Nasal mucosa healing after endoscopic sinus surgery in chronic rhinosinusitis of elderly patients: role of topic alpha-tocopherol acetate

Type 2 diabetes mellitus increases postoperative recurrence risk in Chinese patients with chronic rhinosinusitis

BACKGROUND

The effect of type 2 diabetes mellitus (T2DM) on postoperative recurrence of chronic sinusitis (CRS) is unclear.

OBJECTIVE

To investigate the association between T2DM and postoperative recurrence in CRS patients.

METHODS

CRS patients who underwent surgery in our hospital from January 2018 to April 2020 were included and followed up for three years. Patients were classified into non-recurrent and recurrent CRS groups based on follow-up outcome, and logistic regression analysis was performed to identify risk factors for postoperative recurrence.

RESULTS

A total of 412 CRS patients were included of whom 68 had T2DM. The postoperative recurrence rate was significantly higher in the T2DM group compared to the non-T2DM group (p < .05). T2DM prevalence and fasting blood glucose (FBG) levels were higher in recurrent CRS patients than those in non-recurrent CRS cases (p < .05). Multivariate regression analyses showed that age, duration of disease, FBG, and comorbid allergic rhinitis (AR) were significantly associated with an increased risk of postoperative recurrence of CRS (p < .05). Furthermore, adjusted logistic regression model revealed that T2DM was an independent risk factor for postoperative recurrence of CRS (p < .05).

CONCLUSIONS

Elevated FBG levels may significantly influenced the postoperative recurrence of CRS in Chinese patients, and T2DM was an independent risk factor for recurrence.

How to Promote Skin Repair? In-Depth Look at Pharmaceutical and Cosmetic Strategies

Skin repair encompasses epidermal barrier repair and wound healing which involves multiple cellular and molecular stages. Therefore, many skin repair strategies have been proposed. In order to characterize the usage frequency of skin repair ingredients in cosmetics, medicines, and medical devices, commercialized in Portuguese pharmacies and parapharmacies, a comprehensive analysis of the products' composition was performed. A total of 120 cosmetic products, collected from national pharmacies online platforms, 21 topical medicines, and 46 medical devices, collected from INFARMED database, were included in the study, revealing the top 10 most used skin repair ingredients in these categories. A critical review regarding the effectiveness of the top ingredients was performed and an in-depth analysis focused on the top three skin repair ingredients pursued. Results demonstrated that top three most used cosmetic ingredients were metal salts and oxides (78.3%), vitamin E and its derivatives (54.2%), and Centella asiatica (L.) Urb. extract and actives (35.8%). Regarding medicines, metal salts and oxides were also the most used (47.4%) followed by vitamin B5 and derivatives (23.8%), and vitamin A and derivatives (26.3%). Silicones and derivatives were the most common skin repair ingredients in medical devices (33%), followed by petrolatum and derivatives (22%) and alginate (15%). This work provides an overview of the most used skin repair ingredients, highlighting their different mechanisms of action, aiming to provide an up-to-date tool to support health professionals' decisions.

Oxidative Stress and Antioxidants in Chronic Rhinosinusitis with Nasal Polyps

Oxidative stress results from an imbalance between the production of reactive oxygen species and the body's antioxidant defense system. It plays an important role in the regulation of the immune response and can be a pathogenic factor in various diseases. Chronic rhinosinusitis (CRS) is a complex and heterogeneous disease with various phenotypes and endotypes. Recently, an increasing number of studies have proposed that oxidative stress (caused by both environmental and intrinsic stimuli) plays an important role in the pathogenesis and persistence of CRS. This has attracted the attention of several researchers. The relationship between the presence of reactive oxygen species composed of free radicals and nasal polyp pathology is a key topic receiving attention. This article reviews the role of oxidative stress in respiratory diseases, particularly CRS, and introduces potential therapeutic antioxidants that may offer targeted treatment for CRS.

Rescue therapies for seizure clusters: Pharmacology and target of treatments

The primary goal of treatment for seizure clusters is cessation of the cluster to avoid progression to more severe conditions, such as prolonged seizures and status epilepticus. Rescue therapies are key components of treatment plans for patients with seizure clusters. Three rescue therapies are approved in the United States for the treatment of seizure clusters: diazepam rectal gel, midazolam nasal spray, and diazepam nasal spray. This review characterizes the pharmacological function of rescue therapies for seizure clusters, as well as describing γ‐aminobutyric acid A (GABA_A) receptor functions. GABA_A receptors are heteropentamers, consisting primarily of α1‐6, β1‐3, γ2, and δ subunits in the central nervous system. These subunits can traffic to and from the membrane to regulate membrane potential. Benzodiazepines, such as diazepam and midazolam, are positive allosteric modulators of GABA_A receptors, the activation of which leads to an increase in intracellular chloride, hyperpolarization of the cell membrane, and a reduction in excitation. GABA_A receptor subunit mutations, dysregulation of trafficking, and degradation are associated with epilepsy. Although benzodiazepines are effective GABA_A receptor modulators, individual formulations have unique profiles in practice. Diazepam rectal gel is an effective rescue therapy for seizure clusters; however, adults and adolescents may have social reservations regarding its administration. Intranasal delivery of midazolam or diazepam is a promising alternative to rectal administration because these formulations offer easy, socially acceptable administration and exhibit a rapid onset. Off‐label benzodiazepines, such as orally disintegrating lorazepam and intranasal use of an intravenous formulation of midazolam via nasal atomizer, are less well characterized regarding bioavailability and tolerability compared with approved agents.

Expression of Matrix Metalloproteinases and Their Tissue Inhibitors in Chronic Rhinosinusitis With Nasal Polyps: Etiopathogenesis and Recurrence

Chronic rhinosinusitis with nasal polyps is a multifactorial disease of the nasal and paranasal sinus mucosa and it includes, as comorbidities, anatomic and morphologic alterations, allergic rhinitis, and immunologic diseases. We investigated matrix metalloproteinases (MMP-2, MMP-7, and MMP-9) and their tissue inhibitors (TIMP-1 and TIMP-2) concentration in different etiopathogenetical groups of patients with nasal polyposis (NP) in relation to recurrence after sinonasal surgery. The study group consisted of 45 patients with NP (those with allergic rhinitis, nonallergic rhinitis and asthma or nonallergic rhinitis, and obstruction of osteomeatal complex [OMC]) who underwent endonasal sinus surgery. We also collected 10 patients who underwent septoplasty as control. Immunohistochemistry of nasal mucosa fragments, Western blotting, and polymerase chain reaction analysis showed increased MMPs levels (MMP-9 more than MMP-2 and MMP-7) and decreased tissue inhibitors of MMPs levels (TIMP-1 less than TIMP-2), in patients with chronic rhinosinusitis with nasal polyps compared with control group, in particular in patients with nonallergic rhinitis and asthma compared to those with allergic rhinitis and nonallergic rhinitis and obstruction of OMC. We observed a higher risk of recurrence in patients with nonallergic rhinitis and asthma than in those with allergic rhinitis and nonallergic rhinitis and obstruction of OMC after 36 months from surgery. In this research, we evaluated pathogenesis of NP related to MMPs and their inhibitors concentrations in polypoid tissue.

[Results of inferior nasal turbinate reduction in old and very old patients with chronic rhinitis]

BACKGROUND

Symptoms of chronic rhinitis in old and very old populations may result from isolated hyperplasia of nasal inferior turbinates. Turbinoplasty is a possible method of treatment in these individuals. However, preoperative concerns are associated with their poor general condition: tendency to epistaxis, treatment with anticoagulants, hypertension, and less effective healing.

OBJECTIVE

The aim of this study was to determine differences in results of turbinoplasty obtained in old and very old individuals with chronic rhinitis, compared to young and otherwise healthy patients.

MATERIAL AND METHODS

We analyzed records of 130 patients with hyperplasia of the inferior turbinates, who had undergone bipolar diathermy turbinoplasty: 82 individuals aged 18-59 (mean = 33.8; SD = 10.2), 30 patients aged 60-74 (mean = 66.0; SD = 3.7) and 18 participants aged 75 + years (mean = 85.3; SD = 6.5). The patients were questioned about the intensity of their symptoms before and one month after the surgery, using the SNOT-20 questionnaire. The duration of wound healing and satisfaction scores were also noted.

RESULTS

Nasal patency, nasal discharge and post-nasal drip improved in old and very old patients, similarly as in the young ones. Olfactory and taste function improved significantly more in young individuals. Postoperative healing time was significantly longer in very old patients.

CONCLUSIONS

Some results of turbinoplasty in old and very old patients were significantly worse than in young ones.

Rehabilitation of patients with chronic rhinosinusitis after functional endoscopic sinus surgery

Introduction. In the case of many patients with chronic rhinosinusitis (CRS), antibiotic and steroid therapies fail, and surgery is required. The recovery of patients after surgery equally depends on the postoperative behavior of each individual patient. The paper presents the outcomes of recovery after functional endoscopic sinus surgery (FESS) in a group of 74 patients. Methods. The study was conducted in patients undergoing surgical treatment by FESS, performed by the same surgeon. For the development of the statistical database, the clinical records were collected by the same investigator. Results. On the day of surgery and on the first postoperative day, 72.9% of patients reported facial pain, 41.8% nausea, 9.4% nasal bleeding, 8.8% vomiting. At 6 months postoperatively, 71.6% of patients estimated that they had a better quality of life than before surgery, 64.8% mentioned an improvement of olfaction as an effect, and 6.7% developed septal turbinate synechiae. Conclusions. No major complications were identified in the recovery of CRS patients after FESS. Postoperative facial pain was less well tolerated by young patients (18-35 years old). The improvement of smell and the increase of disease-specific quality of life are the most relevant results of recovery after FESS mentioned by the patients included in our study. The otorhinolaryngologist and the family doctor play an important role in the education of patients regarding the importance of treatment with mineral and thermal waters in post-FESS recovery. Keywords: chronic rhinosinusitis, endoscopic sinus surgery, FESS, rehabilitation, ERAS protocols,

Overcoming the challenges of developing an intranasal diazepam rescue therapy for the treatment of seizure clusters

Seizure clusters must be treated quickly and effectively to prevent progression to prolonged seizures and status epilepticus. Rescue therapy for seizure clusters has focused on the use of benzodiazepines. Although intravenous benzodiazepine administration is the primary route in hospitals and emergency departments, seizure clusters typically occur in out‐of‐hospital settings, where a more portable product that can be easily administered by nonmedical caregivers is needed. Thus, other methods of administration have been examined, including rectal, intranasal, intramuscular, and buccal routes. Following US Food and Drug Administration (FDA) approval in 1997, rectal diazepam became the mainstay of out‐of‐hospital treatment for seizure clusters in the United States. However, social acceptability and consistent bioavailability present limitations. Intranasal formulations have potential advantages for rescue therapies, including ease of administration and faster onset of action. A midazolam nasal spray was approved by the FDA in 2019 for patients aged 12 years or older. In early 2020, the FDA approved a diazepam nasal spray for patients aged 6 years or older, which has a different formulation than the midazolam nasal product and enhances aspects of bioavailability. Benzodiazepines, including diazepam, present significant challenges in developing a suitable intranasal formulation. Diazepam nasal spray contains dodecyl maltoside (DDM) as an absorption enhancer and vitamin E to increase solubility in an easy‐to‐use portable device. In a Phase 1 study, absolute bioavailability of the diazepam nasal spray was 97% compared with intravenous diazepam. Subsequently, the nasal spray demonstrated less variability in bioavailability than rectal gel (percentage of geometric coefficient of variation of area under the curve = 42%–66% for diazepam nasal spray compared with 87%–172% for rectal gel). The diazepam nasal spray safety profile is consistent with that expected for rectal diazepam, with low rates of nasal discomfort (≤6%). To further improve the efficacy of rescue therapy, investigation of novel intranasal benzodiazepine formulations is underway.

The Effects of Postoperative Astaxanthin Administration on Nasal Mucosa Wound Healing

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BACKGROUND

Wound healing of the nasal mucosa after endoscopic sinus surgery (ESS) is frequently complicated by scaring and consequently recurrences are encountered. Methods of optimizing results have been sought. In the present study we evaluated the effects of a powerful antioxidant, astaxanthin, on nasal mucosa healing after surgery, comparing it to the extensively studied properties of dexamethasone.

MATERIALS AND METHODS

63 Wistar rats were used. The nasal mucosa from one side was damaged employing the brushing method. They were randomly divided into three experimental groups, one treated with astaxanthin, the second treated with dexamethasone and the third one acted as the control and was given normal saline. The rats were killed on days 5, 14 and 28 following injury. We observed the temporal evolution of the wound healing process and quantified the results by assessing four parameters: the epithelial thickness index (ETI), the subepithelial thickness index (STI), the goblet cell count and the subepithelial fibrosis index (SFI).

RESULTS

At 28 days, the ETI was significantly lower in the astaxanthin group (p < 0.05) compared to the other two groups. The STI was also lower in the astaxanthin group (p < 0.05), but comparable to the dexamethasone group at 28 days. The goblet cell count was higher in the astaxanthin group. The SFI had similar results in both dexamethasone and astaxanthin groups, with lower values compared to the control group. In the astaxanthin group there was no synechia formation.

CONCLUSION

Astaxanthin given in the post injury period significantly decreases fibrosis, inhibits synechia development and significantly decreases subepithelial fibrosis. Moreover, it has no general or local toxic effects.

Role of α-Tocopherol Acetate on Nasal Respiratory Functions: Mucociliary Clearance and Rhinomanometric Evaluations in Primary Atrophic Rhinitis

Primary atrophic rhinitis is a disease of the nose and of paranasalsinuses characterized by a progressive loss of function of nasal and paranasal mucosa caused by a gradual destruction of ciliary mucosalepithelium with atrophy of serous-mucous glands and loss of bonestructures.The aim of this study was to evaluate the therapeutic effects of topic α-tochopherol acetate (vitamin E) in patients with primary atrophicrhinitis based on subjective and objective data.We analyzed 44 patients with dry nose sensation and endoscopic evidence of atrophic nasal mucosa. We analyzed endoscopic mucosascore, anterior rhinomanometry, and nasal mucociliary clearance before and after 6 months of topic treatment with α-tochopherol acetate. For statistical analysis, we used paired samples t test (95% confidence interval [CI], P < .05) for rhinomanometric and muciliary transit time evaluations and analysis of variance 1-way test (95% CI, P < .05) for endoscopic evaluation. All patients showed an improvement in "dry nose" sensation and inperception of nasal airflow. Rhinomanometric examination showed increase of nasal airflow at follow-up (P < .05); nasal mucociliaryclearance showed a reduction in mean transit time (P < .05); and endoscopic evaluation showed significative improvement of hydration of nasalmucosa and significative decreasing nasal crusts and mucusaccumulation (P < .05). Medical treatment for primary atrophic rhinitis is not clearly documented in the literature; in this research, it was demonstrated that α-ochopherol acetate could be a possible treatment for atrophic rhinitis.

In vitro characterization of physico-chemical properties, cytotoxicity, bioactivity of urea-crosslinked hyaluronic acid and sodium ascorbyl phosphate nasal powder formulation

An innovative lyophilized dry powder formulation consisting of urea-crosslinked hyaluronic acid (HA-CL) and sodium ascorbyl phosphate (SAP) - LYO HA-CL - SAP- was prepared and characterized in vitro for physico-chemical and biological properties. The aim was to understand if LYO HA-CL - SAP could be used as adjuvant treatment for nasal inflammatory diseases. LYO HA-CL - SAP was suitable for nasal delivery and showed to be not toxic on human nasal septum carcinoma-derived cells (RPMI 2650 cells) at the investigated concentrations. It displayed porous, polygonal particles with unimodal, narrow size distribution, mean geometric diameter of 328.3 ± 27.5 µm, that is appropriate for nasal deposition with no respirable fraction and 88.7% of particles with aerodynamic diameter >14.1 µm. Additionally, the formulation showed wound healing ability on RPMI 2650 cells, and reduced interleukin-8 (IL-8) level in primary nasal epithelial cells pre-induced with lipopolysaccharide (LPS). Transport study across RPMI 2650 cells showed that HA-CL could act not only as carrier for SAP and active ingredient itself, but potentially also as mucoadhesive agent. In conclusion, these results suggest that HA-CL and SAP had anti-inflammatory activity and acted in combination to accelerate wound healing. Therefore, LYO HA-CL - SAP could be a potential adjuvant in nasal anti-inflammatory formulations.