European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

Inflammatory breast carcinoma: pathological or clinical entity?

Inflammatory breast carcinoma (IBC) diagnosis is usually based in the presence of typical clinical symptoms (redness and edema in more than 2/3 of the breast), which are not always associated with pathologic characteristics (subdermal lymphatics involvement). Whether exclusively pathologic findings without clinical symptoms are sufficient for IBC diagnosis remains controversial. A retrospective analysis of 163 clinically diagnosed IBC (CIC) either with dermal lymphatics invasion or not, was compared with another group of 99 patients with dermal lymphatics invasion without clinical symptoms (occult inflammatory carcinoma) (OIC). The following clinical and pathological characteristics have been analyzed and compared: age, menopausal status, clinical axillar node involvement, symptoms duration before diagnosis, grade, estrogen receptors, presence of metastases at diagnosis, local recurrence, metastasic dissemination, disease-free (DFS) and overall survival (OS). Median age was younger in CIC (52.3 vs. 63.8 years; p < 0.001). Symptom duration before diagnosis were significantly shorter in CIC (3.4 vs. 6.8 months: p < 0.0001). Visceral (36.2% vs. 17.2%; p = 0.001) and brain metastases (7.4% vs. 1%; p = 0.02) was significantly more frequent in CIC. Negative estrogen receptors were more frequent in CIC (34.9% vs. 65.1%: p < 0.004). Five-years DFS (25.6 vs. 51.6%; p < 0.0001) and OS (28.6 vs. 40%; p < 0.05) were shorter in CIC. CIC (regardless of subdermal lymphatics involvement) must be clearly differentiated from OIC. Prognosis of CIC patients is poorer, so this two entities should be clearly differentiated when therepeutic results are reported.

A survey on the management of acute rhinosinusitis among Asian physicians

BACKGROUND

Based on the `European Position Paper on Rhinosinusitis and Nasal polyps (EP3OS 2007)`, this study aimed to investigate general practitioners (GPs) and other specialists` understanding when managing patients with acute rhinosinusitis (ARS) in Asia.

METHODOLOGY

Among a total of 2662 questionnaires completed, 2524 (94.8%) were valid for analysis. There were 1308 GPs (51.8%), 989 otolaryngologists (39.2%) and 227 paediatricians (9%) from Mainland China, Hong Kong, Indonesia, India, Malaysia, Pakistan, Philippines, Singapore, Thailand and Taiwan.

RESULTS

ARS is affecting an estimated 6 - 10% of patients seen in a daily out-patient practice. The EP3OS criteria are well supported by Asian physicians (94.1%). Most physicians (62.7%) agreed that radiological investigation is not needed to diagnose ARS. However, even for mild ARS (common cold), medical treatments were still recommended by 87% of GPs, 83.9% of otolaryngologists, and 70% of paediatricians. The top three first-line treatments prescribed were antihistamines (39.2%), nasal decongestants (33.6%), and antibiotics (29.5%). Antibiotics usage increased as the first line treatment of moderate (45.9%) and severe (60.3%) ARS.

CONCLUSION

ARS is commonly managed by GPs, otolaryngologists, and paediatricians in Asia. However, understanding of the management of ARS needs further improvement to minimize unnecessary use of radiological investigations, overuse of antibiotics, and under use of nasal corticosteroids.

Bone mass, bone mineral density and muscle mass in professional golfers

The aim of this study was to determine the effects of long-term professional golf participation on whole-body and regional bone mass and density. Dual-energy X-ray absorptiometry was performed on 15 male professional golfers and 18 sedentary individuals, matched for sex, race, age (29+/-1 and 25+/-1 years, respectively), body mass (79+/-2 and 74+/-2 kg), height (1.78+/-0.01 and 1.77+/-0.02 m) and percent body fat (20+/-2 and 21+/-2%; mean +/- sx). We found that long-term professional golf participation is not associated with significant increments in regional or whole-body bone mass or density. Neither the lumbar spine nor the femoral neck showed any noticeable enhancement of bone mass in professional golfers compared with controls from the same population. The only effect of professional golf participation on regional body composition was a 9% increase in muscle mass in the dominant arm (P < 0.05).

Expiratory patterns during sleep in normal full-term and premature neonates

Airflow (V), tidal volume (TV), and EEG polygraphic recordings were performed in 30 normal full-term newborns (FTN) and in 10 premature newborns (PN). Besides the classical expiratory flow (CEF), a retarded expiratory flow (REF) was observed: a phase of slow flow ending with a sharp increase. REF was mostly encountered in quiet sleep (QS) in FTN. During REF, Te and Ttot became longer; Ti became shorter, with an increase in TV. In QS, sighs were more numerous in FTN with a high percentage of REF. Expiratory sudden short arrests of airflow (SSAA), less than or equal to 2 s, during expiration were more frequent in active sleep (AS) in FTN. REF may be due to some obstruction or to postinspiratory diaphragmatic activity; variations in functional capacity may also be involved.

Eastern Spanish experience with nivolumab in metastatic renal cell carcinoma

BACKGROUND (OR PURPOSE)

Nivolumab has been shown to be effective for the treatment of second-line mRCC. The present study has investigated the effectiveness and safety of nivolumab in real-world Eastern Spanish patients with advanced mRCC at TKI progression.

PATIENTS AND METHODS

A retrospective review of mRCC patients treated with nivolumab as a second-line treatment was performed. Analyzed variables included age, sex, ECOG (quality of life scale designed by the Eastern Cooperative Oncology Group), histology, nephrectomy, location of metastases, number of metastasis locations, previous treatments, analytical data from the standard blood count and biochemistry, and response to treatment.

RESULTS

98 patients from 18 sites in Spain were retrospectively reviewed. The majority of patients were male (75%), had ECOG 0-1 (90.6%), had no brain metastasis (91.4%), had undergone one prior systemic regimen (94.3%), and were current/former smokers (97.1%). Fourteen patients (13.1%) had non-clear cell histology, seven (7.1%) had poor-IMDC prognostic group characteristics, 13 patients (13.1%) had liver metastasis and 35 (35.7%) had bone lesions. All patients received prior systemic therapy (63.3% sunitinib, 34.7% pazopanib). During the study, a median of eight doses of nivolumab was given (range 2-62) and 11 patients received more than 12 doses. Eleven patients (11.2%) received nivolumab as a third or fourth line of treatment. Median duration of therapy was 3.6 months (range 0.5-29.3). Confirmed response rate was 25%. Median progression free survival was 7.8 months (range 1.2-12.1). Median overall survival was 16.3 months (range 1.7-29.3). After discontinuation of treatment, 27.58% of the patients received subsequent systemic cancer therapy. Side effects were mostly grade 1-2 (7.2% had hypothyroidism and 6.2% liver toxicity, 4% had nephritis and 2% hypophysitis). Two cases of grade 3-4 adverse events (2%) were reported.

CONCLUSION

Benefit/risk profile of nivolumab in Eastern-Spanish real-world population with mRCC after tyrosine-kinase inhibitors was consistent with prior real-life studies reported as well as pivotal study.

Night sleep heart rate patterns recorded by cardiopneumography at home in normal and at-risk for SIDS infants

It has been reported that infants at higher than normal epidemiological risk for the sudden infant death syndrome (SIDS) have abnormal cardiac autonomic activity. A prospective work was performed using cardiopneumographic recordings (CPG) in order to evaluate heart rate (HR) and heart rate variability (HRV) patterns in sleeping normal control infants (C) and in infants at-risk for SIDS in their normal environment at home. One hundred appropriate-for-gestational age full-term infants were studied: 28 C, 48 SIDS siblings (SS), and 24 near-miss for SIDS (NM) within the first 2 weeks following the first detected apparent life-threatening event. The three groups of infants were comparable with respect to gestational and conceptional ages, birthweights, sex distribution and socio-economic backgrounds. CPG were done over two successive nights. Records were visually analysed for sleep states (quiet: QS, and combined active + indeterminate sleep: AIS) and wakefulness (W) coding. Periods of W were not analysed. An automatic programme allowed us to study HR minute-by-minute, and to assess whether HR and HRV patterns were specific to a certain part of the night, records were divided into three periods (2200-0040 h, 0041-0320 h, and 0321-0600 h). In C and SS groups, the HR was significantly lower in the 2nd night-period than in the 1st and 3rd periods in both QS and AIS (P less than 0.05). In the NM group this difference was only observed during AIS (P less than 0.05). During the three night-periods the HR was significantly elevated in AIS as compared to QS (at least P less than 0.05) in all infant groups except the NM group during the 2nd night-period. During QS the HR was significantly higher in NM than in C and SS groups (P less than 0.02). During AIS the HR did not differ between infant groups. HRV was significantly lower in the NM group during QS in the three night-periods (P less than 0.05). There was no difference in the HR and HRV patterns between C and SS groups with respect to sleep states and night period. We concluded that following the first detected apparent life-threatening event differences in the HR and HRV patterns can be demonstrated when sleeping NM infants are compared with both C and SS infants especially during QS in different night periods studied by CPG at home.

Relationship between respiratory pauses and heart rate during sleep in normal premature and full-term newborns

To investigate the relationship between central respiratory pauses and heart rate, we performed polygraphic recordings in 23 normal newborns (35 to 41 weeks conceptional age). We monitored the electroencephalogram, rapid eye movements, movements of the upper and lower limbs, chin and diaphragmatic electromyogram, electrocardiogram, thoracic and abdominal respiratory movements, air flow and transcutaneous PO2. Heart rate changes were analysed by computer measurement of R-R intervals and by cardiotachography. Respiratory pauses occurring after body movements and those not preceded by movements were studied separately. We analysed 1128 respiratory pauses greater than 3 s duration. No respiratory pause lasted more than 12 s. Independently of age, sleep state and respiratory pause duration, heart rate was significantly lower at the onset of respiratory pause, compared to control periods (selected away from the pause: 10 s before its onset and 20 s after its end). Heart rate slowed still further through the respiratory pause and reverted toward the baseline level after its end. When no movements preceded the respiratory pause, heart rate just before the pause was lower compared to control periods. These findings suggest the existence of simultaneous central commands responsible for both respiratory pause and heart rate deceleration.

Beclin-1 and LC3B expression in canine mast cell tumours: an immuno-ultrastructural and immunohistochemical study of autophagy

Mast cell tumours (MCTs) are common malignant neoplasms in dogs, for which prognosis and therapeutic decisions are based on histological features and proliferation markers. Autophagy is a cellular catabolic process responsible for degrading cytoplasmic components to maintain homeostasis, alterations in which are frequently linked to tumour growth and progression. This study was conducted to investigate the occurrence of autophagy in canine MCTs and to verify its value as a prognostic indicator for dogs with the disease. Beclin-1 and LC3B expressions were investigated using immunohistochemistry, and autophagy was ultrastructurally characterised. The autophagic phenomenon was successfully visualised in neoplastic mast cells under transmission electron and immunoelectron microscopy. MCTs from dogs that died due to the disease showed higher positivity for Beclin-1 and dogs with MCTs presenting a LC3B granular immunohistochemical pattern had a significantly shorter post-surgical survival. The occurrence of autophagy is an indicator of poor prognosis. Future studies are needed to elucidate the specific mechanisms and open new opportunities to treatments targeting this cancer cell advantage.

Extinction of Vibrio cholerae in acidic substrata: contaminated fish marinated with lime juice (ceviche)

Millions of Vibrio cholerae O1 El Tor were rapidly eliminated when added to commercial ceviche prepared by marination of mahi-mahi fish in lime juice. Likewise, large masses of viable vibrios present in laboratory contaminated fish, were readily eliminated after immersion in lime juice, during the preparation of ceviche. The killing effect was evident within 5 min of exposure of vibrios to lime juice, with reductions of more than 99.9% of the initial bacterial mass. After 2 h of marination of fish with lime juice (the minimum recommended), no vibrios were detected in the lowest working dilutions (1:10, 1:100). The Vibrio mass eliminated by lime juice was 2 to 6 logarithms greater than the maximum infectious dose, and 4 to 8 logs greater than the minimum infectious dose to induce cholera El Tor. Also, the killing time was shorter than the elapsing time between preparing and serving food in homes or restaurants. The traditional marination of fish with lime juice or its addition to seafood and meals immediately before consumption, should be protected and promoted to prevent infection with cholera vibrios. In the face of an epidemic of cholera, consumption of ceviche prepared with lime juice would be one of the safest ways to avoid infection with V. cholerae.

Influence of chemotherapy for lymphoma in canine parvovirus DNA distribution and specific humoral immunity

In man, the combination of cancer and its treatment increases patients' susceptibility to opportunistic infections, due to immune system impairment. In veterinary medicine little information is available concerning this issue. In order to evaluate if a similar dysfunction is induced in small animals undergoing chemotherapy, we assessed the complete blood count, leukocytic, plasma and fecal canine parvovirus (CPV) viral load, and anti-CPV protective antibody titers, in dogs with lymphoma treated with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) protocol, before and during chemotherapy. There was no evidence of decreased immune response, either at admission or after two chemotherapy cycles, indicating that the previously established immunity against CPV was not significantly impaired, supporting the idea that immunosuppression as a result of hematopoietic neoplasms and their treatment in dogs requires further investigation and conclusions cannot be extrapolated from human literature.