Differences in the Intended Meaning of Congestion Between Patients and Clinicians

Redundancy of Pharmacologic Ingredients in Over-the-Counter Nasal Sprays

Objective

To evaluate and determine the prevalence of ingredients in over-the-counter (OTC) nasal sprays.

Study Design

Cross-sectional.

Setting

Retail pharmacies.

Methods

An inventory of brand-name and generic OTC nasal sprays was recorded at five national pharmacy outlets in August 2023. Data regarding the active ingredients were collected on commercial websites, MedlinePlus and drugs.com, and frequency statistics were calculated.

Results

Five pharmacies were visited, at which 12 different brand names of nasal sprays were identified at multiple pharmacies. Nine brand names were associated with multiple formulations, accounting for 49 different products. The active ingredients included in our analysis were oxymetazoline, phenylephrine, fluticasone, triamcinolone, budesonide, azelastine, cromolyn sodium, and mometasone. Nasal decongestants had the greatest number of brand name formulations compared to intranasal steroids and antihistamine sprays which had limited choices. Products that included oxymetazoline were the most widely marketed drug (51 unique products) followed sodium chloride (40 unique products).

Conclusion

These findings suggest that there are widespread redundancies in the OTC nasal spray market. Clinician should be aware of the redundancy in OTC formulations and encourage patients to read the labels in order to make informed decisions regarding their use of OTC medications.

Chief Complaint: Nasal Congestion

Nasal obstruction is the subjective perception and objective state of insufficient airflow through the nose. Nasal congestion, conversely, describes a state of not just inadequate airflow or obstructive phenomena but also pressure- and mucus-related states to the patient. Nasal receptors belonging to the transient receptor potential (TRP) protein family mediate the sense of nasal patency via the trigeminal nerve. The transient receptor potential melastatin-8 (TRPM8) responds to temperatures around 8°C to 22°C, and is stimulated by menthol and other cooling agents. The radiant effects of airflow create heat loss to activate these receptors and humans perceive this as nasal patency rather than the direct detection of airflow. The thermovascular state of the mucosa, in conditions such as rhinitis, influence TRPM8 activation. Nasal endoscopy can show signs of rhinitis and should be considered an essential part of the workup of nasal congestion. Efforts to relieve nasal congestion need to manage the mucosal state and surgery needs to ensures that the nasal cavity mucosa is exposed to the cooling effects of airflow rather than simply creating a passage to the nasopharynx.

How Do Patients and Otolaryngologists Define Dizziness?

OBJECTIVE

To assess for differences in how patients and otolaryngologists define the term dizziness.

METHODS

Between June 2020 and December 2022, otolaryngology clinicians and consecutive patients at 5 academic otolaryngology institutions across the United States were asked to define the term "dizziness" by completing a semantics-based questionnaire containing 20 common descriptors of the term within 5 symptom domains (imbalance-related, lightheadedness-related, motion-related, vision-related, and pain-related). The primary outcome was differences between patient and clinician perceptions of dizzy-related symptoms. Secondary outcomes included differences among patient populations by geographic location.

RESULTS

Responses were obtained from 271 patients and 31 otolaryngologists. Patients and otolaryngologists selected 7.7 ± 3.5 and 7.1 ± 4.3 symptoms, respectively. Most patients (266, 98.2%) selected from more than 1 domain and 17 (6.3%) patients identified symptoms from all 5 domains. Patients and clinicians were equally likely to define dizziness using terms from the imbalance (difference, -2.3%; 95% CI, -13.2%, 8.6%), lightheadedness (-14.1%; -29.2%, 1.0%), and motion-related (9.4; -0.3, 19.1) domains. Patients were more likely to include terms from the vision-related (23.6%; 10.5, 36.8) and pain-related (18.2%; 10.3%, 26.1%) domains. There were minor variations in how patients defined dizziness based on geographic location.

CONCLUSIONS

Patients and otolaryngologists commonly described dizziness using symptoms related to imbalance, lightheadedness, and motion. Patients were more likely to use vision or pain-related terms. Understanding of these semantic differences may enable more effective patient-clinician communication.

Are you congested? A comparison of definitions between otolaryngologists and their patients

OBJECTIVE

To assess for differences of intended meaning in the description of congestion-related symptoms among otolaryngology patients and clinicians.

MATERIALS AND METHODS

Between June 2020 and October 2022, a questionnaire consisting of 16 common descriptors of congestion-related symptoms within four domains (obstructive-related, pressure-related, mucus-related, and other symptoms) was completed by patients and otolaryngologists at five tertiary otolaryngology practices. The primary outcome was to assess differences in patient and clinician perceptions of congestion-related symptoms. Differences based on geographic location was a secondary outcome.

RESULTS

A total of 349 patients and 40 otolaryngologists participated. Patients selected a median of 6.8 (standard deviation [SD] 3.0) terms compared with 4.0 (SD 1.6) terms for otolaryngologists (p < 0.001). Otolaryngologists were more likely to select obstruction-related symptoms (difference 6.3%; 95% confidence interval [CI] 3.8%, 8.9%). Patients were more likely to describe congestion using pressure-related (-43.7%; -58.9%, -28.5%), mucus-related (-43.5%; -59.3%, -27.8%), and other symptoms (-44.2; -51.3%, -37.1%) compared with otolaryngologists. There were no significant differences identified based on geographic location with regard to symptom domains on multivariate analysis.

CONCLUSIONS

There are differences between otolaryngologists and their patients in the interpretation of the symptoms of congestion. Clinicians tended to have a narrower interpretation of congestion that was limited to the obstruction-related symptom domain, while patients defined congestion more broadly. This has important counseling and communication implications for the clinician.

Use of Patient-Reported Symptom Data in Clinical Decision Rules for Predicting Influenza in a Telemedicine Setting

INTRODUCTION

Increased use of telemedicine could potentially streamline influenza diagnosis and reduce transmission. However, telemedicine diagnoses are dependent on accurate symptom reporting by patients. If patients disagree with clinicians on symptoms, previously derived diagnostic rules may be inaccurate.

METHODS

We performed a secondary data analysis of a prospective, nonrandomized cohort study at a university student health center. Patients who reported an upper respiratory complaint were required to report symptoms, and their clinician was required to report the same list of symptoms. We examined the performance of 5 previously developed clinical decision rules (CDRs) for influenza on both symptom reports. These predictions were compared against PCR diagnoses. We analyzed the agreement between symptom reports, and we built new predictive models using both sets of data.

RESULTS

CDR performance was always lower for the patient-reported symptom data, compared with clinician-reported symptom data. CDRs often resulted in different predictions for the same individual, driven by disagreement in symptom reporting. We were able to fit new models to the patient-reported data, which performed slightly worse than previously derived CDRs. These models and models built on clinician-reported data both suffered from calibration issues.

DISCUSSION

Patients and clinicians frequently disagree about symptom presence, which leads to reduced accuracy when CDRs built with clinician data are applied to patient-reported symptoms. Predictive models using patient-reported symptom data performed worse than models using clinician-reported data and prior results in the literature. However, the differences are minor, and developing new models with more data may be possible.

Layperson Perception of Reflux-Related Symptoms

Objective

To assess for differences of intended meaning in the description of reflux-related symptoms among otolaryngology patients and clinicians.

Study Design

Cross-sectional survey-based study.

Setting

Five tertiary, academic otolaryngology practices.

Methods

Between June 2020 and July 2022, a questionnaire consisting of 20 common descriptors of reflux-related symptoms within four domains (throat-, chest-, stomach-, and sensory-related symptoms) was completed by patients. Attending otolaryngologists at five academic medical centers then completed the same survey. The primary outcome was to assess differences in patient and clinician perceptions of reflux-related symptoms. Differences based on geographic location was a secondary outcome.

Results

A total of 324 patients and 27 otolaryngologists participated. Patients selected a median of six terms compared with 10.5 for otolaryngologists (p < .001). Otolaryngologists were more likely to select sensory symptoms (difference: 35.8%; 95% confidence interval [CI]: 19.2%, 52.4%), throat-related symptoms (32.4%; 21.2, 43.6%), and chest-related symptoms (12.4%; 8.8, 15.9). Otolaryngologists and patients were equally likely to consider stomach symptoms as related to reflux (4.0%, -3.7%, 11.7%). No significant differences were identified based on geographic location.

Conclusion

There are differences between otolaryngologists and their patients in the interpretation of the symptoms of reflux. Patients tended to have a narrower interpretation of reflux with symptoms primarily limited to classic stomach-related symptoms, while clinicians tended to have a broader definition of reflux that included extra-esophageal manifestations of disease. This has important counseling implications for the clinician, as patients presenting with reflux symptoms may not comprehend the relationship of those symptoms to reflux disease.

Influence of Age and Gender on Nasal Airway Patency as Measured by Active Anterior Rhinomanometry and Acoustic Rhinometry

In this study, we aimed to investigate the influences of age and gender on nasal airway patency, as measured by both active anterior rhinomanometry (AAR) and acoustic rhinometry (AR). The nasal airway patency of healthy subjects was evaluated using AAR and AR. In AAR, the subjects generated airflow actively through inspiration and expiration in repetitions of10, while nasal patency was measured at an inspiratory and expiratory reference pressure of 75 Pa. In AR, we assessed the geometry of the nasal cavity through the analysis of sound waves reflected from the nasal cavities in order to measure both cross-sectional areas and nasal volumes. The subjects were divided by gender, with all males and females then grouped by ages of 20–39 years, 40–59 years and ≥60 years. There were 40 subjects in each group. The mean resistance measured by AAR and the cross-sectional areas and nasal volumes measured by AR were not different between the different age groups; however, the cross-sectional areas and nasal volumes were found to be lesser in females than in males. Our results showed that nasal airway patency was not affected by age, while females were shown to have wider nasal passages than males.

Layperson Perception of Symptoms Caused by the Sinuses

OBJECTIVE

To assess the perceived symptoms caused by the sinuses as defined by otolaryngology patients and clinicians.

STUDY DESIGN

Multi-institutional cross-sectional study.

SETTING

Six academic outpatient otolaryngology practices.

METHODS

We performed a multi-institutional, cross-sectional study using a semantics-based questionnaire. Consecutive patients were enrolled at 6 academic otolaryngology centers from June 2020 to May 2021. The primary outcome examined patient and provider definitions for the symptoms caused by the sinuses from a list of 28 proposed terms covering 6 general categories. These data were also collected from otolaryngology faculty at the same institutions.

RESULTS

Responses were obtained from 451 patients (54% female, mean age 48.3 years) and 29 otolaryngologists (38% female, mean age 37.4 years). Patients selected a median of 12 terms, compared to 8.5 for otolaryngologists. Among patients, the most frequently selected symptom domains were mucus (419, 92.9%), airflow (412, 91.4%), and pain (389, 86.3%). Compared to clinicians, patients more frequently selected symptoms related to the ear (difference, 48.3%; 95% confidence interval [CI], 34.8%-59.3%), throat (difference, 35.7%, 95% CI, 22.0%-47.5%), systemic (difference, 34.4%, 95% CI, 21.2%-46.0%), mucus (difference, 20.5%, 95% CI, 10.2%-30.6%), and airflow domains (difference, 19.0%, 95% CI, 8.4%-29.3%). Multiple domains were selected by 98% of patients and 79% of providers.

CONCLUSION

Semantic differences exist between patients and clinicians regarding the symptoms caused by the sinus with patients having a broader range of perceived symptoms. These differences may provide clues to improve communication between otolaryngologists and their patients.

What do we mean when we have a "sinus infection?"

INTRODUCTION

Sinus infections are a common reason patients seek medical care. However, the intended meaning of the term sinus infection among patients and otolaryngologists is incompletely understood.

METHODS

In this multi-institutional cross-sectional study, a semantics-based questionnaire was provided to consecutive patients presenting to otolaryngology clinics at six academic centers from June 2020 until May 2021. The primary outcome was respondent definitions for sinus infection from a list of 28 proposed terms covering six general categories. Secondary outcome measures included differences between geographic regions.

RESULTS

Responses were obtained from 560 patients (54% female, mean age 48.9 years) and 29 otolaryngologists (42% female, mean age 37.4 years). Patients and otolaryngologists selected a median of 10 and 11 terms, respectively, to define a sinus infection. Among patients the most frequently selected symptom categories were mucus (500, 89.3%), pressure/pain (480, 85.7%), and airflow (468, 83.6%). Compared to patients, clinicians selected with greater frequency the symptom categories of pressure/pain (14.3% difference; 95% CI, 7.6% to 22.5%), mucus (10.7% difference; 95% CI, 4.7% to 18.3%) and airflow (13.0% difference; 95% CI, 4.8% to 21.7%). Multiple categories were selected by 96% of patients and 100% of providers.

CONCLUSION

The definition of sinus infection appears variable for both patients and otolaryngologists, though patients appear to apply a broader range of symptoms to the term sinus infection. There were no pronounced geographic differences in the description of a sinus infection in this US sample population. Patients commonly described sinus infection in the context of pain-related symptoms. Appreciation of these semantic differences may enable more effective patient-clinician communication.

A Dizzying Complaint: Investigating the Intended Meaning of Dizziness Among Patients and Providers

OBJECTIVE/HYPOTHESIS

To assess for semantic differences regarding the definition of dizziness among otolaryngology patients, otolaryngologists, and non-otolaryngologist providers.

STUDY DESIGN

Cross-sectional survey.

METHODS

Between March and May 2020, a survey consisting of 20 common descriptors for dizziness within five domains (lightheadedness, motion sensitivity, imbalance, vision complaints, and pain) was completed by patients at two outpatient otolaryngology clinics. Surveys were subsequently obtained from otolaryngology and non-otolaryngology providers attending a multidisciplinary dizziness lecture. The primary outcome measure was to assess for differences in definition of dizziness between patients and providers. Secondary outcome measures included assessing differences between otolaryngologists and non-otolaryngologists.

RESULTS

About 221 patients and 100 providers participated. Patients selected a median of 7 terms compared to 8 for providers (P = .375), although providers had a larger overall distribution of number of terms selected (P = .038). Patients were more likely than providers to define dizziness according to the following domains: lightheadedness (difference 15.0%; 95% confidence interval [CI] 5.5%-25.3%), vision complaints (difference 21.6%, 95% CI 12.0%-29.6%), and pain (difference 11.5%, 95% CI 4.7%-17.1%). Providers were more likely to define dizziness according to the motion sensitivity domain (difference 13.8%, 95% CI 6.8%-19.6%). Otolaryngology and non-otolaryngology providers defined dizziness similarly across symptom domains.

CONCLUSION

Although patients and providers both view dizziness as imbalance, patients more commonly describe dizziness in the context of lightheadedness, vision complaints, and pain, whereas providers more frequently define dizziness according to motion sensitivity. These semantic differences create an additional barrier to effective patient-provider communication.

LEVEL OF EVIDENCE

4. Laryngoscope, 131:E1443-E1449, 2021.

Assessment of Pharmacologic Ingredients in Common Over-the-Counter Sinonasal Medications

Importance

Sinonasal remedies are the most frequently purchased category of over-the-counter (OTC) drugs in the United States. A variety of options for relief are available under proprietary names, although the actual number of available options may not be readily appreciated by the consumer or the clinician.

Objective

To determine the prevalence of specific ingredients in OTC sinonasal products.

Design, Setting, and Participants

This cross-sectional study took physical inventory of brand-name and generic OTC drugs marketed as sinus, cold, allergy, or nasal remedies. Retail pharmacies in New Orleans, Louisiana, commercial websites, and the Drugs, Herbs and Supplements section of MedlinePlus and drugs.com were searched. Data were collected and analyzed from July 1 to 31, 2018.

Main Outcomes and Measures

Frequency of active ingredients in OTC formulations.

Results

Five pharmacies were visited to identify 18 brands, for which the commercial websites were then searched. The 14 most common brands represented 211 unique products. Only 8 unique nonanalgesic ingredients were identified among these products, with many products sold under the same brand name and with the same active ingredient. Phenylephrine hydrochloride, dextromethorphan hydrobromide, pseudoephedrine hydrochloride, guaifenesin, chlorpheniramine maleate, brompheniramine maleate, diphenhydramine hydrochloride, and doxylamine succinate were the common active ingredients, with all available OTC sinonasal remedies consisting of 1 or more of these ingredients. The frequency of occurrence of each ingredient ranged from 10 to 261 different products. Combinations of 2, 3, or 4 active ingredients occurred frequently in OTC sinonasal products.

Conclusions and Relevance

These findings suggest that proliferation of brand extension products under a common name is pervasive. Clinicians should be aware of the large array of redundant OTC formulations and lack of specificity when discussing brand-name sinonasal remedies with their patients.

Virulence-mediated infectiousness and activity trade-offs and their impact on transmission potential of influenza patients

Communicable diseases are often virulent, i.e. they cause morbidity symptoms in those infected. While some symptoms may be transmission-enhancing, other symptoms are likely to reduce transmission potential. For human diseases, the reduction in transmission opportunities is commonly caused by reduced activity. There is limited data regarding the potential impact of virulence on transmission potential. We performed an exploratory data analysis of 324 influenza patients at a university health centre during the 2016/2017 influenza season. We classified symptoms as infectiousness-related or morbidity-related and calculated two scores. The scores were used to explore the relationship between infectiousness, morbidity (virulence), and activity level. We found a decrease in the activity level with increasing morbidity scores. There was no consistent pattern between an activity level and an infectiousness score. We also found a positive correlation between morbidity and infectiousness scores. Overall, we find that increasing virulence leads to increased infectiousness and reduced activity, suggesting a trade-off that can impact overall transmission potential. Our findings indicate that a reduction of systemic symptoms may increase host activity without reducing infectiousness. Therefore, interventions should target both systemic- and infectiousness-related symptoms to reduce overall transmission potential. Our findings can also inform simulation models that investigate the impact of different interventions on transmission.

Direct-To-Consumer Advertising of Over-the-Counter Sinonasal Remedies: A History of Mixed Messages

Sinus, cold, and allergy remedies comprise the most widely used sector of the over-the-counter (OTC) drug market. Direct-to-consumer advertising (DTCA) of pharmaceutical products has increased over the past 30 years, including the promotion of OTC drugs. The influence of DTCA on OTC sinonasal remedies comprises several positive and negative effects. Favorable aspects of this influence include empowerment and promotion of autonomy among patients, avoidance of low-value clinical encounters, self-directed education, and decreased healthcare expenditures. This is balanced by potential concerns, including the lack of rigorous regulation of OTC drugs, the burden of self-diagnosis, the risk of unsupervised use resulting in adverse effects or drug interactions, and redistribution of pharmacy costs to the consumer. Despite the proliferation of product options and consumer-directed information, healthcare utilization and cost of treating sinonasal disease remains high. Moreover, the availability of OTC sinonasal remedies and exposure to DTCA has had mixed effects without apparent overall benefit to patient and consumer health. Laryngoscope, 130:2114-2119, 2020.