Latent class analysis of structured histopathology in prognosticating surgical outcomes of chronic rhinosinusitis with nasal polyps in Singapore.

BACKGROUND: Structured histopathology profiling is recommended when reporting chronic rhinosinusitis with nasal polyp (CRSwNP) tissue. The objective of this study is to identify features in structured histopathology that predict outcome after functional endoscopic sinus surgery (FESS) in a cohort of CRSwNP patients from Singapore. METHODS: Latent class analysis was performed on structured histopathology reports of 126 CRSwNP patients who had undergone FESS. Outcome measures were polyp recurrence, need for systemic corticosteroids, revision surgery or biologics, and disease control at 2 years post-FESS. RESULTS: Three classes were identified. Class 1 was characterised by mild, predominantly lymphoplasmacytic inflammation. Class 2 comprised of 100 eosinophils/HPF, hyperplastic seromucinous glands, mucosal ulceration and mucin containing eosinophil aggregates and Charcot-Leyden crystals. Classes 2 and 3 were significantly associated with uncontrolled disease at 2 years post-FESS. Class 3 was additionally associated with the need for systemic corticosteroids. CONCLUSIONS: Eosinophil count, degree of inflammation, predominant inflammatory type, hyperplastic seromucinous glands, mucosal ulceration and mucin containing eosinophil aggregates and Charcot-Leyden crystals predicted need for systemic corticosteroids and uncontrolled disease at 2 years post-FESS. The presence of >100 eosinophils/HPF should be reported, as this subset of tissue eosinophilia was associated with less favourable outcomes after FESS.

Increase of poorly proliferated p63+ /Ki67+ basal cells forming multiple layers in the aberrant remodeled epithelium in nasal polyps.

BACKGROUND: Aberrant epithelial remodeling with the ectopic expression of p63 (basal cell markers) is an important pathologic phenomenon seen in chronically inflamed airway epithelium such as in nasal polyps (NPs). METHODS: Biopsies were obtained from 55 NP patients and 18 healthy controls (inferior turbinate). Among NP patients, 15 were treated with oral and nasal steroids, so that two sets of NP biopsies were taken before and after the treatments. p63, Ki67, type IV ß-tubulin, and cell cycle markers were investigated in these specimens. RESULTS: The number of p63+ cells is significantly higher in both hyperplastic (1.53-fold, P < 0.0001) and squamous metaplastic (2.02-fold, P < 0.0001) epithelium from NPs than from healthy controls. There are three types of proliferative basal cells (p63+ /Ki67+ ) which are in different phases of the cell cycle, such as G1 phase (type I cells), S to G2 phase (type II cells), and mitosis (type III cells). Of importance, some type I cells may arrest after proliferation although they may still be p63+ /Ki67+ . In healthy epithelium, the ratio of the type I and II cells is almost 50:50. However, less type II cells are found in hyperplastic epithelium (34.85%, P = 0.012) and in squamous metaplastic epithelium (30.77%, P = 0.02) together with the presence of type III cells (3.45%, P = 0.01). These findings were not changed after steroid treatments. CONCLUSIONS: An increase of poorly proliferated basal cells forming multiple layers, which may stain for basal cell markers but does not form a proper epidermal barrier, is an important histopathologic phenomenon in aberrant remodeled epithelium of NPs.

Sublingual immunotherapy in patients with house dust mite allergic rhinitis: prospective study of clinical outcomes over a two-year period.

BACKGROUND: Sublingual immunotherapy in patients with allergic rhinitis sensitised to house dust mites is safe, but its efficacy is controversial and sublingual immunotherapy with Blomia tropicalis has not yet been studied. This study sought to evaluate the efficacy of sublingual immunotherapy with house dust mite extract in children and adults with house dust mite allergic rhinitis over a period of two years. METHODS: A prospective observational study was conducted of children and adults diagnosed with house dust mite allergic rhinitis who were treated with sublingual immunotherapy from 2008 to 2012. Total Nasal Symptom Scores, Mini Rhinoconjunctivitis Quality of Life scores and medication usage scores were assessed prospectively. RESULTS: Thirty-nine patients, comprising 24 children and 15 adults, were studied. Total Nasal Symptom Scores and Mini Rhinoconjunctivitis Quality of Life scores dropped significantly at three months into therapy, and continued to improve. Medication usage scores improved at one year into immunotherapy. CONCLUSION: Sublingual immunotherapy with house dust mite extracts, including B tropicalis, is efficacious as a treatment for patients with house dust mite allergic rhinitis.

Ministry of Health clinical practice guidelines: Management of Rhinosinusitis and Allergic Rhinitis.

The Ministry of Health publishes national clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the Ministry of Health clinical practice guidelines on Management of Rhinosinusitis and Allergic Rhinitis, for the information of readers of the Singapore Medical Journal. Chapters, page and figure numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=24046). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

A clinical survey on compliance in the treatment of rhinitis using nasal steroids.

BACKGROUND: In the treatment of persistent rhinitis, the observed efficacy with intranasal steroids in clinical practice often falls short of that reported in clinical trials. We postulate that this could be due to patient non-compliance and thus designed this study to evaluate the impact of patient compliance on the efficacy of treatment in patients with persistent rhinitis. METHODS: Sixty-three consecutive adult patients with allergic and non-allergic rhinitis, treated with intranasal triamcinolone acetonate, were included in the study. Compliance was determined both by direct questioning and by measuring the weight of medication consumed (WMC) after 30 days of therapy. Nasal symptom scores were used to determine treatment efficacy. RESULTS: Forty-nine patients (77.8%) reported a forgetfulness of using medication for a few times (1-5 times) during the treatment period. Less than 50% compliance was reported by one patient (1.6%) but detected in seven patients (11%) by WMC. There was a significant (P < 0.001) improvement in mean total symptom score before (7.45 +/- 1.99) and after (3.59 +/- 2.72) treatment in patients with WMC of at least 50%, but not when WMC was <50% (8.43 +/- 1.72 vs 6.29 +/- 2.43; P = 0.114). With >50% WMC, the positive predictive values for relief of each symptom were rhinorrhoea: 78%, nasal itch: 70%, nasal obstruction: 67% and sneezing: 65%. CONCLUSION: Patients compliance has a significant impact on treatment efficacy with intranasal steroids. There is a discrepancy between reported and actual compliance. It is thus important to establish the actual compliance when evaluating patients who fail to respond to therapy.

Rhinosporidiosis: an unusual cause of nasal masses gains prominence.

INTRODUCTION: Rhinosporidiosis is a rare cause of nasal masses locally, with only two cases reported over a 35-year period. METHODS: Four patients with rhinosporidiosis, all from the Indian subcontinent, were managed at our tertiary referral centre over a recent five-year period. They presented with nasal masses and the diagnosis was confirmed by histological examination. RESULTS: All patients were treated by local excision of the nasal masses, and two also received dapsone therapy after surgery. During follow-up, local recurrence was found in two patients, one of whom had received dapsone. CONCLUSION: With a significant number of foreign workers from endemic regions, this uncommon disease may be observed more frequently in the future. It is thus important to consider the diagnosis of rhinosporidiosis in patients from endemic regions presenting with nasal masses. The mainstay of treatment should be wide surgical excision.

Pseudocyst of the auricle.

OBJECTIVE: To study the epidemiological profile of patients with pseudocyst of the auricle and to review the effectiveness of surgical excision of the anterior cartilage with compression buttoning in this condition. STUDY DESIGN: Medical records of patients with pseudocyst of the auricle treated in the Department of Otolaryngology of the Singapore General Hospital were reviewed retrospectively during the period from March 1, 2000, to November 30, 2001. METHODS: A retrospective descriptive analysis of the epidemiological profile of patients with pseudocyst of the auricle was done. Surgical excision with compression buttoning was evaluated as the definitive treatment in this condition. RESULTS: Eighty-seven percent of our patients were male and the mean age was 38.9 years old. There was no racial predisposition. All 9 patients who had simple aspiration of the cyst had prompt re-accumulation of the pseudocyst. None of the patients had recurrence following excision and compression buttoning of the pseudocyst. The complication rate in our study was 2.4%. Only one patient developed initial perichondritis with a resultant cauliflower deformity following surgical excision. CONCLUSION: Pseudocyst of the auricle typically presents as a painless unilateral swelling of the auricle in young adult males. Treatment options are varied. Excision of the anterior cartilage with compression buttoning yielded excellent results with no recurrence.

Impaired production of nitric oxide, superoxide, and hydrogen peroxide in glucose 6-phosphate-dehydrogenase-deficient granulocytes.

Since the generation of superoxide and hydrogen peroxide by NADPH oxidase and nitric oxide (NO) by NO synthase (NOS) in granulocytes is NADPH-dependent, we investigated the production of NO, superoxide and H2O2 in glucose 6-phosphate dehydrogenase (G6PD)-deficient human granulocytes. Our results showed that upon stimulation with either 5 microg/ml of lipopolysaccharide (LPS) or 10 microM of phorbol 12-myristate 13-acetate (PMA), the production of nitrite in normal granulocytes was elevated, 252 +/- 135% and 239 +/- 72%, respectively, compared to the resting stage. In contrast, G6PD-deficient granulocytes did not produce more nitrite upon stimulation with either LPS or PMA compared to the resting stage. Western blot analysis indicated a normal expression pattern of inducible NOS in G6PD-deficient granulocytes. In addition, the production of H2O2 and superoxide was also significantly impaired in G6PD-deficient granulocytes compared to control cells. These data demonstrate that G6PD deficiency causes an impairment in the production of NO, superoxide and H2O2.

Endothelial regeneration. VI. Chronic nondenuding injury in baboon vascular grafts.

The cellular lining of 4-mm polytetrafluoroethylene (PTFE) arterial bypass grafts of differing porosity implanted into baboons for a period of 3 months was investigated. Endothelial outgrowth onto the less porous (30-mu) PTFE grafts varied from approximately 1 to 3 cm, and 75% of the grafts were totally reendothelialized within 3 months. These luminal cells stained positive for Factor VIII.R.Ag. The endothelial replication in the healed grafts was significantly elevated as compared with that observed in adjacent arteries. By electron microscopy, no breaks were detected in the integrity of the endothelium and no increase in indium activity over the graft was recorded after injection of 111In-labeled platelets. To ensure that the increased cell replication was not related to regrowth, a more porous PTFE graft (60 mu) was implanted which reendothelialized within 2 weeks. Three months after implantation, the replication rate of endothelium in the graft was still significantly increased. The authors concluded that this increased replication represented a desquamating nondenuding injury and that flow characteristics along the graft might be responsible.