International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Factors affecting adherence to intranasal treatment for allergic rhinitis: A qualitative study

Objective

To determine the facilitators of and barriers to adherence to use of intranasal pharmacotherapy (daily intranasal corticosteroids and/or antihistamine, and nasal saline irrigation [NSI]), for allergic rhinitis (AR).

Methods

Patients were recruited from an academic tertiary care rhinology and allergy clinic. Semi-structured interviews were conducted after the initial visit and/or 4-6 weeks following treatment. Transcribed interviews were analyzed using a grounded theory, inductive approach to elucidate themes regarding patient adherence to AR treatment.

Results

A total of 32 patients (12 male, 20 female; age 22-78) participated (seven at initial visit, seven at follow-up visit, and 18 at both). Memory triggers, such as linking nasal routine to existing daily activities or medications, were identified by patients as the most helpful strategy for adherence at initial and follow-up visits. Logistical obstacles related to NSI (messy, takes time, etc.) was the most common concept discussed at follow-up. Patients modified the regimen based on side effects experienced or perceived efficacy.

Conclusions

Memory triggers help patients adhere to nasal routines. Logistical obstacles related to NSI can deter from use. Health care providers should address both concepts during patient counseling. Nudge-based interventions that incorporate these concepts may help improve adherence to AR treatment.

Level of Evidence

2.

Positional Installation of Intranasal Corticosteroids in the Treatment of Chronic Rhinosinusitis: A Systematic Review of the Literature

OBJECTIVES

First-line treatment of chronic rhinosinusitis includes topical corticosteroids aimed at decreasing inflammation of sinonasal mucosa. No guidelines exist regarding the effect of head position during administration of corticosteroids. We hypothesize certain positions enhance delivery to the paranasal sinuses, with further improvement in delivery after sinus surgery.

METHODS

A systematic review of the literature was conducted using Medline Ovid, Embase, Scopus, and Cochrane databases. All studies evaluating intranasal medications administered in 2 or more head positions were included. Study population, head position(s), method/volume of delivery, and outcome metrics were recorded.

RESULTS

Twenty-four studies compared head positions and their role in distribution of intranasal medication. Of 12 papers studying surgically naive subjects, 6 found improvement in delivery to specific sinonasal regions (middle meatus; lateral, superior, or posterior nasal cavity) and/or symptomatic improvement, in the lying head back (LHB) or head down and forward (HDF) positions, but only 3 reached statistical significance. Of 12 papers studying surgically altered patients, 10 found delivery improved in the HDF, LHB, and head forward 45° or 90° positions. Of 5 studies of extended frontal sinus procedures (Draf IIb/III), a majority found distribution to the frontal sinus improved with the head forward 90° position. Patients found the HDF position most uncomfortable.

CONCLUSIONS

Studies found no statistically significant difference in distribution to unoperated sinuses among different head positions. A minority of studies supported the use of the LHB and HDF positions. This suggests that in surgically naive patients, intranasal corticosteroid delivery to sinonasal regions and/or symptomatic improvement may be best achieved with the sinuses positioned inferior to the delivery device. Surgery improved distribution to the paranasal sinuses regardless of head position, although tilting the head forward 90° was particularly effective in delivery to the frontal sinus after extended frontal sinus procedures.

Fluoroscopically Guided Facet Injections: Comparison of Intra-Articular and Periarticular Steroid and Anesthetic Injection on Immediate and Short-Term Pain Relief

BACKGROUND AND PURPOSE

The effectiveness of facet injections is unclear in the literature. Our objective was to determine the immediate and short-term efficacy of intra-articular and periarticular steroid/anesthetic injections for facet-mediated lumbar pain.

MATERIALS AND METHODS

All outpatient fluoroscopically guided facet injections at a single institution during a 54-month period were retrospectively and independently reviewed by 2 musculoskeletal (MSK) trained radiologists. All intra-articular, all periarticular, and partial intra-/periarticular injection locations were determined. Periarticular and partial peri-/intra-articular injections were combined for analysis. Preinjection, immediate, and 1-week postinjection numeric pain scores, patient age, sex, anesthetic/steroid mixture, fluoroscopic time, and physician performing the procedure were recorded.

RESULTS

Seventy-seven patients (mean age, 51.1 years) had 100 procedures with 205 total facet joints injected. All intra-articular, all periarticular, and partial peri-/intra-articular injections constituted 54%, 20%, and 26% of the cases, respectively. The immediate and 1-week postprocedural change in pain was -3.7 (95% CI, -4.5 to -2.8; P < .001) and -1.4 (95% CI, -2.2 to -0.6; P = .001) for the all intra-articular and -3.6 (95% CI, -4.4 to -2.9; P < .001) and -1.2 (95% CI, -1.9 to -0.4; P = .002) for the combined group. Changes in immediate pain were significantly associated with the prepain level (P < .001) and patient age (P = .024) but not with the anesthetic used. Analyses revealed no significant difference in pain reduction between the groups either immediately or 1 week postinjection. Intra-articular injections required less fluoroscopic time (geometric mean, 39 versus 52 seconds) (P = .005).

CONCLUSIONS

Intra-articular and periarticular fluoroscopically guided facet injections provide statistically significant and similar pain relief both immediately and 1 week postinjection.

Seasonal gonadal development and age-related maturity patterns of introduced pumpkinseed (Lepomis gibbosus Linnaeus, 1758) in a heated thermal reservoir and an adjacent river reach

Testis and ovarian maturation status, maturity profile and gonado-somatic index (GSI) were assessed in pumpkinseed (Lepomis gibbosus) collected from Mirgenbach, a cooling-water reservoir associated with a nuclear power plant, and from the River Moselle 7km downstream of the reservoir's thermal outflow. Histological investigation indicated that in both sexes, gonadal development of pumpkinseed in the heated reservoir was more advanced than in the cooler Moselle River throughout the breeding season. The histological maturity profile of reservoir males ranked by the advancement of sperm cells was highly correlated with its GSI (rs=0.73, P<0.001). GSI of females in the reservoir increased with the stage at maturity, but GSI was not significantly correlated with total length, age or growth rate of the individual. All sampled individuals of both sexes were mature at age 1 in the heated reservoir, whereas 48% of age 1 males and 57% of age 1 females were not mature in the river. GSI patterns suggest that males in the reservoir adopted one of two reproductive strategies (nesters or cuckolders), whereas no small males with large enough testes to be considered cuckolders were apparent in the river. The warm thermal regime of Mirgenbach Reservoir led to precocial maturity, early season reproduction, and the greater prevalence of apparent cuckolder males than would normally occur in this climatic zone.

Accuracy of enhanced and unenhanced MRI in diagnosing scaphoid proximal pole avascular necrosis and predicting surgical outcome

PURPOSE

Determine the sensitivity, specificity and accuracy of unenhanced and enhanced MRI in diagnosing scaphoid proximal pole (PP) avascular necrosis (AVN) and correlate whether MRI can help guide the selection of a vascularized or nonvascularized bone graft.

METHODS

The study was approved by the IRB. Two MSK radiologists independently performed a retrospective review of unenhanced and enhanced MRIs from 18 patients (16 males, 2 females; median age, 17.5 years) with scaphoid nonunions and surgery performed within 65 days of the MRI. AVN was diagnosed on the unenhanced MRI when a diffusely decreased T1-W signal was present in the PP and on the enhanced MRI when PP enhancement was less than distal pole enhancement. Surgical absence of PP bleeding was diagnostic of PP AVN. Postoperative osseous union (OU) was assessed with computed tomography and/or radiographs.

RESULTS

Sensitivity, specificity and accuracy for PP AVN were 71, 82 and 78% for unenhanced and 43, 82 and 67% for enhanced MRI. Patients with PP AVN on unenhanced MRI had 86% (6/7) OU; 100% (5/5) OU with vascularized bone grafts and 50% (1/2) OU with nonvascularized grafts. Patients with PP AVN on enhanced MRI had 80% (4/5) OU; 100% (3/3) OU with vascularized bone grafts and 50% (1/2) OU with nonvascularized grafts. Patients with viable PP on unenhanced and enhanced MRI had 91% (10/11) and 92% (12/13) OU, respectively, all but one with nonvascularized graft.

CONCLUSIONS

When PP AVN is evident on MRI, OU is best achieved with vascularized grafts. If PP AVN is absent, OU is successful with nonvascularized grafts.

Morphological change and phenotypic plasticity in native and non-native pumpkinseed sunfish in response to sustained water velocities

Phenotypic plasticity can contribute to the proliferation and invasion success of nonindigenous species by promoting phenotypic changes that increase fitness, facilitate range expansion and improve survival. In this study, differences in phenotypic plasticity were investigated using young-of-year pumpkinseed sunfish from colonies established with lentic and lotic populations originating in Canada (native) and Spain (non-native). Individuals were subjected to static and flowing water treatments for 80 days. Inter- and intra-population differences were tested using ancova and discriminant function analysis, and differences in phenotypic plasticity were tested through a manova of discriminant function scores. Differences between Iberian and North American populations were observed in dorsal fin length, pectoral fin position and caudal peduncle length. Phenotypic plasticity had less influence on morphology than genetic factors, regardless of population origin. Contrary to predictions, Iberian pumpkinseed exhibited lower levels of phenotypic plasticity than native populations, suggesting that canalization may have occurred in the non-native populations during the processes of introduction and range expansion.

Morphological variation between non-native lake- and stream-dwelling pumpkinseed Lepomis gibbosusin the Iberian Peninsula

The objective of this study was to test if morphological differences in pumpkinseed Lepomis gibbosus found in their native range (eastern North America) that are linked to feeding regime, competition with other species, hydrodynamic forces and habitat were also found among stream- and lake- or reservoir-dwelling fish in Iberian systems. The species has been introduced into these systems, expanding its range, and is presumably well adapted to freshwater Iberian Peninsula ecosystems. The results show a consistent pattern for size of lateral fins, with L. gibbosus that inhabit streams in the Iberian Peninsula having longer lateral fins than those inhabiting reservoirs or lakes. Differences in fin placement, body depth and caudal peduncle dimensions do not differentiate populations of L. gibbosus from lentic and lotic water bodies and, therefore, are not consistent with functional expectations. Lepomis gibbosus from lotic and lentic habitats also do not show a consistent pattern of internal morphological differentiation, probably due to the lack of lotic-lentic differences in prey type. Overall, the univariate and multivariate analyses show that most of the external and internal morphological characters that vary among populations do not differentiate lotic from lentic Iberian populations. The lack of expected differences may be a consequence of the high seasonal flow variation in Mediterranean streams, and the resultant low- or no-flow conditions during periods of summer drought.

Heated competition: how climate change will affect non-native pumpkinseed Lepomis gibbosus and native perch Perca fluviatilis interactions in the U.K

Heated and ambient temperature experimental ponds were used to examine competition between introduced pumpkinseed Lepomis gibbosus and native perch Perca fluviatilis in England, U.K., and how these interactions are likely to change under climate warming conditions. Results from three sets of two-week experiments indicated that in both species and in all sets, growth was faster in heated than in ambient temperature ponds. Growth of both P. fluviatilis and L. gibbosus in sympatry did not differ significantly from that observed in allopatric ponds. Diet analysis indicated that increased resource partitioning occurred when P. fluviatilis and L. gibbosus were reared in sympatry, with P. fluviatilis shifting to a diet higher in microcrustaceans. The results do not support the previous claims of adverse effects of L. gibbosus on P. fluviatilis populations. Under conditions of climate change, however, which have been demonstrated experimentally to enhance L. gibbosus recruitment, this species is expected to become invasive in England, resulting in higher densities that may exert a stronger competitive effect than examined in this study.

The effect of elevated temperature on spawning of introduced pumpkinseed Lepomis gibbosus in Europe

In an experimental comparison of pumpkinseed Lepomis gibbosus reproduction under ambient and climate change water temperature regimes, spawning occurred earlier in the season, which is likely to lead to greater young-of-the-year survival with concomitant implications in the U.K. under warmer climatic conditions.

Identification of a new ribosomal RNA in Drosophila melanogaster

This study reports the cloning, characterization and identification of a previously undetected ribosomal RNA in Drosophila melanogaster. The ribosomal RNA is 370 nucleotides in length and contains the 5.8S and 2S ribosomal RNA coding regions. Analysis of polysome-containing cell extracts indicates that the RNA is present on polysomes suggesting a functional role within the ribosome. Northern blot analysis indicates that the RNA is also present in adult Drosophila melanogaster flies.

Identification of a Drosophila 60S ribosomal protein

We have previously reported the cloning and sequencing of a cDNA from Drosophila (DL43; GenBank Accession # U40226) which predicts a small protein homologous to a ribosomal protein in yeast and rat. In this study we show that a 330 nucleotide transcript encoding the putative ribosomal protein is expressed in Drosophila Kc cells under normal growth conditions (25 degrees C). This RNA is associated with the translational machinery and is present on polysomes. The DL43 cDNA was transcribed using T7 RNA polymerase and the resulting transcripts translated in a wheat germ extract. SDS/PAGE analysis of the in vitro transcribed and translated DL43 cDNA yields a small protein of approximately 9 kDa. Using two-dimensional gelelectrophoresis we have established that the radiolabeled DL43 protein comigrates with a small basic protein in the 60S ribosomal subunit. The electrophoretic mobilities of the in vitro and in vivo synthesized DL43 proteins are indistinguishable providing support for the identity of this protein.

A cDNA encodes the Drosophila homolog of yeast 60S ribosomal protein YL43

We describe the nucleotide sequence of a cDNA clone isolated from Drosophila Kc cells which encodes an amino acid sequence homologous to a 60S ribosomal protein from yeast (YL43) and rat (p23). The DL43 cDNA is 320 nucleotides in length and predicts a protein of 76 amino acids and a calculated molecular mass of 8.9 kiloDaltons. Northern blot analysis demonstrates the presence of the DL43 transcript under both control (25 degrees C) and heat shock (37 degrees C) conditions. The Drosophila protein shares an 86% identity over the first 22 amino acids with the yeast YL43 protein and a 60% identity over the entire length of the partial sequence available for this protein.

Long-chain alcohol and aldehyde dehydrogenase activities in Acinetobacter calcoaceticus strain HO1-N

Three alcohol dehydrogenases have been identified in Acinetobacter calcoaceticus sp. strain HO1-N: an NAD(+)-dependent enzyme and two NADP(+)-dependent enzymes. One of the NADP(+)-dependent alcohol dehydrogenases was partially purified and was specific for long-chain substrates. With tetradecanol as substrate an apparent Km value of 5.2 microM was calculated. This enzyme has a pI of 4.5 and a molecular mass of 144 kDa. All three alcohol dehydrogenases were constitutively expressed. Three aldehyde dehydrogenases were also identified: an NAD(+)-dependent enzyme, an NADP(+)-dependent enzyme and one which was nucleotide independent. The NAD(+)-dependent enzyme represented only 2% of the total activity and was not studied further. The NADP(+)-dependent enzyme was strongly induced by growth of cells on alkanes and was associated with hydrocarbon vesicles. With tetradecanal as substrate an apparent Km value of 0.2 microM was calculated. The nucleotide-independent aldehyde dehydrogenase could use either Würster's Blue or phenazine methosulphate (PMS) as an artificial electron acceptor. This enzyme represents approximately 80% of the total long-chain aldehyde oxidizing activity within the cell when the enzymes were induced by growing the cells on hexadecane. It is particulate but can be solubilized using Triton X-100. The enzyme has an apparent Km of 0.36 mM for decanal.

Delayed split whole abdominal irradiation in the combined modality treatment of ovarian cancer

Fifty-eight patients with ovarian malignancies have been treated using a delayed split whole abdominal irradiation technique (DSA) allowing the entire tumor volume to be irradiated with tumoricidal fractional doses without undue toxicity. The lower hemiabdomen was irradiated with 2 Gy per fraction to a total dose of 40 Gy. A 2-6 hour delay was used between the irradiation of each half of the abdomen to avoid excessive acute gastrointestinal toxicity. The upper hemiabdomen was irradiated with 1.5 Gy per fraction to a total dose of 30 Gy. The acute toxicity was acceptable, with 53 of 58 patients able to complete the prescribed course of treatment. Three patients (5%) experienced grade 3 or greater acute gastrointestinal toxicity. Fourteen of 60 patients (24%) required treatment breaks because of thrombocytopenia. Nadir platelet counts were lower in patients who had received previous chemotherapy than in previously untreated patients (80,000 vs 118,000; p = .02). However, only 4 out of 60 patients were unable to complete DSA because of prolonged thrombocytopenia. In addition to DSA, patients were also treated with intraperitoneal 32P (52 patients), intraperitoneal human ovarian antitumor serum (14 patients), and prior (14 patients) or subsequent (32 patients) chemotherapy. Granulocytopenia was more severe among patients who had received prior chemotherapy (mean nadir 900 vs 2200). Seven patients (11.5%) developed delayed bowel obstruction in the absence of recurrence. There was one death caused by hepatitis, presumably related to colloidal 32P and DSA. Twenty-five percent of Stage III optimally cytoreduced patients were disease-free at 5 years; these patients had a median survival of 45 months. DSA irradiation is an acceptable technique for delivering a high fractional dose of radiation to the entire peritoneal cavity. Shielding of the iliac crests spares bone marrow allowing DSA irradiation to be integrated into an aggressive combined modality treatment plan.

A two-step timed sequential treatment for acute myelocytic leukemia

Since 1980, adults with acute myelocytic leukemia (AML) have been treated on two clinical studies using intensive timed sequential therapy. All patients ages 16 to 80, including those with secondary AML (SAML) and those with AML preceded by a hematologic disorder (AHD), were treated, regardless of medical complications at the time of diagnosis. The first study combined high doses of cytarabine (ara-C, AC) and daunorubicin (DRN, D) in sequence (Ac2-D-Ac) and resulted in a complete remission rate of 55%. A group of these patients selected by functional status was able to receive a second course of therapy in remission, which resulted in a disease-free survival (DFS) of greater than 40% at 7 years. Because of toxicity in that study, 114 patients were entered on a second trial initiated 4 years ago, using a less aggressive first course, with amsacrine, to achieve a stable remission (Ac2-D-Amsa). This first treatment was followed by a more intensive second course (Ac6-D-Ac). With this two-step approach, a higher complete remission (CR) rate (76% for de novo AML and 54% for SAML-AHD) was achieved, and more patients were able to receive the second course of therapy. At the current median follow-up of 26 months, the median duration of DFS and overall survival are 11 and 14 months for patients with de novo AML. Age less than or equal to 55 is the most significant prognostic factor for both prolonged DFS and overall survival, with median durations of 17 and 18 months, respectively, for these younger patients. Patients with SAML-AHD remain relatively refractory to treatment despite aggressive chemotherapy, with median durations of DFS and overall survival of 9 months and 5 months, respectively.

In vivo cell growth and pharmacologic determinants of clinical response in acute myelogenous leukemia

A predictable increase in the proliferative rate of malignant cells remaining after initial cytoreduction in vivo forms the rationale for timed sequential therapy (TST) with 1-B-D-arabinofuranosylcytosine (ara-C) for adult acute myelogenous leukemia (AML). The relationship between in vivo leukemic cell growth, intracellular ara-C metabolism, and clinical response to ara-C-containing TST was evaluated by comparing AML marrow cell growth kinetic and biochemical pharmacologic determinants obtained before therapy (day 0) and at the predicted peak of in vivo postdrug residual tumor proliferation (day 8). Serial measurements of DNA synthesis and net intracellular ara-C metabolism demonstrated marked increases in both determinants in day 8 residual tumor when compared with the pretreatment cells for newly diagnosed adults achieving complete remission but not for TST-refractory patients. The interrelationship of AML cell proliferation and biochemical pharmacology together quantitate cytotoxicity measured by both achievement and duration of remission and serve to predict eventual clinical outcome in response to TST with ara-C where both growth and favorable pharmacokinetics are intrinsic to the success of the drug schedule.

Oxygen uptake by Diclidophora merlangi (Monogenea)

Diclidophora merlangiwas found to consume oxygen under a variety of experimental conditions. TheQo2of homogenates was 0.415 μl oxygen consumed/mg wet wt/h. Oxygen uptake was reduced in the presence of inhibitors: cyanide 0.1 mM and 5.0 mM, 100%; rotenone 10−6M, 56%; antimycin A10−6M, 63 %; malonate 10 mM, 36 %; arsenite 5 mM, 46 %; fluoroacetate 5 mM, 47 %. Worms died after 1 h incubation in 1 mM cyanide. It is suggested that these data provide evidence for the existence of a functional TCA cycle and respiratory chain of the classical pattern in this fluke.