International Forum of Allergy & Rhinology最新文献

Objective

To assess the effect of allergen immunotherapy (AIT) on patients with central compartment atopic disease (CCAD) and house dust mite (HDM) sensitization post-surgery.

Methods

A retrospective cohort of surgically treated, HDM-sensitized CRSwNP patients phenotyped as CCAD was assessed. Patients were divided into two groups based on whether they had AIT commenced as part of their surgical care. All AIT patients started immunotherapy prior to their surgery. The primary endpoint was reformation of middle turbinate (MT) edema 12 months postsurgery. Secondary endpoints were corticosteroid irrigation use (<4 times/week vs. ≥4 times/week, %) and the rhinologic domain of the 22-item sino-nasal outcome test (SNOT-22). Demographic characteristics, concomitant asthma, smoking status, history of aspirin-exacerbated respiratory disease, conjunctival symptoms, polysensitization, serum eosinophils (cell × 10⁹/L), tissue eosinophilia (% > 100/HPF), and serum IgE (kU/L) were also recorded.

Results

Eighty-six CCAD patients were assessed (41 ± 14 yrs, 64% female). AIT was applied in 37% (n = 32). Baseline features were similar apart from greater conjunctival symptoms (72 vs. 45%, p = 0.02) in the AIT group. At 12 months post-surgery, the AIT group has less MT edema (% ≥ diffuse 15.6 vs. 52.9, p < 0.01). Patients on AIT also had less pharmacotherapy requirements at 12 months (% ≥ 4/week, 37.5 vs. 79.6%, p < 0.01). The rhinologic symptoms were similar (21.1 ± 17.1 vs. 20.1 ± 21.6, p = 0.83).

Conclusions

Surgery and pharmacotherapy are effective in managing CCAD, but the addition of AIT improved allergic phenomenon and allowed de-escalation of topical therapy. Longer term studies are required to demonstrate further immunomodulation.

Background

Functional endoscopic sinus surgery (FESS) is one of the most commonly performed otolaryngologic procedures and is associated with significant cost variability.

Methods

We performed a retrospective analysis of all inflammatory sinus surgeries at a single tertiary care medical center from July 2021 to July 2023. The electronic medical record was reviewed for patient factors and cost variables for each procedure, and multivariable analysis was performed.

Results

A total of 221 patients were included in analysis with a mean age of 48.2 years. There was a 44.8% incidence (n = 99) of nasal polyps and 31.2% (n = 69) of cases were revision surgeries. The average total cost for the surgical encounter was $8960.31 (standard deviation $1967.97). Operating room time represented $4912.46 (54.8% of all costs), while average operating room supply costs were $1296.06 (14.5%) and recovery room costs were $919.48 (10.3%). Total costs were significantly associated with length of surgery ($7.83/min, p = 0.04), in addition to presence of nasal polyps ($531.96, p = 0.04). There was no significant association between total costs and the remaining clinical and demographic factors.

Conclusions

Costs associated with ambulatory FESS for inflammatory sinus disease vary across patients and this cost variability is predominantly driven by time efficiency within the operating room, as well as supply utilization and nasal polyposis to a lesser degree. As a result, operating room efficiency represents a primary target for cost-related interventions. Additionally, our data provide a framework for surgeons and hospitals to make evidence-based decisions on intraoperative equipment in a tradeoff between efficiency and supply costs. Our findings indicate that an approach focused on streamlining efficiency across the entire ambulatory surgery encounter will have the greatest impact on reducing healthcare expenses for both the patient and the health system.

Key points

Background

The management of acute exacerbations of chronic rhinosinusitis (AECRS) is understudied and the most cost-effective management of AECRS has not been previously investigated. The aim of this study is to determine the most cost-effective strategy for the initial management of AECRS.

Methods

The study design consisted of a decision-tree economic model comparing three different initial strategies for managing a patient perceived AECRS: observation, upfront rescue medications, or clinic visit with diagnostic nasal endoscopy (DNE). The primary study outcome was the disease burden of a single AECRS, which was determined by the health utility value and the duration of symptoms. Strategies with an incremental cost-effectiveness ratio < $50,000/quality-adjusted life year (QALY) or equivalently < $137/quality-adjusted life day (QALD) were considered cost-effective.

Results

Observation was the most cost-effective strategy at a willingness to pay of $137 per QALD. One-way sensitivity analysis demonstrated that observation was more effective than upfront rescue medications when the probability of bacterial infection as the cause of AECRS was <24.0%. Upfront rescue medications wer more cost effective than observation when the probability of bacterial infection exceeded 49.0%. Clinic visit with DNE was the most effective strategy to manage an AECRS, but it was not considered cost-effective.

Conclusion

Observation is the most cost-effective strategy for the initial management of AECRS when there is a low likelihood of bacterial infection. When the probability of bacterial etiology of AECRS exceeds 49.0%, upfront rescue medications proved to be the most cost-effective strategy.

Key points

Background

Biologic therapies approved for treating chronic rhinosinusitis with nasal polyps (CRSwNP) have well-established safety profiles but reports of rheumatic adverse events (AEs) are increasing and not well defined. This review aims to assess the risk and incidence of rheumatic AEs associated with biologic therapy in CRSwNP and summarize current reported management strategies.

Methods

A protocol was registered in PROSPERO [CRD42024525663]. A search was conducted in four electronic databases: Medline (Ovid), Embase, Scopus, and Cochrane CENTRAL from inception until January 4, 2024. Two reviewers independently screened citations and extracted data. Methodological quality was assessed using the Joanna Briggs Institute's critical appraisal tool. Data were pooled using a random effects model to calculate overall incidence and relative risk.

Results

Twenty-one studies met the final inclusion criteria, totaling 3434 patients of which 2763 (80%) received either dupilumab (n = 2257; 82%), mepolizumab (n = 372; 13%), or omalizumab (n = 134; 5%) for treatment of CRSwNP. The overall incidence rate for any on-treatment rheumatic AE was 0.05 per person–year (95% CI, 0.03–0.09, I² = 75%). Biologic therapy increased the risk of developing a rheumatic AE (RR = 2.53; 95% CI, 1.29–4.94) compared with placebo. The most frequently reported rheumatic AE was arthralgia or joint pain (n = 94; 95%), followed by lupus-like syndrome or lupus erythematosus-like reaction (n = 2; 2.5%). Discontinuation of treatment was the most common intervention (n = 21, 39%).

Conclusion

Biologic therapy increases the risk of rheumatic AEs in CRSwNP patients by over twofold. Healthcare providers should remain vigilant in monitoring rheumatic AEs and apply appropriate management strategies on a case-by-case basis.

Background

Practical biomarkers for endotypic characterization of chronic rhinosinusitis (CRS) remain elusive, hindering clinical utility. Eosinophil peroxidase (EPX) is an enzyme released by activated eosinophils. The objective of this study was to evaluate a clinic EPX assay as a marker of eosinophilic CRS.

Methods

Subjects with and without CRS presenting to a tertiary care rhinology clinic were prospectively enrolled, and nasal cytology brushings were collected from the middle meatus during in-clinic nasal endoscopy. ELISA assay was used to quantify EPX levels, and a customized multiplex immunoassay was used to quantify inflammatory cytokine mediators. Findings were correlated with clinical data.

Results

Forty-two subjects were enrolled, including 31 CRS subjects and 11 controls. Median EPX levels were 125.0 ng/mL (standard deviation [SD] 1745.8) and 6.5 ng/mL (SD 99.0) for CRS group and controls, respectively (p = 0.003). EPX levels were associated with history of asthma (p = 0.015), allergies (p = 0.028), polyps (p = 0.0006), smell loss (p = 0.006), and systemic eosinophilia or elevated immunoglobulin E (p ≤ 0.0001). Twenty-eight subjects from both the CRS and control groups had prior pathology for comparison, with histologic confirmation of local tissue eosinophilia (>10 eosinophils/hpf) in 11 subjects. This subgroup had a median EPX level of 967.5 ng/mL compared to 10.6 ng/mL in 17 subjects without local tissue eosinophilia (p = 0.0008). EPX levels were positively correlated to interleukin-5 levels (p = 0.0005).

Conclusion

EPX levels can be measured via well-tolerated in-clinic collection of nasal mucus. EPX levels are associated with clinical markers of type 2 inflammation and tissue eosinophilia and may provide a valuable diagnostic tool to delineate eosinophilic CRS.

Background

Overall symptom severity (OSS) and patient-reported chronic rhinosinusitis (CRS) control are global measures of CRS identified as consensus, essential criteria for CRS disease control assessment. We sought to determine the functional relationship between these two metrics.

Methods

Using an international multicenter mixed-methods design, 260 CRS patients were recruited. OSS score was measured using a visual analog scale. Patient-reported CRS control was measured as “controlled,” “partly controlled,” and “uncontrolled.” Twelve participants underwent semi-structured interviews to discuss OSS and patient-reported CRS control.

Results

The majority of interviewed participants felt OSS and patient-reported CRS control measured different constructs—while OSS only measured symptoms, patient-reported CRS control was more global, including not only symptom severity but also concepts such as medication usage, activity impairment, and exacerbations. Nevertheless, OSS score was strongly correlated with (ρ = 0.67, p < 0.001) and highly predictive of patient-reported CRS control. OSS score of >4 (95% confidence interval [CI]: 1.8–4.2) had 74.7% sensitivity and 93.2% specificity in identifying patients reporting their CRS as not controlled. OSS score of >6.6 (95% CI: 4.1–7.1) had 77.0% sensitivity and 75.9% specificity in identifying patients reporting their CRS as uncontrolled. The 22-item Sinonasal Outcome Test score was also predictive of patient-reported CRS disease control but OSS was significantly more predictive.

Conclusions

Patients conceptually view patient-reported CRS control as a more global measure that subsumes OSS. Quantitatively, however, OSS is highly correlated with patient-reported CRS control, possibly reflecting their redundancy. For ease of use, we recommend patient-reported CRS control be reflected by OSS <4 for controlled, 4 ≤ OSS < 7 for partly controlled, and OSS ≥7 for uncontrolled CRS.