An eosinophil peroxidase activity assay accurately predicts eosinophilic chronic rhinosinusitis

BACKGROUND

A definitive diagnosis of eosinophilic chronic rhinosinusitis (eCRS) requires invasive surgical tissue sampling and histologic enumeration of intact eosinophils. Eosinophil peroxidase (EPX) is an accurate biomarker of sinonasal tissue eosinophilia in CRS regardless of polyp status. A less invasive and rapid method that accurately identifies tissue eosinophilia would be of great benefit to patients.

OBJECTIVE

We sought to evaluate a new clinical tool that uses a nasal swab and colorimetric EPX activity assay to predict a diagnosis of eCRS.

METHODS

A prospective, observational cohort study was conducted using nasal swabs and sinonasal tissue biopsies obtained from patients with CRS electing endoscopic sinus surgery. Patients were classified as non-eCRS (n = 19) and eCRS (n = 35) on the basis of pathologically determined eosinophil counts of less than 10 or greater than or equal to 10 eosinophils/HPF, respectively. Swab-deposited EPX activity was measured and compared with tissue eosinophil counts, EPX levels, and CRS-specific disease metrics.

RESULTS

EPX activity was significantly increased in patients with eCRS than in patients without eCRS (P < .0001). With a relative absorbance unit cutoff value of greater than or equal to 0.80, the assay demonstrated high sensitivity (85.7%) and moderate specificity (79.0%) for confirming eCRS. Spearman correlations between EPX activity and tissue eosinophil counts (rs = 0.424), EPX levels (rs = 0.503), and Lund-Kennedy endoscopy scores (rs = 0.440) in eCRS were significant (P < .05).

CONCLUSIONS

This investigation evaluates a nasal swab sampling method and EPX activity assay that accurately confirms eCRS. This method could potentially address the unmet need to identify sinonasal tissue eosinophilia at the point-of-care, as well as to longitudinally monitor eosinophil activity and treatment response.

Pharmacokinetics of Intranasal Amiloride in Healthy Volunteers

Anxiety and panic disorders are the most common mental illnesses in the United States and lack effective treatment options. Acid-sending ion channels (ASICs) in the brain were shown to be associated with fear conditioning and anxiety responses and therefore are potential targets for treating panic disorder. Amiloride is an inhibitor of the ASICs in the brain and was shown to reduce panic symptoms in preclinical animal models. An intranasal formulation of amiloride will be highly beneficial to treat acute panic attacks due to advantages such as the rapid onset of action and patient compliance. The aim of this single-center, open-label trial was to evaluate the basic pharmacokinetics (PK) and safety of amiloride after intranasal administration in healthy human volunteers at three doses (0.2, 0.4, and 0.6 mg). Amiloride was detected in plasma within 10 minutes of intranasal administration and showed a biphasic PK profile with an initial peak within 10 minutes of administration followed by a second peak between 4-8 hours of administration. The biphasic PK indicates an initial rapid absorption via the nasal pathway and later slower absorption by non-nasal pathways. Intranasal amiloride exhibited a dose-proportional increase in the area under the curve and did not exhibit any systemic toxicity. These data indicate that intranasal amiloride is rapidly absorbed and safe at the doses evaluated and can be further considered for clinical development as a portable, rapid, noninvasive, and nonaddictive anxiolytic agent to treat acute panic attacks.

An evidence-based approach to provide essential and desirable components to develop surveys on Sudden Unexpected Death in Epilepsy (SUDEP) for doctors: A focused review

Sudden Unexpected Death in Epilepsy (SUDEP) is a major concern for people with epilepsy, their families, their care givers, and medical professionals. There is inconsistency in the SUDEP counselling doctors provide, compared to what is recommended in clinical guidelines. Numerous national and international surveys have highlighted how epilepsy professionals, usually doctors, deliver SUDEP risk counselling, particularly, when they deliver it and to whom. These surveys help understand the unmet need, develop suitable strategies, and raise awareness among clinicians with the eventual goal to reduce SUDEPs. However, there is no standardised survey or essential set of questions identified that can be used to evaluate SUDEP counselling practice globally. This focused review analyses the content of all published SUDEP counselling surveys for medical professionals (n=16) to date covering over 4000 doctors across over 30 countries and five continents. It identifies 36 question themes across three topics. The questions are then reviewed by an expert focus group of SUDEP communication experts including three doctors, an expert statistician and SUDEP Action, an UK based charity specialising in epilepsy deaths with a pre-set criterion. The review and focus group provide ten essential questions that should be included in all future surveys inquiring on SUDEP counselling. They could be used to evaluate current practice and compare findings over time, between services, across countries and between professional groups. They are provided as a template to download and use. The review also explores if there is a continued need in future for similar surveys to justify this activity.

Evaluating Distance Bias in Chronic Rhinosinusitis Outcomes

Importance

The distance traveled by patients for medical care is associated with patient outcomes (ie, distance bias) and is a limitation in outcomes research. However, to date, distance bias has not been examined in rhinologic studies.

Objective

To evaluate the association of distance traveled by a cohort of patients with chronic rhinosinusitis with baseline disease severity and treatment outcomes.

Design, Setting, and Participants

A total of 505 patients with chronic rhinosinusitis were prospectively enrolled in a multi-institutional, cross-sectional study in academic tertiary care centers between April 2011 and January 2020. Participants self-selected continued appropriate medical therapy or endoscopic sinus surgery. The 22-item Sinonasal Outcome Test (SNOT-22) and Medical Outcomes Study Short Form 6-D (SF-6D) health utility value scores were recorded at enrollment and follow-up. Data on the distances traveled by patients to the medical centers, based on residence zip codes, and medical comorbid conditions were collected.

Exposures

Distance traveled by patient to obtain rhinologic care.

Main Outcomes and Measures

SNOT-22 and SF-6D scores. Scores for SNOT-22 range from 0 to 110; and for SF-6D, from 0.0 to 1.0. Higher SNOT-22 total scores indicate worse overall symptom severity. Higher SF-6D scores indicate better overall health utility; 1.0 represents perfect health and 0.0 represents death.

Results

The median age for the 505 participants was 56.0 years (IQR, 41.0-64.0 years), 261 were men (51.7%), 457 were White (90.5%), and 13 were Hispanic or Latino (2.6%). These categories were collected according to criteria described and required by the National Institutes of Health and therefore do not equal the entire cohort. Patients traveled a median distance of 31.6 miles (50.6 km) (IQR, 12.2-114.5 miles [19.5-183.2 km]). Baseline (r = 0.00; 95% CI, 0.00-0.18) and posttreatment (r = 0.01; 95% CI, -0.07 to 0.10) SNOT-22 scores, as well as baseline (r = -0.12; 95% CI, -0.21 to -0.04) and posttreatment (r = 0.07; 95% CI, -0.02 to 0.16) SF-6D scores, were not associated with distance. There was no clinically meaningful correlation between distance traveled and mean comorbidity burden. Nevertheless, patients with a history of endoscopic sinus surgery were more likely to travel longer distances to obtain care (Cliff delta = 0.28; 95% CI, 0.19-0.38).

Conclusions and Relevance

Although this cross-sectional study found that some patients appear more willing to travel longer distances for chronic rhinosinusitis care, results suggest that distance traveled to academic tertiary care centers was not associated with disease severity, outcomes, or comorbidity burden. These findings argue for greater generalizability of study results across various cohorts independent of distance traveled to obtain rhinologic care.

Trial Registration

ClinicalTrials.gov Identifier: NCT02720653.

The impact of COVID-19 on epilepsy care: Perspectives from UK healthcare workers

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We surveyed UK healthcare workers (HCWs) involved in the care of people with epilepsy.

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During the pandemic, 70% of respondents held most consultations remotely.

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HCWs experienced increased mental strain and concern for colleagues/family members.

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HCWs reported being less confident in diagnosing epilepsy remotely.

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Clinicians were more reluctant to withdraw seizure medications during the pandemic.

The COVID-19 pandemic has created an immense pressure on healthcare providers, resulting in a shift to remote consultations and the redeployment of healthcare workers (HCWs). We present survey data from the United Kingdom (UK) HCWs to outline how changes in healthcare provision impact clinicians' wellbeing and ability to provide adequate care. We designed an online survey to gather the experiences of HCWs providing care to people with epilepsy. We received seventy-nine responses from UK-based HCWs, of whom 43% reported an impact on their mental health. Changes to service delivery have resulted in 71% of clinicians performing > 75% of their consultations remotely. Diagnosing and treating epilepsy has changed, with a fifth of respondents being significantly less confident in diagnosing epilepsy. Ultimately, these results show that COVID-19 has had an overall negative impact on HCWs and their ability to provide epilepsy care. These results must be considered when reorganizing health services to ensure optimal outcomes for people with epilepsy.

Cell Adhesion Molecules are Upregulated and May Drive Inflammation in Chronic Rhinosinusitis with Nasal Polyposis

Purpose

Chronic rhinosinusitis with nasal polyps (CRSwNP) is predominantly characterized by eosinophil- and T helper 2 cell (Th2)-biased inflammation. Integrins and intercellular adhesion molecules (ICAMs) are superfamilies of cell adhesion molecules (CAMs) that facilitate the recruitment and trafficking of immune cells and have been implicated in coordinating eosinophil and Th2 cell adhesion and signaling in asthma. The roles of CAMs in CRSwNP, however, remain poorly understood. The purpose of this study was to characterize the systemic and local expression of CAMs and identify which CAMs are potentially involved in CRSwNP pathology.

Materials and Methods

A prospective observational study was conducted using peripheral blood and anterior ethmoid tissues of patients with CRSwNP (n=32) and controls (n=15). Multiplex gene analysis and Pearson correlations were performed to identify associations between systemically and locally expressed CAMs. Based on the gene expression results, immunohistochemical evaluation and quantification of cells expressing integrins ITGAM, ITGAX, and ITGB2, as well as ICAM-3 in sinonasal tissues were conducted to compare local protein expression patterns.

Results

Integrin and ICAM genes were significantly elevated in the blood (p<0.001 to p<0.05) and sinuses (p<0.0003 to p<0.05) of patients with CRSwNP compared to controls. Strong positive correlations of genes expressed in the blood (p<0.01 to p<0.05) and sinuses (p<0.01) were observed between ITGAM, ITGAX, ITGB2, and ICAM3. ITGAM-, ITGB2-, ICAM-3-, and ICAM-3/ITGB2-positive cell counts were significantly increased in CRSwNP compared to controls (p<0.0001 to p<0.04), and a positive correlation between ICAM-3/ITGB2- and ITGAM-positive cell counts was observed (p<0.02).

Conclusion

The systemic and local expression of ITGAM, ITGB2, and ICAM-3 is significantly upregulated in CRSwNP, suggesting that integrin complex ITGAM/ITGB2 and ICAM-3 serve a potential role in inflammation-mediated signaling in CRSwNP.

Comorbidities Known to Affect Physical Function Negatively Impact Baseline Health-Related Quality-of-Life in Patients With Chronic Rhinosinusitis

BACKGROUND

Medical comorbidities are commonly encountered in chronic rhinosinusitis (CRS) and may impact both physical function and patient reported health-related quality-of-life (HRQOL). The functional comorbidity index (FCI) is designed to elucidate the role of comorbidities on functional prognosis. The objective of this study was to understand the impact of comorbidities known to impact physical function on baseline HRQOL using the FCI.Methodology: Patients meeting diagnostic criteria for CRS were prospectively enrolled in a cross-sectional study. Responses from the Sinonasal Outcomes Test-22 (SNOT-22), a measure of patient HRQOL, as well as the Lund-Kennedy and Lund-Mackay scores were recorded at enrollment. FCI was calculated retrospectively using the electronic medical record. Information was collected and compared for patients without (CRSsNP) and with nasal polyps (CRSwNP) using chi-square and t-tests. Spearman's correlations, followed by multivariate regression analysis, were used to assess the association between FCI and SNOT-22 scores.

RESULTS

One hundred and three patients met inclusion criteria for analysis. There were no significant differences in age, gender, and SNOT-22 scores between patients with CRSsNP and those with CRSwNP. FCI was significantly and independently associated with worse SNOT-22 scores (P = .012). FCI did not correlate with endoscopy and computed tomography scores. The mean FCI for patients with CRSsNP and CRSwNP was 2.02 and 2.24, respectively, and did not differ significantly between the two cohorts (P = .565).

CONCLUSIONS

Major medical comorbidities known to affect physical function are associated with worse SNOT-22 scores in patients with CRS as measured by the FCI.

Sleep Dysfunction is an Independent Predictor of Productivity Losses in Patients with Chronic Rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is known to have a significant impact on economic productivity. Sleep dysfunction is associated with staggering productivity losses and is highly prevalent in patients with CRS. The effect of sleep dysfunction on productivity in CRS has not been elucidated. The objective of this study was to determine the relationship between sleep dysfunction and lost productivity in patients with CRS.

METHODS

Eighty-two adult patients with CRS were prospectively enrolled into a cross-sectional cohort study. Patients with obstructive sleep apnea were excluded. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). Presenteeism (reduced work efficiency), absenteeism (missed work days), and lost work, household, and overall productivity were analyzed. The primary aim was assessing the correlation between PSQI and productivity. Regression analyses were performed to account for disease severity, pain, and depression.

RESULTS

Sleep dysfunction is significantly correlated with overall lost productivity (R² = 0.397, P < .05). Presenteeism is the most strongly affected by sleep dysfunction (R² = -0.441, P < .001). Higher PSQI scores were significantly associated with productivity losses, whereas lower scores were not. Sleep remained an independent predictor of productivity when regression analysis accounted for disease severity, depression, and pain.

CONCLUSION

Sleep dysfunction has a significant association with lost productivity in patients with CRS, particularly with worsening PSQI scores. More clearly defining those components of CRS that most impact a patient's daily function will allow clinicians to more optimally manage and counsel patients with CRS.

Inflammation-driven vascular dysregulation in chronic rhinosinusitis

BACKGROUND

Altered neovascularity is typically observed in chronic inflammatory diseases with overlapping pathophysiology to that observed in chronic rhinosinusitis (CRS). However, characterization of these inflammatory-induced vascular-mediated changes in CRS is limited. Understanding the underlying vascular changes in CRS will allow for strategic design and development of new drug-delivery technologies that exploit vascular permeability for increased extravasation into the target sinonasal tissues.

METHODS

Patients with CRS with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) and non-CRS controls were enrolled in this prospective, observational study. The extent of angiogenesis in tissue was characterized using immunohistochemical and multiplex gene expression analyses. Vascular permeability, interendothelial junction structures, and endothelial barrier morphology were evaluated using transmission electron microscopy.

RESULTS

Sinonasal vascularity was increased significantly in CRSsNP and CRSwNP (p < 0.05) when compared with controls, as assessed by enumerating the platelet endothelial cell adhesion molecule (PECAM-1)-positive blood vessels. Pro-angiogenic gene expression, including PECAM1 and platelet-activating factor receptor, was elevated significantly in patients with CRSwNP when compared with controls (p < 0.05). The fenestration sizes between endothelial cells (17-280 nm) were larger in CRSwNP compared with CRSsNP (10-33 nm) patients and controls (4-12 nm). Global thinning of the endothelial cell lining was observed in CRS patients but not in controls.

CONCLUSION

Significant increases in vascularity, the pro-angiogenic gene, and protein expression and blood vessel morphogenesis were observed in CRS patients compared with controls. In addition, fenestration sizes between interendothelial junction structures were larger in CRS patients than in controls, suggesting inflammation-driven vascular dysregulation in CRS pathology.

Pilot Investigation: Prospective Needs Assessment of Knowledge, Attitude, and Insight About Mental Health Treatment Options in Patients With Chronic Rhinosinusitis

INTRODUCTION

Mood disorders frequently coexist with chronic rhinosinusitis (CRS), yet patient views of how mental health impacts their disease, and their willingness to engage in treatment is not well understood.

METHODS

Subjects with CRS were enrolled regardless of their mental health status and completed a needs questionnaire on mental health as it related to CRS. In addition, demographic and disease-specific data were collected.

RESULTS

We enrolled 55 subjects. In addition, 29.1% of them had polyps, with mean endoscopy/computed tomography (CT)/Sino-Nasal Outcome Test (SNOT-22) scores of 3.9/9.7/41.2, respectively and 45% thought depression was common in CRS patients. In total, 78.2% were open to taking a depression screener and would be comfortable discussing mental health with their Ear Nose and Throat provider, 76.4% of patients felt that treating mental health problems could improve sinus-related quality of life (QOL), and 87.3% were open to meeting with a mental health professional or participating in a course on managing stress/anxiety/mental health issues. The multivariate regression model of whether patients felt that treating the mind would improve sinus-related QOL as predicted by age, gender, SNOT-22, CT scores, and endoscopy scores was statistically significant (P = .027) and explained 42% of the variance in answers, but only age and gender approached statistical significance (P = .06 and .04).

CONCLUSIONS

CRS patients acknowledged the high prevalence of comorbid mood disorders and were willing to discuss and be treated for mental health issues. Many patients felt that treating their mental health would improve their disease-specific QOL. These findings warrant further study of how to incorporate the management of metal health into CRS treatment algorithms.

Correlation between systemic inflammatory response and quality of life in patients with chronic rhinosinusitis

BACKGROUND

Local sinonasal inflammation resulting from altered T-cell immune signaling is a contributor to the pathogenesis of chronic rhinosinusitis (CRS). CRS patients experience negative impacts on quality of life (QOL) and suffer from comorbidities linked to systemic inflammation. However, systemic inflammatory profiling to evaluate the association between systemic inflammation and QOL in CRS has not been performed. Our objectives were to compare local and systemic inflammatory gene expression in patients with CRS to determine if systemic markers of inflammation associate with disease severity and disease-specific QOL.

METHODS

A prospective observational study was conducted comparing 16 patients with CRS to 10 controls. Inflammatory gene expression in the anterior ethmoid tissues and peripheral blood of patients was measured using multiplex gene expression analysis and correlated to disease severity (computed tomography and nasal endoscopy) and disease-specific QOL (22-item Sino-Nasal Outcome Test [SNOT-22] and Rhinosinusitis Disability Index) using linear regression analyses.

RESULTS

Patients with CRS showed significant increases in the expression of ctla4 and jak1 in sinonasal tissue and blood (p < 0.05), whereas the gene expression of hla-dqa1, hla-dqb1, and dusp4 was significantly decreased in patients with CRS compared to controls (p < 0.05). Soluble and local ctla4 and jak1 showed a significant positive correlation with clinical markers of disease severity and disease-specific QOL (p < 0.05).

CONCLUSION

Local and systemic gene expression involved in T-cell immune signaling was found to be significantly altered in the blood and sinonasal tissues of patients with CRS compared to controls and significantly correlated to disease severity and QOL in patients with CRS.

Calgranulin C (S100A12) Is Differentially Expressed in Subtypes of Chronic Rhinosinusitis

Background Calgranulin C (S100A12) is an innate immune peptide at the air-mucosal interface associated with neutrophil involvement, which when overexpressed has been implicated as a biomarker of inflammatory diseases. Decreased epithelial expression of certain innate immune peptides has been reported in chronic rhinosinusitis (CRS). We hypothesized that S100A12 is differentially expressed in the sinonasal mucosa of patients with CRS compared to controls and that S100A12 is a potential biomarker of CRS-specific quality of life (QOL) and disease severity. Methods A prospective observational study was conducted which included 70 patients: 17 controls, 28 having CRS without (CRSsNP), and 25 with (CRSwNP) nasal polyps. The expression of S100A12 and human neutrophil elastase (HNE) was assessed in the anterior ethmoid tissues from all patients using enzyme-linked immunosorbent assay (ELISA) and immunohistochemical (IHC) analyses. Disease-specific QOL (Rhinosinusitis Disability Index) and disease severity (computed tomography [CT] and endoscopy) were evaluated and correlated to the expression levels of S100A12. Results S100A12 and HNE were significantly elevated in patients with CRSsNP compared to normal controls ( P < .05 and P < .001, respectively) and patients with CRSwNP ( P < .05 and P < .001, respectively), as measured by ELISA and IHC analyses. Patients with CRS exhibited worse CRS-specific disease severity compared to normal controls ( P < .05), and the increased protein levels of S100A12 were significantly correlated to disease severity, represented by CT scores ( P < .05). Conclusions S100A12 is differentially expressed in CRS subtypes and is significantly elevated in patients with CRSsNP and associated with CRS-specific disease severity.

Decreasing the risk of sudden unexpected death in epilepsy: structured communication of risk factors for premature mortality in people with epilepsy

BACKGROUND AND PURPOSE

Good practice guidelines highlight the importance of making people with epilepsy aware of the risk of premature mortality in epilepsy particularly due to sudden unexpected death in epilepsy (SUDEP). The SUDEP and Seizure Safety Checklist ('Checklist') is a structured risk communication tool used in UK clinics. It is not known if sharing structured information on risk factors allows individuals to reduce SUDEP and premature mortality risks. The aim of this study was to ascertain if the introduction of the Checklist in epilepsy clinics led to individual risk reduction.

METHODS

The Checklist was administered to 130 consecutive people with epilepsy attending a specialized epilepsy neurology clinic and 129 attending an epilepsy intellectual disability (ID) clinic within a 4-month period. At baseline, no attendees at the neurology clinic had received formal risk advice, whereas all those attending the ID clinic had received formal risk advice on multiple occasions for 6 years. The Checklist was readministered 1 year later to each group and scores were compared with baseline and between groups.

RESULTS

Of 12 risk factors considered, there was an overall reduction in mean risk score for the general (P = 0.0049) but not for the ID (P = 0.322) population. Subanalysis of the 25% of people at most risk in both populations showed that both sets had a significant reduction in risk scores (P < 0.001).

CONCLUSION

Structured discussion results in behavioural change that reduces individual risk factors. This impact seems to be higher in those who are at current higher risk. It is important that clinicians share risk information with individuals as a matter of public health and health promotion.

The effects of nasal closure on quality of life in patients with hereditary hemorrhagic telangiectasia

Introduction

Epistaxis is the most common symptom of hereditary hemorrhagic telangiectasia (HHT). Complete nasal closure is one of the treatment options for patients with severe, intractable epistaxis. In our experience, this surgery can be life changing in a positive sense; but many patients as well as their physicians understandably fear that such a procedure will diminish certain aspects of quality of life (QOL).

Methods

Case-control study of HHT patients treated at the University of Utah HHT Center of Excellence with and without nasal closure from January 2005 to January 2016. Patients were matched according to epistaxis severity. Each included patient was issued three surveys: Epistaxis Severity Score (ESS), the Pittsburg Sleep Quality Index (PSQI), and the Nasal Obstruction Symptom Evaluation (NOSE).

Results

After treatment, the mean PSQI and NOSE scores were not significantly different between the two groups. However, the mean ESS score in the nasal closure group was significantly lower at 1.10 compared to the severe epistaxis group with a mean score of 3.99 (P = .027).

Conclusion

The results of this study demonstrate that nasal closure significantly improves epistaxis severity without having a significant effect on sleep or nasal obstruction as they relate to QOL. These findings suggest that nasal closure should be considered for HHT patients with chronic severe epistaxis.

Level of Evidence

4.

The price of pain in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is associated with productivity losses exceeding US$13 billion annually. Although pain is well known to significantly affect patient productivity in other diseases, its economic impact on CRS-related lost productivity has not been examined. The objective of this study was to determine whether CRS-related facial pain correlates with lost productivity in patients with CRS.

METHODS

Seventy patients with CRS were enrolled in a cross-sectional investigation. Patients with a history of systemic inflammatory disease, ciliary dysfunction, chronic pain syndromes, migraines, and fibromyalgia were excluded. Pain was measured using the Brief Pain Inventory Short Form (BPI-SF) and the Short-Form McGill Pain Questionnaire (SF-MPQ). Presenteeism, absenteeism and lost work, and household and overall productivity were assessed. Regression analysis was performed to assess potential confounders, including depression.

RESULTS

Pain as measured with BPI-SF and SF-MPQ total scores correlated with all domains of productivity losses. Overall, lost productivity was significantly correlated with pain (R range, 0.354-0.485; p < 0.001). Presenteeism (reduced work efficiency) had the highest correlation with all of the overall pain scores (R range, -0.366 to -0.515; p < 0.001). Lost household productivity time was the least affected by pain (R range, 0.267-0.389; p < 0.05). These correlations remained statistically significant after regression analysis, which accounted for depression (p < 0.05).

CONCLUSION

A significant correlation exists between CRS-related facial pain and productivity losses in patients with CRS that is independent of depression. Facial pain has the strongest correlation with presenteeism, which is the main driver of productivity losses and indirect costs associated with CRS.

Time, Resident Involvement, and Supply Drive Cost Variability in Septoplasty with Turbinate Reduction

Objective To determine factors that influence cost variability in septoplasty with inferior turbinate reduction. Study Design Case series with chart review. Setting Tertiary care hospital and affiliated ambulatory surgical center. Subjects and Methods Surgical costs were reviewed for adult patients undergoing septoplasty with inferior turbinate reduction between December 2014 and September 2017. Cases where additional procedures were performed were excluded. Operative supply costs, operative time, room time, and resident involvement were determined. Contribution of these factors to total costs and variability were analyzed. Results The study included 116 patients (mean age, 38 years) and 4 faculty surgeons. Total cost was primarily driven by operative time (74%), with a smaller portion of total cost arising from supplies (26%). Time cost ( P < .0001) and supply cost ( P = .006) varied significantly among surgeons. A resident was involved in 46.6% of cases. When subanalyzed by resident year, no-resident and senior resident (postgraduate years 4 and 5) cases had nearly identical mean times, while junior resident (postgraduate years 1-3) cases had mean times and operative time costs that were 39% greater ( P < .001). Conclusion For septoplasty with inferior turbinate reduction, the greatest driver of cost variation was operative time. Resident involvement correlated with increased time and cost. Supply costs had a much smaller impact. When subanalyzed by resident year, junior resident-involved cases were significantly longer than no-resident cases.

International Frontal Sinus Anatomy Classification and anatomic predictors of low-lying anterior ethmoidal arteries

BACKGROUND

The International Frontal Sinus Anatomy Classification (IFAC) was introduced to more accurately characterize ethmoid and frontal sinus pneumatization patterns. The prevalence of IFAC cells and their anatomic associations have not been described.

OBJECTIVE

The goal was to examine the prevalence of IFAC cells and determine radiologic features associated with a low-lying anterior ethmoidal artery (LAEA).

METHODS

Imaging of adult patients who underwent computed tomographies from January 2015 to March 2016 were retrospectively reviewed by using the IFAC classification. We also measured the distance from the skull base to the anterior ethmoidal artery (AEA), the height of the lateral lamella of the cribriform plate, and anterior-posterior diameter from the anterior wall of the frontal sinus to the skull base (APF). Patients with a history of sinus surgery, trauma, malignancy, or congenital anomaly were excluded. Statistical analysis was performed by using Pearson correlation coefficients and χ2 tests.

RESULTS

A total of 95 patients met the inclusion criteria. There was a significant association between supraorbital ethmoid cells and an LAEA (p < 0.001), with a significant effect size (φ = 0.276, p = 0.007). An inverse relationship was observed between Keros type I classification I and an LAEA (p < 0.001), with a significant effect size (φ = -0.414, p = 0.000). Significant associations were found between the AEA distance from the skull base and the cribriform lateral lamella height (R = 0.576, p < 0.001). In addition, there was a significant association between the AEA distance from the skull base and the APF (R = 0.497, p < 0.001).

CONCLUSION

The presence of a supraorbital ethmoid cell and a wide APF were associated with an LAEA. There was a significant relationship between Keros type I classification and the AEA adjacent to the skull base. Delineation of these anatomic relationships may be helpful during endoscopic sinus surgery to avoid complications.

Single-Blinded Prospective Implementation of a Preoperative Imaging Checklist for Endoscopic Sinus Surgery

Objective To determine if the introduction of a systematic preoperative sinus computed tomography (CT) checklist improves identification of critical anatomic variations in sinus anatomy among patients undergoing endoscopic sinus surgery. Study Design Single-blinded prospective cohort study. Setting Tertiary care hospital. Subjects and Methods Otolaryngology residents were asked to identify critical surgical sinus anatomy on preoperative CT scans before and after introduction of a systematic approach to reviewing sinus CT scans. The percentage of correctly identified structures was documented and compared with a 2-sample t test. Results A total of 57 scans were reviewed: 28 preimplementation and 29 postimplementation. Implementation of the sinus CT checklist improved identification of critical sinus anatomy from 24% to 84% correct ( P < .001). All residents, junior and senior, demonstrated significant improvement in identification of sinus anatomic variants, including those not directly included in the systematic review implemented. Conclusion The implementation of a preoperative endoscopic sinus surgery radiographic checklist improves identification of critical anatomic sinus variations in a training population.

The pain-depression dyad and the association with sleep dysfunction in chronic rhinosinusitis

BACKGROUND

Depression, pain, and sleep disturbance is a symptom cluster often found in patients with chronic illness, exerting a large impact on quality of life (QOL). A wealth of literature exists demonstrating a significant association between depression, pain, and sleep dysfunction in other chronic diseases. This relationship has not been described in patients with chronic rhinosinusitis (CRS).

METHODS

Sixty-eight adult patients with CRS were prospectively enrolled. Patients at risk for depression were identified using the Patient Health Questionnaire-2 (PHQ-2) using a cut-off score of ≥1. Pain experience was measured using the Brief Pain Inventory Short Form (BPI-SF) and the Short Form McGill Pain Questionnaire (SF-MPQ). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Forty-seven patients were at risk for depression. Significant positive correlations were found between total PSQI scores and all pain measures (R = 0.38-0.61, p ≤ 0.05) and between total PSQI scores and PHQ-2 scores (R = 0.46, p < 0.05). For patients at risk for depression, significant, positive correlations were found between pain measures, the total PSQI score, and the 3 PSQI subdomains (sleep latency, sleep quality, and daytime dysfunction; R = 0.31-0.61, p < 0.05). The relationship between pain and sleep dysfunction scores was not seen in the absence of depression.

CONCLUSION

Depression, pain, and sleep dysfunction are interrelated in patients with CRS. In the absence of depression, significant correlations between pain and sleep are not observed, suggesting that depression plays a key role in this interaction. Further research is needed to investigate the complex relationship between depression, pain, and sleep dysfunction in CRS.

Dyad of pain and depression in chronic rhinosinusitis

BACKGROUND

Pain and depression often coexist as comorbidities in patients with chronic disease and exert a major impact on quality of life (QOL). Little is known about the relationship between pain and depression in chronic rhinosinusitis (CRS). Our objective was to investigate this relationship and to analyze the effect of pain and depression on QOL in CRS.

METHODS

Patients with CRS were prospectively recruited as part of an observational cohort study. A total of 70 participants provided pain scores using both the Brief Pain Inventory Short Form (BPI-SF) and the Short Form McGill Pain Questionnaire (SF-MPQ). Patients at risk for depression were identified using the Patient Health Questionnaire-2 (PHQ-2). CRS-specific QOL was determined using the 22-item Sino-Nasal Outcome Test (SNOT-22).

RESULTS

Significant positive correlations were found between depression scores and all pain measures (R = 0.475 to 0.644, p < 0.001). Patients with a PHQ-2 score ≥1 had significantly higher scores on all reported pain measures. Significant positive correlations were found between all pain measures, the total SNOT-22 score, and 3 SNOT-22 subdomains (sleep, psychological dysfunction, and ear/facial symptoms; R = 0.323 to 0.608, p < 0.05).

CONCLUSION

Adult patients with CRS at risk for depression experience more pain and have overall worse disease-specific QOL. Further research investigating the complex interactions between depression and pain and the role it plays in CRS disease-specific QOL is warranted.

Cognitive dysfunction associated with pain and quality of life in chronic rhinosinusitis

BACKGROUND

Cognitive dysfunction and its relationship to both pain and disease-specific quality of life (QOL) in chronic rhinosinusitis (CRS) have not been investigated previously. We sought to analyze the correlations of pain and disease-specific QOL with cognitive function in CRS.

METHODS

Adults with CRS were prospectively enrolled in a cross-sectional study. Participants' cognitive function was assessed using the Cognitive Failures Questionnaire. Pain was characterized using the Short-Form McGill Pain Questionnaire (SF-MPQ) and the Brief Pain Inventory Short Form. Disease-specific QOL was ascertained using the Rhinosinusitis Disability Index (RSDI) and 22-item Sinonasal Outcome Test (SNOT-22). Disease severity was assessed using nasal endoscopy and computed tomography. Bivariate correlations of pain and cognitive dysfunction, disease-specific QOL, and clinical measures of disease severity were ascertained.

RESULTS

In patients with CRS (n = 70) there was a significant correlation between cognitive dysfunction and pain severity scores (Spearman's correlation [R(s)] = 0.321, p < 0.01). A similar correlation was identified with pain interference (R(s) = 0.317, p < 0.01) and cognitive dysfunction scores. This is mirrored by a significant correlation between another measure of pain severity, the SF-MPQ and cognitive dysfunction (R(s) = 0.498, p < 0.01). In patients with CRS there was a significant correlation between disease-specific QOL scores and cognitive function scores as measured by the SNOT-22 (R(s) = 0.395, p < 0.01) and the RSDI (R(s) = 0.528, p < 0.01).

CONCLUSION

In patients with CRS, increasing pain and worse QOL are associated with cognitive dysfunction. Possible mechanisms for this cognitive dysfunction include differential neural activation secondary to chronic pain and/or the sequela of a chronic inflammatory state.

Characterization of facial pain associated with chronic rhinosinusitis using validated pain evaluation instruments

BACKGROUND

Prior investigations into facial pain associated with chronic rhinosinusitis (CRS) have yielded important results, but have yet to use pain-specific outcome measures. This study seeks to characterize facial pain associated with CRS using validated pain-specific instruments.

METHODS

Adults with CRS were enrolled into a prospective, cross-sectional study along with control participants presenting with non-CRS diagnoses. Facial pain was characterized in both groups using the Brief Pain Inventory Short Form (BPI-SF) and the Short-Form McGill Pain Questionnaire (SF-MPQ). CRS-specific measures of disease were measured including the 22-item Sino-Nasal Outcome Test-22 (SNOT-22), nasal endoscopy, and computed tomography scoring.

RESULTS

The patients comprised of CRS with nasal polyposis (CRSwNP; n = 25), CRS without nasal polyposis (CRSsNP; n = 30), and control participants (n = 8). Subjects with CRSwNP and CRSsNP were less likely to be pain free than controls (16.0%, 6.7%, and 62.5% respectively, p = 0.001) and carried greater burden of pain as measured by the BPI-SF and SF-MPQ than controls (p = 0.002 and p = 0.017, respectively). Pain in CRS was most commonly located around the eyes and characterized as "throbbing" and "aching." Nasal polyp status was not associated with differences in character, severity, or location of pain.

CONCLUSION

Subjects with CRS have a greater burden of facial pain relative to control subjects across several standardized pain measures. Further, facial pain in CRS significantly correlated to quality of life and CRS-specific disease severity measures. Study across larger cohorts using standardized pain measures is warranted to clarify the association of facial pain with CRS.

Diverse populations of intrinsic cholinergic interneurons in the mouse olfactory bulb

Cholinergic activities affect olfactory bulb (OB) information processing and associated learning and memory. However, the presence of intrinsic cholinergic interneurons in the OB remains controversial. As a result, morphological and functional properties of these cells are largely undetermined. We characterized cholinergic interneurons using transgenic mice that selectively mark choline acetyltransferase (ChAT)-expressing cells and immunolabeling. We found a significant number of intrinsic cholinergic interneurons in the OB. These interneurons reside primarily in the glomerular layer (GL) and external plexiform layer (EPL) and exhibit diverse distribution patterns of nerve processes, indicating functional heterogeneity. Further, we found these neurons express ChAT and vesicular acetylcholine transporter (VAChT), but do not immunoreact to glutamatergic, GABAergic or dopaminergic markers and are distinct from calretinin-expressing interneurons. Interestingly, the cholinergic population partially overlaps with the calbindin D28K-expressing interneuron population, revealing the neurotransmitter identity of this sub-population. Additionally, we quantitatively determined the density of VAChT labeled cholinergic nerve fibers in various layers of the OB, as well as the intensity of VAChT immunoreactivity within the GL, suggesting primary sites of cholinergic actions. Taken together, our results provide clear evidence showing the presence of a significant number of cholinergic interneurons and that these morphologically and distributionally diverse interneurons make up complex local cholinergic networks in the OB. Thus, our results suggest that olfactory information processing is modulated by dual cholinergic systems of local interneuron networks and centrifugal projections.

Present status of the infant of very low birth weight treated in a referral neonatal intensive care unit in 1974

In 1974, 250 infants with birth weights of 1500 g or less were referred to the Intensive Care Unit at the Hospital for Sick Children, Toronto. Sixty-six per cent survived. Prospective follow-up studies of the survivors have been completed over a minimum of two years. Infants at highest risk for handicapping defects (about 85%) are those who survived intracranial haemorrhage during the neonatal period. Neurological defects encountered in these children were severe--hydrocephalus, spastic quadriplegia, hemiplegia or microcephalus--and were usually associated with low psychometric scoring. The second highest risk group were small for gestational age infants. Of these, 53% were significantly handicapped at two years of age, and 43% had developmental quotients of less than 80. These defects could not be related to postnatal events. The third category at high risk were infants with birth weights of 1000 g or less. Among these, 30% had a significant handicap by two years of age. The outcome in the remainder of the sample was generally good. These results suggest that the decreased mortality of the very premature infant is associated with an increased number of relatively normal survivors and that the infants at highest risk for subsequent defects can be identified at or shortly after birth.

Pregnancy outcome and infant development following gestational cocaine use by social cocaine users in Toronto, Canada

To determine the effect of first trimester cocaine use on pregnancy outcome we conducted a prospective cohort study of 30 women admitting to social cocaine use (SCU) during early pregnancy, 20 users of cannabis during the first trimester and 30 matched recreational drug-free control subjects. The groups were of similar age, marital status, and obstetric history and were predominantly white. They were of similar socioeconomic status (SES), however the spouses of the cocaine users were of significantly lower SES than those of both control groups (p less than 0.005). The number of years of education of the cocaine users and the fathers of the SCU-exposed fetuses was significantly lower than that of the recreational drug-free control subjects (p = 0.004), however, female IQ was similar among the three groups (109.1 +/- 12.4 cocaine; 109.1 +/- 25.2 cannabis; 114.1 +/- 11.7 drug-free). Alcohol and cigarette use was greater among the cocaine users than among subjects of the recreational drug-free control group (p less than 0.025). Cocaine and the associated lifestyle were not associated with any adverse obstetric or neonatal endpoint (pregnancy weight gain, incidence of delivery complications, gestational age, birth weight, Apgar scores, and rates of major and minor malformations). There were no differences between groups in attaining developmental milestones. Mental and motor scores on the Bayley Scales of Infant Development and Vineland Adaptive Behavior Scales were identical among the three groups, studied at a mean of 19.7 months of age. We conclude that outcome of pregnancy of social cocaine users and subsequent infant physical and cognitive development are within normal limits at 1.6 years of age.

The prognostic value of computed tomography of the brain in asphyxiated premature infants

Computed tomography brain scans were done during the first two weeks of life in 145 asphyxiated or apneic newborn infants with birth weights less than 1,500 gm. Sixty-two survived and were assessed neurodevelopmentally at 18 months from the term date. Follow-up CT scans were done at six months post term. There were major neurodevelopmental defects in 15 children, minor defects in 10, and no gross abnormalities in 37. The neonatal CT scans showed germinal layer hemorrhage in 45 (73%) of the survivors and was combined with ventricular bleeding in 29 cases (47%). Areas of hypodensity of brain tissue were present in all neonatal CT and were extensive in 84%. Ventricular dilatation occurred in 31%. There was a significant relationship between hydrocephalus and CT findings of IVH and dilated ventricles, but no relationship between outcome at 18 months and any other features of the neonatal CT. Only four of 56 CT scans done at six months post term were normal. Dilatation of the ventricles and subarachnoid spaces was common but was not related to subsequent neurodevelopmental status.

Is intensive care justified for infants weighing less than 801 gm at birth?

During 1974-1977, 158 infants of birth weights less than 801 gm were referred from outlying hospitals. The survival rate was 25% for the whole group and 35% for those weighing 700 to 800 gm. Many were in a poor condition on arrival. One hundred and nineteen died. The most common causes of death were intracranial hemorrhage (39), RDS (26), and infection (13). Thirty-seven of the 39 survivors were followed until 18 months postterm. Growth failure was common--57% were below the third percentile in weight, 37% in length, and 17% in head circumference. Three had retrolental fibroplasia. Five children (14%) had major neurologic sequelae. Eight were severely handicapped with a Bayley score of less than 70 and ten were moderately handicapped with a Bayley score between 70 and 84, resulting in a neurodevelopmental handicap rate of 49%. Significant factors correlating with survival and intact outcome were birth weight greater than or equal to 700 gm, gestation greater than or equal to 26 weeks, the absence of asphyxia, and good condition on arrival at the NICU. There was no intact survival below 700 gm birth weight. The handicap rate of survivors between 700 and 800 gm was only 39%. Although intensive care in a referral unit may not be justified for those less than 700 gm, every effort should be made in the care of those 700 to 800 gm.

The prognostic value of computed tomography as an adjunct to assessment of the term infant with postasphyxial encephalopathy

Prospective follow-up studies were done on 62 term infants who were treated as neonates for clinical evidence of postasphyxial encephalopathy. Computed tomographic studies were done during the first two weeks of life and repeated at six months of age. All children were followed a minimum of 18 months, at which time they underwent a psychometric and a neurologic evaluation. Major neurodevelopmental sequelae consisted of: hydrocephalus; spastic quadriplegia, hemiplegia, or diplegia; or a mean Bayley score less than 70. Major sequelae were present in 29 (47%) of the children: all were severely handicapped. Five other children scored between 70 and 85 on the Bayley test. Computed tomographic scans were highly predictive of status at 18 months. Eleven of the 15 with intraventricular or parenchymal hemorrhage were severely handicapped. Eighteen of 20 with extensive areas of hypodensity of the white and gray matter (neonatal CT) were abnormal at 18 months. All but two were severely handicapped. The results suggest that CT studies are very useful in the care of the asphyxiated term infant who has clinical signs of encephalopathy.

The status at two years of low-birth-weight infants born in 1974 with birth weights of less than 1,001 gm

A two-year follow-up study of 43 infants of birth weight less than or equal to 1,000 gm born during 1974 revealed the following: average height at two years was between the tenth and twenty-fifth percentiles; average weight between the third and tenth percentiles. Fifteen (35%) developed lower respiratory tract infections during the first two years. Seven (16%) had retrolental fibroplasia. Major neurologic defects occurred in four (9%); severe developmental delay (mean developmental quotient less than 80) was found in nine others (21%). Defects of the central nervous system were closely associated with a neonatal history of intracranial hemorrhage or seizures or both.

Mechanical ventilation of infants of less than 1,501 gm birth weight: Health, growth, and neurologic sequelae

A two-year follow-up study of 73 low-birth-weight ( less than 1,501 gm) infants treated with positive pressure ventilation as neonates revealed the following: 24% incidence of lower respiratory tract infections during the first year; weight and height at two years averaging between tenth and twenty-fifth percentiles; major neurologic defects diagnosed in 14 boys (39%) and seven girls (18%) with one-year Bayley scores of less than 80. Major neurologic sequelae were closely associated with a neonatal history of seizures and intracranial hemorrhage and were more common in boys, survivors weighing more than 1,000 gm and following high-risk pregnancies.