Prevalence of Bronchiectasis in Patients with Chronic Rhinosinusitis in a Tertiary Care Center.

BACKGROUND: Whereas chronic rhinosinusitis (CRS) is associated with asthma, and vice versa, the association between CRS and other lower respiratory conditions is not well-established. Bronchiectasis is characterized by permanent damage of the airways, and as many as 45% of bronchiectasis patients have CRS, but the prevalence of bronchiectasis among CRS patients is not known. OBJECTIVE: To determine the prevalence of bronchiectasis among CRS patients and to characterize demographic and clinical features of patients with bronchiectasis and CRS. METHODS: Electronic medical records of patients with rhinosinusitis were searched by computer algorithm supplemented with manual chart review to identify patients with CRS, asthma, and/or bronchiectasis. Demographic and clinical features and antibiotic courses for sinopulmonary infections 2 years before and after sinus surgery were obtained by manual chart review. RESULTS: The prevalence of bronchiectasis as determined by International Classification of Diseases, Ninth Revision code was significantly higher in CRS patients than in asthmatic patients (2.3% vs 1.7%; P < .003). Similarly, based on a text word search of "bronchiectasis" in the chest computed tomography (CT) scan reports, patients with CRS who had chest CT scans had a higher prevalence of bronchiectasis than did asthmatic patients with chest CT scans (24.3% vs 19.5%; P = .005). Patients with CRS and concurrent bronchiectasis did not have a reduction in the frequency of sinopulmonary infections after sinus surgery compared with patients with CRS without bronchiectasis (P < .05). CONCLUSIONS: Bronchiectasis is an important comorbidity in patients with CRS and may identify a severe phenotype of chronic sinonasal disease.

Clinical Characteristics of Patients with Chronic Rhinosinusitis without Nasal Polyps in an Academic Setting.

BACKGROUND: Although patients with chronic rhinosinusitis without nasal polyps (CRSsNP) represent a majority of the chronic rhinosinusitis (CRS) population, they have not been completely characterized phenotypically. OBJECTIVE: To perform a comprehensive phenotypic characterization of subjects with CRSsNP, using CRS with nasal polyps (CRSwNP) as a comparator. METHODS: Patients with a history of CRS with positive sinus computed tomography (>18 years old) evaluated in the allergy/immunology or otolaryngology clinics of an academic center between 2002 and 2012 were identified via International Classification of Diseases, Ninth Revision codes. A retrospective chart review was performed on a subset of 507 patients with CRSsNP and 874 with CRSwNP. Characteristics analyzed included demographics, comorbid conditions, and radiologic sinus severity. RESULTS: Of the total CRS population, approximately 82% had CRSsNP and 18% had CRSwNP. Of the 507 patients in the CRSsNP group, 319 (63%) were female compared with 393 of 847 (45%) in the CRSwNP group. The prevalence of atopy was 52% in CRSsNP versus 76% in CRSwNP (P < .0001). In CRSsNP, atopic patients had more severe radiographic disease compared with nonatopic patients (P < .005). The prevalence of asthma was 36% in CRSsNP versus 56% in CRSwNP (P < .0001). Comorbid asthma was not associated with radiographic sinus disease severity in CRSsNP but was associated with severity in CRSwNP (P < .0001). CONCLUSIONS: The relative prevalence of CRS phenotypes in the western population is approximately 80% CRSsNP and 20% CRSwNP. Patients with CRSsNP were predominantly female, whereas patients with CRSwNP were predominantly male. The prevalence of asthma was higher in our cohort of patients with CRSsNP than previously described. Atopy was associated with more severe radiographic sinonasal disease in CRSsNP, whereas asthma was not associated with radiographic sinonasal disease severity.

Infectious Chronic Rhinosinusitis.

Chronic rhinosinusitis (CRS) is a persistent inflammatory disease that affects a multitude of people worldwide. The pathogenesis of CRS involves many factors including genetics, status of the sinonasal microbiome, infections, and environmental influences. Comorbidities associated with CRS include asthma, allergic rhinitis, bronchiectasis, and certain kinds of immunodeficiency. CRS can be divided into different subtypes based on endotypes and phenotypes. Infectious CRS is one such category. The etiology of infectious CRS is usually secondary to chronic bacterial infection that commonly begins with a viral upper respiratory tract infection. Humoral antibody deficiencies can underlie difficult-to-treat or recurrent CRS. Infectious CRS can be treated with antimicrobials, topical or oral corticosteroids, and nasal saline irrigations. Patients with CRS and humoral immunodeficiency may require an aggressive treatment approach including immunoglobulin replacement therapy. Despite advancements in the field of CRS, targeted therapies and reliable biomarkers are still lacking.

Evaluation and management of hypersensitivity to proton pump inhibitors.

OBJECTIVE: Proton pump inhibitors (PPIs) are widely used for the treatment of gastroesophageal reflux disease and peptic ulcer disease. PPIs are well tolerated, but they can cause hypersensitivity reactions (HSRs). Although simply avoiding a PPI after an HSR is appropriate for most patients, there are clinical scenarios that require treatment with a PPI. DATA SOURCES: A comprehensive literature review was performed to propose an evidence-based approach to the evaluation and management of HSRs to PPIs. STUDY SELECTIONS: Articles from June 1986 through September 2012 on PPI hypersensitivity were reviewed. Thirty-nine studies that met the search criteria were included in the review. HSRs to PPIs and skin testing protocols used to evaluate HSRs were analyzed from the 39 identified publications. For each case, the culprit drug and dose, the age and sex of the patient, and the symptoms and timing of the HSR were recorded. HSRs were classified into immune- or nonimmune-mediated categories. RESULTS: A total of 118 cases of immune-mediated HSRs to 5 PPIs were identified, most of which were suspected IgE-mediated HSRs. Omeprazole was the culprit PPI most frequently associated with HSRs. The most common clinical manifestations of PPI HSRs were cutaneous reactions. Nonirritating concentrations for skin prick and intradermal testing were identified. Skin testing showed variable cross-reactivity patterns among the different PPIs. CONCLUSION: The HSRs to PPIs should be formally investigated, especially when reasonable alternative therapies do not exist. The reviewers propose an evidence-based algorithm for evaluating and managing patients with an HSR to a PPI.

Effect of diet on serotonergic neurotransmission in depression.

Depression is characterized by sadness, purposelessness, irritability, and impaired body functions. Depression causes severe symptoms for several weeks, and dysthymia, which may cause chronic, low-grade symptoms. Treatment of depression involves psychotherapy, medications, or phototherapy. Clinical and experimental evidence indicates that an appropriate diet can reduce symptoms of depression. The neurotransmitter, serotonin (5-HT), synthesized in the brain, plays an important role in mood alleviation, satiety, and sleep regulation. Although certain fruits and vegetables are rich in 5-HT, it is not easily accessible to the CNS due to blood brain barrier. However the serotonin precursor, tryptophan, can readily pass through the blood brain barrier. Tryptophan is converted to 5-HT by tryptophan hydroxylase and 5-HTP decarboxylase, respectively, in the presence of pyridoxal phosphate, derived from vitamin B(6). Hence diets poor in tryptophan may induce depression as this essential amino acid is not naturally abundant even in protein-rich foods. Tryptophan-rich diet is important in patients susceptible to depression such as certain females during pre and postmenstrual phase, post-traumatic stress disorder, chronic pain, cancer, epilepsy, Parkinson's disease, Alzheimer's disease, schizophrenia, and drug addiction. Carbohydrate-rich diet triggers insulin response to enhance the bioavailability of tryptophan in the CNS which is responsible for increased craving of carbohydrate diets. Although serotonin reuptake inhibitors (SSRIs) are prescribed to obese patients with depressive symptoms, these agents are incapable of precisely regulating the CNS serotonin and may cause life-threatening adverse effects in the presence of monoamine oxidase inhibitors. However, CNS serotonin synthesis can be controlled by proper intake of tryptophan-rich diet. This report highlights the clinical significance of tryptophan-rich diet and vitamin B(6) to boost serotonergic neurotransmission in depression observed in various neurodegenerative diseases. However pharmacological interventions to modulate serotonergic neurotransmission in depression, remains clinically significant. Depression may involve several other molecular mechanisms as discussed briefly in this report.

Lymphocyte-predominant Hodgkin disease: a comprehensive overview.

Lymphocyte-predominant Hodgkin disease is a rare form of Hodgkin lymphoma that is recognized as a separate histopathological entity. This disease tends to have multiple relapses, but has an overall good prognosis. Owing to its rarity, and the prolonged time period between recurrence and transformation events, there is no consensus regarding optimal management. However, the National Comprehensive Cancer Network guidelines indicate that for early stages, appropriate treatment is radiotherapy. Several management options have been reported including observation, radiation, chemotherapy, combined chemoradiotherapy, and anti-CD20 antibody therapy. Salvage therapy remains effective in inducing prolonged remission in patients with relapsed/refractory disease.

Human bronchial epithelial cells differentiate to 3D glandular acini on basement membrane matrix.

To create a model system that investigates mechanisms resulting in hyperplasia and hypertrophy of respiratory tract submucosal glands, we developed an in vitro three-dimensional (3D) system wherein normal human bronchial epithelial (HBE) cells differentiated into glandular acini when grown on a basement membrane matrix. The differentiation of primary HBE cells into glandular acini was monitored temporally by light microscopy. Apoptosis-induced lumen formation was observed by immunofluorescence analysis. The acinar cells expressed and secreted MUC5B mucin (marker for glandular mucous cells) and lysozyme, lactoferrin, and zinc-α2-glycoprotein (markers for glandular serous cells) at Day 22. ß-Tubulin IV, a marker for ciliated cells, was not detected. Expression of mucous and serous cell markers in HBE glandular acini demonstrated that HBE cells grown on a basement membrane matrix differentiated into acini that exhibit molecular characteristics of respiratory tract glandular acinar cells. Inhibition studies with neutralizing antibodies resulted in a marked decrease in size of the spheroids at Day 7, demonstrating that laminin (a major component of the basement membrane matrix), the cell surface receptor integrin α6, and the cell junction marker E-cadherin have functional roles in HBE acinar morphogenesis. No significant variability was detected in the average size of glandular acini formed by HBE cells from two normal individuals. These results demonstrated that this in vitro model system is reproducible, stable, and potentially useful for studies of glandular differentiation and hyperplasia.

Management of pediatric orbital cellulitis in patients with radiographic findings of subperiosteal abscess.

OBJECTIVE: Controversies remain regarding the management of orbital cellulitis (OC). The objective of this study was to examine the outcomes of patients admitted to our institution for orbital cellulitis during a 7-year period. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral pediatric hospital. SUBJECTS AND METHODS: Charts of 465 consecutive OC admissions were reviewed for presentation, imaging, medical and surgical treatment, and outcome. RESULTS: Of these patients, 189 were treated in the emergency room and 276 were admitted. CT scan was performed on 240 patients. Subperiosteal abscess (SPA) was noted in 68 patients. Of these, 47 were treated medically and 21 had surgery. Surgical patients were older (8.3 vs 6.2 years, P = 0.039), had larger abscesses (>10 mm, P < 0.001), required a longer admission (10.2 vs 6.6 days, P < 0.001), and had higher temperatures on admission (38.0 degrees C vs 37.3 degrees C, P = 0.03). CONCLUSION: The majority of small SPAs as diagnosed on CT scans in younger children can be successfully treated medically. Surgery, however, should be considered for a worsening clinical examination. Our findings confirm those of previous reports on this clinical entity.

Avoiding early revision rhytidectomy: a biomechanical comparison of tissue plication suture techniques.

BACKGROUND: Manipulation and suspension of the superficial musculoaponeurotic system (SMAS) is performed by 74% of rhytidectomy surgeons. Multiple variations in suture techniques are employed in this task, but they have never been evaluated for differences in their ability to withstand stress. OBJECTIVE: To compare the biomechanical properties of two different suture techniques that are used in SMAS plications during rhytidectomy: a double-layered running locking (DRL) stitch and multiple horizontal mattress stitches. METHODS: Fourteen horizontal mattress plications, in rows of six sutures, and comparable lengths of 16 DRL stitch plications of pig skin samples, were stressed using a tensometer with grip displacement increasing at a constant rate of 0.5 cm/Min. The required force to cause plication failure was recorded for each sample at three suture break points. RESULTS: There was no significant difference between the two groups in the force required to cause the initial suture failure. Unlike the horizontal mattress plication, an initial break seemed to cause minimal to no distortion of the DRL tissue plication. When results were normalized by the initial break forces to account for small variations in tissue properties, the force ratio required to cause a second suture break was significantly larger in the DRL group than in the horizontal mattress technique. This is evidenced by the average second to first break force ratios of 1.62 vs. 1.13 for the DRL and horizontal mattress stitches, respectively, with a P-value of .60. The mean ratios of third to first break forces for the DRL and horizontal mattress groups were 2.08 and 0.91, respectively, with a P-value of .08. CONCLUSION: The DRL stitch requires more force than the horizontal mattress stitch to cause significant failure of tissue plication. This technique may enable plastic surgeons to avoid early revision rhytidectomy due to suture failure, and to create a long-lasting, youthful cosmetic result.

Thiersch grafting in recurrent herpes-induced lip depigmentation.

Recurrent herpes induced lip-depigmentation is an uncommon condition observed rarely in patients suffering from recurrent herpes labialis. Patients usually belong the age group between 20 and 40 who have had herpes labialis for 4--12 years. These patients do not respond to available methods of treatment such as psoralens and phototherapy because there is reactivation of the virus. Ten cases of recurrent herpes-induced lip depigmentation (HILD) were successfully treated with a combination therapy of acyclovir 400 mg twice a day for one year with Thiersch grafting six months after starting therapy.