Long-term low-dose macrolides for chronic rhinosinusitis in adults - a systematic review of the literature.

BACKGROUND: Chronic rhinosinusitis is a very common inflammatory disease that impairs quality of life and is associated with high healthcare spending. Chronic rhinosinusitis treatment commonly involves the use of intranasal corticosteroids, oral antibiotics, and surgery. Macrolides have been identified as a potential treatment option for chronic rhinosinusitis due to their immunomodulatory effects; however, the evidence supporting their use is still conflicting. OBJECTIVE: The purpose of this systematic review was to evaluate new evidence along with previously reported studies of the use of macrolides in the treatment of chronic rhinosinusitis. SEARCH STRATEGY: Medline, EMBASE, Cochrane CENTRAL, LILACS, clinicaltrials.gov, and the International Clinical Trials Registry Platform were all searched (until June 2015 Medline and EMBASE searches were updated January 2016). Randomised controlled trials comparing low-dose macrolide antibiotics versus placebo, as an adjunct to other therapies, or low-dose macrolide therapy alone versus other therapies were included in this review. EVALUATION METHOD: Quality of the evidence was evaluated using the Cochrane risk of bias tool. Continuous outcomes were expressed as mean differences or standardised mean differences with 95% confidence interval. Data were pooled using fixed-effects models. RESULTS: Nine randomised controlled trials met the inclusion criteria. Studies were classified into three distinct comparisons: Low-dose macrolide therapy vs. placebo, low-dose macrolide +/- nasal steroids vs. nasal steroid and low-dose macrolides vs. other therapies. The overall quality of the evidence is low due to limitations in study design, imprecision, and indirectness. CONCLUSIONS: Positive results were seen with the use of macrolide therapy in the postoperative period in patients with nasal polyps. A firm conclusion with respect to the effectiveness of the use of macrolides for the treatment of chronic rhinosinusitis cannot be reached based on the available evidence. Further study using a placebo-controlled design evaluating the use of macrolides in clearly defined chronic rhinosinusitis populations is needed.

A double-blind randomised controlled trial assessing the efficacy of topical lidocaine in extended flexible endoscopic nasal examinations.

OBJECTIVE: To test the hypothesis that using lidocaine nasal spray will result in improved pain and comfort outcomes during an extended flexible endoscopic nasal examination. DESIGN: A split-body, double-blind, placebo-controlled randomised trial. After receiving a rinse of oral mouthwash (Listerine(®)), patients were randomised to receive placebo in one nasal cavity and 30 mg of topical lidocaine in the other. SETTING: A tertiary care centre outpatient Otolaryngology clinic. PARTICIPANTS: Twenty-two patients who required an extended bilateral flexible endoscopic nasal examination. An extended nasal examination consisted of an examination of a minimum of two osteomeatal regions on each side of the nasal cavity. MAIN OUTCOME MEASURES: Discomfort and pain were assessed using a 100-mm Visual Analogue Scale (VAS). Our study utilised the definition of pain based on International Association for the Study of Pain. Pain was defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Discomfort was defined as the overall unpleasant experience of the procedure. This included all aspects of the examination such as the pain or other negative sensations associated with the examination, any side effects associated with the application of the nasal sprays as well as any anxiety associated with the examination. A Wilcoxon sign-rank test was used for the primary outcome measures. RESULTS: There was a significant reduction in discomfort scores on the treatment side of the nasal cavity compared with the control side (median VAS score of 18.6 mm versus 44.6 mm; P = 0.01). The change in pain between the treatment side compared with the control side did not reach our definition of statistical significance (5.1 mm versus 9.2 mm; P = 0.05). Patients with an active or uncontrolled inflammatory disorder of the nasal cavity experienced a significantly greater reduction in pain compared to those without an inflammatory condition (median change of the VAS score, -15.6 versus +1.0; P = 0.01). CONCLUSIONS: After a rinse with oral mouthwash, the use of lidocaine results in a significant reduction in the discomfort associated with an extended bilateral flexible endoscopic nasal examination. Patients undergoing such an examination would benefit from the application of lidocaine after masking the negative flavour using oral mouthwash.

Cost-effectiveness of a topically applied pre-operative tissue expansion device for radial forearm free flaps: a cohort study.

OBJECTIVES: The objective of this study is to test the hypothesis that using a non-invasive and inexpensive pre-operative tissue expansion device (DynaClose) for radial forearm free-flap donor sites will result in a significant reduction in the cost of both in-hospital and out-of-hospital wound care compared with that of unexpanded radial forearm free-flap donor sites. DESIGN: A cohort study consisting of patients previously randomised in a randomised controlled trial. An intention to treat design was utilised. SETTING: A large tertiary care centre in eastern Ontario, Canada. PATIENTS: Thirty-four patients presenting to Otolaryngology Head and Neck clinic were enroled. Of these patients, 29 were previously enroled in a randomised controlled trial, while an additional five patients were enroled and randomised for the purpose of this study. INTERVENTIONS: Patients were randomised to either the treatment (pre-operative tissue expansion, DynaClose Expansion System) or control group. MAIN OUTCOME MEASURES: Wound care costs (in US dollars) were calculated for all patients for both in-hospital care and for patients requiring home care. Non-parametric data analysis was utilised for statistical assessment. RESULTS: There was a 93% reduction in the use of split-thickness skin grafts in the treatment group. There was a significant reduction in total wound care cost for patients in the treatment group versus the control group (P < 0.0001). Patients in the treatment group required a mean (SD) total of $36.00 (23.50) per patient, while the control group required $277.00 (325.00) of wound care. After excluding the cost of home care, the treatment group continued to have a significant reduction in total and in-hospital wound care costs compared with the control group (P < 0.001). CONCLUSIONS: Using a simple, inexpensive and non-invasive method of pre-operative tissue expansion results in a significant reduction in the costs of wound care for both in-hospital and out-of-hospital treatment. The DynaClose dynamic skin expansion system results in a cost-effective method to reduce the need of a split-thickness skin graft for coverage of a radial forearm free-flap donor site.

ALS incidence in Nova Scotia over a 20-year-period: a prospective study.

OBJECTIVE: Previous studies have suggested that the incidence of amyotrophic lateral sclerosis (ALS) in Nova Scotia is relatively high and increasing over time. This study was performed to determine the current incidence of ALS in Nova Scotia and to compare this to data collected in 1984 and 1995. METHODS: All physiatrists and neurologists were surveyed on a monthly basis over one year to record all new cases of ALS diagnosed in Nova Scotia. Data was compared to that collected using similar methods in 1984 and 1995. To validate our methods, we also performed a retrospective study using a provincial health care database. RESULTS: There were 21 new ALS cases in Nova Scotia during the 2003 study period, yielding a crude incidence of 2.24/100,000. The age-adjusted incident rate for 2003 was 2.13 (95% CI = 0.11-4.15). The age-adjusted rate for 1995 was 2.3 (95% CI = 0.08-4.53) while the age-adjusted rate for 1984 was 2.22 (95% CI = 0.13-4.32). Analysis of provincial health records identified 24 cases of ALS and an age-adjusted incidence of 2.44/100,000. CONCLUSIONS: The age-adjusted incidence of ALS in Nova Scotia has remained stable over the period 1984-2003. The incidence is similar to that reported in several other parts of the world.

Proactive balance strategy while maintaining a stationary wheelie.

OBJECTIVE: To test the hypothesis that a reactive balance strategy is used while maintaining a stationary wheelie, specifically that a forward pitch from the wheelie equilibrium position is associated with a forward displacement of the wheelchair and a rear pitch with rear displacement, with the displacement slightly after the change in pitch. DESIGN: Descriptive and quantitative kinematic analysis. SETTING: Kinesiologic laboratory. PARTICIPANTS: A convenience sample of 10 able-bodied adults. INTERVENTION: Subjects taught to pop and maintain a stationary wheelie for 15 seconds while remaining within a .75 x .75 m2. Three trials of 5 seconds; digitized targets videotaped for analysis. MAIN OUTCOME MEASURES: Pitch angle and rear-wheel position of the wheelchair, derived from digitized videotape and time-series analysis of phase lag. RESULTS: There was an inverse relationship between the direction of pitch and linear displacement-rear pitch was associated with forward wheel displacement and forward pitch was associated with rearward wheel displacement. The mean pitch angle +/- standard deviation was 13.6 degrees +/- 2.3 degrees and the mean horizontal position of the wheelchair was 0.0 +/- 4.9cm. There was little or no phase lag between pitch and displacement. CONCLUSIONS: Wheelie performers maintaining a stationary wheelie appeared to use a proactive balance strategy, in which they used a functional base of support that was larger than the geometric one. These findings may have significance for those who are learning and teaching wheelies and provide broader insights into the nature of dynamic balance.