pre-test) and 30.32 ± 3.22 (post-test; p < 0.001), while in the non-immunotherapy group was 41.92 ± 2.75 (pre-test) and 41.84 ± 2.87 (post-test; p = 0.987). The F-COPES value in the immunotherapy group was 101.56 ± 5.78 (pre-test) and 105.20 ± 4.31 (post-test; p = 0.015), while in the non-immunotherapy group was 100.36 ± 9.63 (pre-test) and 99.96 ± 9.98 (post-test; p = 0.224). The SN-5 value in the immunotherapy group was 30.04 ± 2.78 (pre-test) and 11.00 ± 2.33 (post-test; p < 0.001), while in the non-immunotherapy group was 30.04 ± 2.78 (pre-test) and 30.04 ± 2.78 (post-test; p = 0.767). There was a significant comparison between the immunotherapy group and the non-immunotherapy group on the specific IgE (p = 0.013), SDSC (p < 0.001), and SN-5 (p < 0.001) values. Meanwhile, there was no significant difference in the F-COPES value (p = 0.129).

Conclusions

The administration of HDM immunotherapy can improve the participant's immunity, quality of life, and sleep disorder.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Bidirectional association between asthma and chronic rhinosinusitis: Two longitudinal follow-up studies using a national sample cohort

The aim of this study was to evaluate an epidemiologic association of asthma and chronic rhinosinusitis (CRS) using a national sample cohort of the Korean population. We collected data from the Korean Health Insurance Review and Assessment Service-National Sample Cohort between 2002 and 2013, and two different case-control cohorts were designed (1st: asthmatic patients matched in a 1:1 ratio with 204,119 non-asthmatics as control I, 2nd: CRS patients matched in a 1:4 ratio with 124,020 non-CRS patients as control II). Bidirectional association was examined using Cox proportional hazard models stratified by age, sex, income, and region of residence. Patients with asthma had an increased risk of developing CRS [adjusted hazard ratio (95% confidence interval) = 1.74 (1.67–1.80)], both with nasal polyps [1.55 (1.36–1.78)], without nasal polyps [1.74 (1.67–1.81)]. In the second cohort, patients with CRS had increased risk of developing asthma [1.85 (1.80–1.91)] with similar results for those with and without nasal polyps. The strongest association for risk of CRS was in 20–39 years old men with asthma [2.41 (1.97–2.96)], while the strongest association for increased risk of asthma in those with CRS group was also seen in this same subgroup [2.40 (2.18–2.63)]. CRS and asthma had a bidirectional influence on each other. CRS increased the risk of asthma, and asthma increased the risk of CRS, especially in young men.

Severity of Rhinosinusitis: Comparison Between Visual Analog Scale Given by Patients and Otorhinolaryngologists

BACKGROUND

Visual Analog Scale (VAS) as determined by the patient is recommended by the European Position Paper on Rhinosinusitis and Nasal Polyps 2012 in evaluation of the total severity of the chronic rhinosinusitis (CRS) patients' symptoms.

OBJECTIVE

To evaluate the correlation between evaluations performed by otorhinolaryngologists and CRS patients with commonly used systems.

METHODS

Scores of VAS and Sino-Nasal Outcome Test-20 (SNOT-20) Chinese version were obtained from 110 CRS patients with nasal polyps (CRSwNPs, n = 61) and without nasal polyps (CRSsNPs, n = 49) before surgery, which were compared with scores of Lund-Kennedy endoscopic staging system, the Lund-Mackay computed tomography (CT) staging system, and VAS from 3 attending otorhinolaryngologists.

RESULTS

The median VAS scores given by CRS patients (6.0; 4.25-7.5) do not correlate significantly with the VAS scores by the 3 otorhinolaryngologists (5.5; 4.83-6.5) with a correlation coefficient of .218 (-0.146 to 0.466). For CRS patients, there was only a moderate correlation between scores of VAS and the SNOT-20 (r = .37), and no significant difference of VAS scores between CRSwNP and CRSsNP, and between unilateral and bilateral nasal polys. For otorhinolaryngologists, a higher median VAS score was found in CRSwNP (6.0; 5.17-7.0), especially in bilateral (6.0; 5.0-7.08) and revision surgery (6.08; 5.33-7.63). The VAS scores of otorhinolaryngologists correlated significantly with the Lund-Mackay CT score (r = .7536) and Lund-Kennedy endoscopic staging (r = .5947).

CONCLUSIONS

VAS scores between patients and physicians are not correlated significantly in this study, but they fall within the same therapeutic range and do not change the clinical management of the patients.

Cost and operative time estimation itemized by component procedures of endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) is a variable combination of individual procedures. Cost estimates for ESS as a single entity have wide variation, likely influenced by variation in procedures performed. We sought to identify operative time, supply costs, and total procedure cost specific to the component procedure combinations comprising ESS.

METHODS

Bilateral ESS cases at 13 Intermountain Healthcare facilities (2008 to 2016) were identified from a database with corresponding cost and time data. Procedure details were obtained by chart review. Least-squares (LS) means of cost (in 2016 US dollars) and time for specific procedures were obtained by multivariable gamma regression models.

RESULTS

Among 1477 bilateral ESS cases with 19 different procedure combinations, operative time ranged from 59.5 (95% confidence interval [CI], 48.6-73.0) minutes for total ethmoid to 147.1 (95% CI, 126.4-171.2) minutes for full ESS with maxillary and sphenoid tissue removal. Sphenoidotomy had lowest total and supply costs (in US dollars) of $2112 (95% CI, $1672-$2667) and $636 (95% CI, $389-$1040), respectively. Total cost was highest for full ESS with maxillary tissue removal at $4640 (95% CI, $4115-$5232). Supply cost was highest for full ESS with maxillary and sphenoid tissue removal at $2191 (95% CI, $1649-$2909).

CONCLUSION

Operative time and costs for ESS vary depending on the procedures performed, demonstrating the importance of procedure specificity in assessment of ESS time, cost, and, ultimately, value. These procedure-specific estimates of cost enable nonbinary valuation of ESS, appropriate for the multitude of procedure options intended to optimize individual outcomes.

Symptom Profile of Chronic Rhinosinusitis Versus Obstructive Sleep Apnea in a Tertiary Rhinology Clinic

Objectives:

Patients with undiagnosed obstructive sleep apnea (OSA) often present to an otolaryngologist with symptoms of chronic rhinosinusitis (CRS). This study analyzes symptom profiles of such patients to help identify those who may benefit from polysomnography.

Methods:

This is a 2-year retrospective analysis of adult patients at an academic practice with a rhinologic chief complaint. Results of the 22-Item Sinonasal Outcomes Test (SNOT-22) were compared between patients with untreated OSA without CRS (OSA group) and a control group of CRS patients (CRS group). Univariate analysis with Bonferroni correction and multiple logistic regression were used.

Results:

Forty-one patients were included in the OSA group (mean apnea-hypopnea index = 28.8, SD = 21.0) and 124 patients in the CRS group. CRS group demonstrated higher scores in nasal, extra-nasal, and ear/facial symptom domains ( P < .001), while OSA group displayed higher psychological ( P = .020) and sleep domain scores ( P = .048). Nasal discharge ( P < .001) and loss of smell/taste ( P = .004) scores were higher in CRS group, whereas facial pain ( P = .285) and nasal obstruction ( P = .822) were not significantly different. On logistic regression, thick nasal discharge, loss of smell/taste, and ear pain were predictive of CRS, while waking up tired was predictive of OSA. Finally, OSA group was more likely to choose a sleep-related issue as a most important symptom (MIS) ( P < .001).

Conclusions:

OSA and CRS have significant overlap in symptom profiles. The SNOT-22 can help identify those with undiagnosed OSA. OSA should be suspected in patients who report a sleep-related item as a MIS and display higher psychological and sleep domain scores.

Different effects of allergic rhinitis on nasal mucosa remodeling in chronic rhinosinusitis with and without nasal polyps

Background

Allergic rhinitis (AR) has been reported to be associated with chronic rhinosinusitis (CRS). The objective of this study was to investigate the effect of AR on nasal mucosa remodeling in CRS.

Methods

Patients were enrolled and divided into the following groups: CRS with nasal polyps (NP) with allergic rhinitis (AR)(CRSwNPwAR; n = 20), CRS with NP without AR (CRSwNPsAR; n = 20), CRS without NP with AR (CRSsNPwAR; n = 20), CRS without NP without AR (CRSsNPsAR; n = 20), AR without CRS (AR; n = 20) and controls (n = 14). Eosinophil infiltration, mucus production, and collagen deposition were examined by hematoxylin and eosin, periodic acid schiff and masson’s trichrome staining, respectively. VEGF-A and microvessel density were detected by immunohistochemistry. The expression of remodeling markers, including TGF-β1, MMP-7, MMP-9 and TIMP-1 were measured by Western blot.

Results

The expression of remodeling factors, including VEGF-A, CD31, CD34 and TIMP-1 were significantly increased in CRSwAR compared to CRSsAR. Goblet cell hyperplasia, as well as VEGF-A, CD31, CD34, and MMP-9 expression were significantly higher in CRSwNPwAR compared to CRSwNPsAR. However, the expression of collagen fibers, MMP-7 and TGF-β1 were significantly higher in CRSsNPwAR compared to CRSsNPsAR.

Conclusions

AR could enhance the remodeling process in CRS. Moreover, AR had different effects on CRSwNP and CRSsNP.

Operative time and cost variability for functional endoscopic sinus surgery

BACKGROUND

Understanding the variation in costs of endoscopic sinus surgery (ESS) is critical to defining value. Current published costs of ESS have not identified potential sources of variation. Our objective was to analyze ESS costs to identify sources of variance that could guide value-improving decisions.

METHODS

ESS cases (n = 1739) performed between 2008 and 2016 were identified from a database of 22 rural to tertiary facilities. Cost and time data were extracted from the database. Medical records were reviewed to confirm procedures. Three bilateral groupings were examined (n = 895 cases from 13 facilities): (1) full ESS (all sinuses); (2) intermediate ESS (total ethmoid, maxillary); and (3) anterior ESS (anterior ethmoid, maxillary). Cost and operative time were analyzed using multivariable gamma regression.

RESULTS

Median costs for full, intermediate, and anterior ESS were $4281, $3716, and $2549 U.S. dollars (p < 0.001). Median durations were 87, 60, and 58 minutes (p < 0.001). Among patients with no additional procedures, those with full ESS had operative duration, total cost, and supply costs that were 1.37 (95% confidence interval [CI], 1.17 to 1.61), 1.52 (95% CI, 1.32 to 1.75), and 2.40 (95% CI, 1.76 to 3.25) times greater than anterior ESS, respectively (all p < 0.001). Intermediate ESS duration at community urban facilities was 1.87 (95% CI, 1.74 to 2.02) times that of community rural facilities (p < 0.001).

CONCLUSION

Duration of surgery, extent of surgery, and location of surgery are sources of significant variation in the cost of ESS. These findings will assist healthcare policy makers, hospitals, and surgeons in optimizing the value of ESS.