The Efficacy of Budesonide as Intrapolyp Injection Agent in the Management of Type 2 CRSwNP

OBJECTIVES

To assess the efficacy and safety of budesonide as an intrapolyp injection in chronic rhinosinusitis with nasal polyps (CRSwNP) in comparison to control and systemic steroids.

METHOD

In a prospective double-blinded controlled randomized clinical trial, 150 patients with CRSwNP were divided into 3 groups in a ratio 1:1:1 where group (A) was given oral prednisolone 1 mg/kg tapered daily for 2 weeks, group (B) was given budesonide intrapolyp injection weekly for 5 consecutive weeks, and group (C) was given intrapolyp injection with saline as the control group. Patients were assessed upon Sinonasal Outcome Test (SNOT-22) score, Total Nasal Polyp score (TNPS), Serum IgE, absolute eosinophilic count, and morning cortisol level before treatment, 1 week and 6 months after completing their treatment protocol.

RESULTS

SNOT 22 score improved significantly in all groups compared to those at baseline. Reduction in the oral and injection groups was much greater than the control group (P2 < 0.001), (P3 < 0.001), and the same trend concerning TNPS score (P2 < 0.001), (P3 < 0.001) but with no significant change in the control group.

CONCLUSION

Intrapolyp steroid injection is considered a safe and effective method in nasal polyposis with limited side effects in comparison to systemic steroids. Using Budesonide as an agent for intrapolyp injection appears to be promising. It's advisable in patients with multiple relapses or high-risk patients to avoid repeated courses of oral steroids.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:2085-2092, 2024.

Effect of Oral Prednisone on the Prevention and Management of Proliferative Vitreoretinopathy After Open-Globe Injury

Purpose: To determine the impact of oral prednisone on the final visual acuity (VA) and prevention of proliferative vitreoretinopathy (PVR) in patients having pars plana vitrectomy (PPV) for globe injuries. Methods: A retrospective chart review was performed of all globe injuries with an initial repair and subsequent PPV between 2009 and 2018. Data included the initial VA, zones of injury, initial closure date, time to secondary intervention (PPV), oral prednisone (1 mg/kg/day) use, the final VA, and enucleation rate. Multivariable regression models were used to assess the impact of oral prednisone use on anatomic and functional outcomes. Results: The mean (±SD) patient age was 46.25 ±18.56 years (range, 13-92); 131 (83.9%) were men. Oral prednisone intake was recorded in 81 patients (52.3%). The prednisone group had significantly more zone 3 involvement (P = .001), worse initial VA (2.28 vs 1.92 logMAR; P = .003), and a greater mean number of surgeries (P = .020) than the no-steroids (control) group but an equivalent final logMAR VA (1.57 vs 1.52; P = .881). The prednisone group had significant VA improvement (P = .025); however, oral prednisone use did not predict the development of PVR (29.23% vs 12.90%; odds ratio [OR], 2.81; 95% CI, 0.89-8.85) or retinal detachment (27.27% vs 29.58%; OR, 0.59; 95% CI, 0.23-1.56). Conclusions: Despite a worse initial clinical presentation, patients who received oral prednisone had significant visual improvement compared with the control group. However, oral prednisone (1 mg/kg/day) use at the time of injury did not decrease the PVR rate.

Recovery of Breakthrough Asthma Attacks Treated With Oral Steroids While on Monoclonal Antibody Therapy: Protocol for a Prospective Observational Study (BOOST)

BACKGROUND

Asthma attacks are a common and important problem. Someone experiences an asthma attack in the United Kingdom every 10 seconds. Asthma attacks cause coughing, wheezing, breathlessness, and chest tightness and are highly stressful for patients. They result in reduced quality of life, with days lost from work or school. Asthma attacks are treated with oral corticosteroids (OCSs), but these have many short- and long-term side effects. Asthma monoclonal antibodies (mAbs) have revolutionized the treatment of severe asthma by reducing asthma attacks and OCS burden by over 50%, but some people still experience attacks while on mAbs. The MEX study showed that residual asthma attacks are broadly eosinophilic (high fractional exhaled nitric oxide [FeNO]) or noneosinophilic (low FeNO), but it did not measure response to OCS treatment. There is an evidence gap in understanding the clinical and inflammatory responses that occur when using OCSs to treat residual asthma attacks in patients taking asthma mAbs.

OBJECTIVE

The primary objective is to compare the clinical recovery between high-FeNO and low-FeNO attacks after acute treatment with oral prednisolone among people established on long-term asthma mAb treatment. The exploratory objective is to compare the inflammatory response to acute treatment with oral prednisolone between high-FeNO and low-FeNO attacks.

METHODS

BOOST (Breakthrough Asthma Attacks Treated With Oral Steroids) is a single-center, prospective observational study of 60 adults established on long-term asthma mAb treatment who receive acute treatment with oral prednisolone (usual care) for an asthma attack. The primary outcome will be the proportion of treatment failure (the need to start oral prednisolone or antibiotics or an unscheduled health care visit for asthma, following an attack) at day 28. The secondary outcomes will be the change in forced expiratory volume in 1 second and the change in visual analogue scale symptom score between the stable state, attack, day 7, and day 28 visits. The exploratory outcomes include the changes in sputum, nasal, and blood inflammometry between the stable state, attack, day 7, and day 28 visits.

RESULTS

The last asthma attack visit is anticipated to occur in December 2023. Data analysis and publication will take place in 2024.

CONCLUSIONS

We will test the hypothesis that there is a difference in the rate of recovery of clinical and inflammatory measures between high-FeNO and low-FeNO asthma attacks that occur in patients on mAb therapy. The study data will help power a future randomized placebo-controlled trial of prednisolone treatment for nonsevere attacks in patients treated with asthma mAbs and will provide important information on whether corticosteroid treatment should be FeNO-directed.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46741.

Combining intralesional steroid injection with oral steroids in patients with idiopathic granulomatous mastitis

Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory breast disease. Currently, there is no international standard for steroid use in IGM, particularly for intralesional steroid injections. This study aimed to determine whether patients with IGM who received oral steroids could benefit from intralesional steroid injection. We analyzed 62 patients with IGM whose main clinical presentation was mastitis masses and who received preoperative steroid therapy. Group A (n = 34) received combined steroid treatment: oral steroids (starting dose, 0.25 mg/kg/d; tapered off) and intralesional steroid injection (20 mg per session). Group B (n = 28) received oral steroids only (starting dose, 0.5 mg/kg/d; tapered off). Both groups underwent lumpectomy at the end of steroid treatment. We analyzed the preoperative treatment time, preoperative mass maximum diameter reduction rate, side effects, postoperative satisfaction, and rate of IGM recurrence. The mean age of the 62 participants was 33.6 ± 2.3 (range, 26-46) years, and all had unilateral disease. We found that oral steroids combined with intralesional steroid injection yielded better therapeutic effects than did oral steroids alone. The median maximum diameter reduction of the breast mass was 52.06% in group A and 30.00% in group B (P = .002). Moreover, the use of intralesional steroids reduced the duration of oral steroid use; the median durations of preoperative steroid therapy were 4 and 7 weeks in groups A and B, respectively (P < .001). Group A patients were more satisfied (P = .035) with the postoperative results, including postoperative appearance and function. No statistically significant between-group differences were noted regarding side effects and recurrence rates. Preoperative administration of oral steroids combined with intralesional steroid injection yielded better therapeutic effects than did oral steroids alone and may be an effective future treatment for IGM.

Comparison of the Oral Steroids, Macrolides and Combination Therapy in Nasal Polyposis Patients

Objectives

In this study, our aim was to compare oral steroid therapy with macrolide therapy and with oral steroid + macrolide (combine) therapy in patients with nasal polyposis (NP).

Methods

All patients were treated with nasal steroid therapy for eight weeks and divided randomly into three groups as follows: Oral steroid group, oral macrolide group and combine group. All patients underwent endoscopic staging, radiological grading, odour testing and completed the sino-nasal outcome test-22 (SNOT-22) questionnaire before and after treatment.

Results

Significant improvement was observed in all parameters after treatment in all three groups. All parameters were significantly better in the combined group than in the macrolide group. Comparison of the oral steroid group and macrolide group revealed significantly better radiological grading and odour test changes for the oral steroid group, but no statistically significant differences existed according to endoscopic staging and SNOT-22. The post-treatment SNOT-22 score was significantly better in the combined group than in the steroid group. A comparison of the combined and steroid groups showed better results for the combined group for all parameters, but the differences were not significant.

Conclusion

All treatment protocols were effective and the successful use of macrolide indicates its potential as an alternative in patients with contraindications to oral steroid treatment. The combined treatment may demonstrate significantly better results than steroid treatment alone if larger studies with more patients are performed.

Effectiveness and safety of dupilumab for the treatment of severe asthma in a real-life French multi-centre adult cohort

BACKGROUND

Dupilumab is a monoclonal anti-IL-4Rα antibody developed for the treatment of severe asthma (SA). An early access programme for dupilumab was opened in France in SA patients experiencing unacceptable steroids side-effects and/or life-threatening exacerbations.

OBJECTIVE

To assess changes in asthma control between baseline and 12 months of treatment.

METHODS

Multi-centre (n = 13) retrospective real-life cohort study. This study is registered on ClinicalTrials.gov (NCT04022447).

RESULTS

Overall, 64 patients with SA (median age 51, interquartile range [44-61]; 53% females) received dupilumab as add-on therapy to maximal standard of care; and 76% were on oral daily steroids at baseline. After 12 months, median asthma control test score improved from 14 [7-16] to 22 [17-24] (P < .001); median forced expiratory volume in 1 seconds increased from 58% [47-75] to 68% [58-88] (P = .001); and daily prednisone dose was reduced from 20 [10-30] to 5 [0-7] mg/d (P < .001). Annual exacerbations decreased from 4 [2-7] to 1 [0-2] (P < .001). Hypereosinophilia ≥1500/mm³ was observed at least once during follow-up in 16 patients (25%), persisting after 6 months in 8 (14%) of them. Increase in blood eosinophil count did not modify the clinical response during the study period. Injection-site reaction was the most common side effect (14%). Three deaths were observed, none related to treatment by investigators.

CONCLUSION & CLINICAL RELEVANCE

In this first real-life cohort study of predominantly steroid-dependent SA, dupilumab significantly improved asthma control and lung function and reduced oral steroids use and exacerbations rate. Despite limitations due to the retrospective study, these results are consistent with controlled trials efficacy data. Further studies are required to assess the clinical significance and long-term prognosis of sustained dupilumab-induced hypereosinophilia.

Sudden sensorineural hearing loss with end-stage renal disease: a report of 32 cases

Background: Patients with end-stage renal disease (ESRD) have a higher risk of suffering sudden sensorineural hearing loss (SSNHL), but little is known about this population. Aims and objectives: To investigate the clinical characteristics, treatment and recovery of SSNHL patients with ESRD. Materials and methods: Records of 32 SSNHL patients with ESRD were reviewed, including clinical characteristics and hearing recovery. Patients were divided into intratympanic steroid (ITS) group and oral steroid (OS) group, and hearing recovery was compared between two groups. Results: Twenty-six patients (81.3%) exhibited tinnitus, and 18 patients (56.3%) suffered vertigo. Mean pure-tone threshold at the initial presentation was 73.2 ± 19.4 dB, and the audiogram configuration was ascending in 9.4%, descending in 9.4%, flat in 34.4% and profound in 46.9% cases. At 3-month follow-up, percentages of patients in complete recovery, partial recovery, slight recovery, and no improvement were 18.8%, 31.3%, 21.9% and 28.1%, respectively. Furthermore, the overall recovery rate, complete recovery rate and hearing improvement were significantly higher in the ITS group than those in the OS group. Conclusion: SSNHL patient with ESRD often suffered a severe hearing loss with a high rate of accompanying tinnitus and vertigo. ITS may provide better audiological results for SSNHL with ESRD than OS.

Comparison of the Treatment Outcome of Oral Tofacitinib with Other Conventional Therapies in Refractory Alopecia Totalis and Universalis: A Retrospective Study

Treatment of alopecia totalis and alopecia universalis is often challenging and unsatisfactory. Recently, Janus kinase inhibitor has shown promising results. The aim of this study is to compare the efficacy and tolerability of oral tofacitinib and conventional modalities for treating refractory alopecia totalis/universalis. A total of 74 patients (18 treated with tofacitinib, 26 treated with conventional oral treatment (steroid ± cyclosporine), and 30 treated with diphenylcyclopropenone) were included in the study. The patients' medical records were reviewed retrospectively. After 6 months, 44.4% of patients in the tofacitinib group, 37.5% in the conventional oral treatment group, and 11.1% in the diphenylcyclopropenone group achieved 50% improvements in the Severity of Alopecia Tool score. During treatment, 10% of patients in the tofacitinib group, 73.1% in the conventional oral treatment group, and 10% in the diphenylcyclopropenone group experienced adverse drug reactions. In conclusion, oral tofacitinib was more effective than diphenylcyclopropenone immunotherapy and more tolerable than conventional oral treatment after 6 months of treatment.

Shared decision making and time to exacerbation in children with asthma

Objective: Although shared decision making (SDM) is a promising approach for improving outcomes for patients with chronic diseases, no evidence currently supports the use of SDM to delay asthma exacerbations. We evaluated the impact of an SDM intervention implemented by providers in a real-world setting on time to exacerbation in children with asthma. Methods: This study used a prospective cohort observed between 2011 and 2013 at five primary care practices that serve vulnerable populations (e.g., Medicaid and uninsured patients) in Charlotte, NC. Patients aged 2 to 17 receiving SDM were matched to those receiving usual care using propensity scores. Time to asthma exacerbation (asthma hospitalization, emergency department visit or oral steroid prescription in the outpatient setting) was compared between groups using Kaplan-Meier curves and conditional Cox proportional hazards models. Results: The cohort included 746 children, 60.5% male and 54.2% African American, with a mean age of 8.6 years. Of these, 625 received usual care and 121 received SDM. The final analysis included 100 matched pairs of children. Kaplan-Meier curves showed longer exacerbation-free time for patients in the SDM intervention compared to those in usual care (p = 0.005). The difference in risk of experiencing an exacerbation was marginally significant between the two groups (HR = 0.56, 95% C.I. = 0.29-1.08, p = 0.08). Conclusions: SDM was found to delay exacerbations among children with asthma. Clinicians should consider incorporating patient preferences in treatment decisions through SDM as a means for longer exacerbation-free time among children with poor asthma control.

Results from a pragmatic prospective cohort study: Shared decision making improves outcomes for children with asthma

OBJECTIVE

Patient/provider shared decision making (SDM) improves asthma control in a pragmatic clinical trial setting. This study evaluated the impact of an evidence-based SDM toolkit on outcomes for patients with asthma implemented by providers in a real world setting. We hypothesized that these patients with asthma would demonstrate improved outcomes such as reduced emergency department (ED) visits, hospitalizations, and oral steroid use in the 12 months following a SDM visit compared to those who did not receive the intervention.

METHODS

Patients with asthma were identified within six primary care practices that serve vulnerable populations in Charlotte, NC (746 children; 718 adult patients). Propensity scores were used to match 200 children and 206 adults for analysis. The primary outcome variable was asthma exacerbation defined as an ED visit or hospitalization for asthma or outpatient prescription of an oral steroid. Patients were monitored at 3, 6, and 12 months after the intervention date. The outcome variables of ED visits, hospitalizations, and oral steroids were compared between intervention and matched control patients.

RESULTS

The proportion of pediatric patients with one or more exacerbations was significantly lower in the SDM intervention group compared to controls during 12 months after exposure to the intervention (33% vs. 47%, p = 0.023). For adults, there was not a strong association between use of the SDM intervention and outcomes improvement.

CONCLUSIONS

The evidence-based SDM intervention implemented in this study was associated with improved asthma outcomes for pediatric patients but not adult patients in a real world clinical setting.

A case of ocular toxocariasis successfully treated with albendazole and triamcinolon

We present a case of ocular toxocariasis treated successfully with oral albendazole in combination with steroids. A 26-year-old male visited the authors' clinic with the chief complaint of flying flies in his right eye. The fundus photograph showed a whitish epiretinal scar, and the fluorescein angiography revealed a hypofluorescein lesion of the scar and late leakage at the margin. An elevated retinal surface and posterior acoustic shadowing of the scar were observed in the optical coherence tomography, and Toxocara IgG was positive. The patient was diagnosed with toxocariasis, and the condition was treated with albendazole (400 mg twice a day) for a month and oral triamcinolone (16 mg for 2 weeks, once a day, and then 8 mg for 1 week, once a day) from day 13 of the albendazole treatment. The lesions decreased after the treatment. Based on this study, oral albendazole combined with steroids can be a simple and effective regimen for treating ocular toxocariasis.

Examining the relationship between depression and asthma exacerbations in a prospective follow-up study

BACKGROUND

Although depression has been linked with asthma, its relationship with asthma exacerbations, including emergency department (ED) visits and oral steroid (OS) use, has not been well documented. The aim is to investigate whether depression increases exacerbations among patients with asthma.

METHOD

The study included 568 participants with asthma who were between 18 and 56 years old, were taking an inhaled corticosteroid, and participated in baseline and follow-up surveys. Surveys and medical records from a large, health system were collected as part of the Adherence Feedback for Improving Respiratory Medication Use trial. Number of ED visits and OS prescription fills for asthma were calculated for 12-month periods before and after the follow-up survey. Depression was measured using a standardized two-item instrument. Negative binomial regression and modified proportional hazards models were used.

RESULTS

Among patients with asthma, those who had depression (n = 187; 32.9%) were at increased risk for an asthma-related ED visit (adjusted relative risk = 1.96, 95% confidence interval [CI] = 1.02-3.75), but not an OS fill (adjusted relative risk = 0.98; 95% CI = 0.72-1.32). Participants with depression and asthma who received psychiatric treatment via antidepressant medication (n = 126; 22.2%) or psychotherapy (n = 39; 6.9%) were more likely to have an ED visit (medication hazard ratio = 2.09, 95% CI = 1.35-3.25; psychotherapy hazard ratio = 2.07, 95% CI = 1.38-3.22).

CONCLUSIONS

This study suggests a temporal relationship between depression and asthma-related ED visits. Research and practice must consider the importance of these comorbid conditions. Trial Registration ClinicalTrials.gov identifier: NCT00459368.