Treatment of unilateral olfactory neuroblastoma: Appropriate extent of surgical resection and potential for olfactory preservation

Historically, comprehensive surgical resection for olfactory neuroblastoma has included the bilateral olfactory epithelium, cribriform plate, overlying dura, olfactory bulbs and tracts. This results in postoperative anosmia that may significantly impact a patient's quality of life without definitive added benefit in survival. The prevalence of occult intracranial disease is low, especially for Hyams grade I and II tumors. A unilateral approach sparing the contralateral cribriform plate and olfactory system can be considered for select cases of early stage, low-grade tumors when the disease does not cross midline to involve the contralateral olfactory cleft or septal mucosa and when midline dural margins can be cleared with frozen pathology. Approximately half of patients who undergo unilateral resection may have residual olfaction even with adjuvant unilateral radiation. Early data suggest favorable disease-free survival and overall survival for patients who underwent the unilateral approach; however, larger sample studies are needed to confirm comparability to bilateral resections regarding oncologic outcomes.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Chemosensory function recovery in COVID-19 patients: A cross-sectional study

OBJECTIVE

To determine whether subjects who have recovered from COVID-19 smell and taste disturbance perform similarly to their COVID-naïve baseline, on gold-standard smell and taste tests.

STUDY DESIGN

Prospective cross-sectional study.

SETTING

University of Miami Department of Otolaryngology in Miami, FL between September 2021, and August 2022.

METHODS

Those previously COVID-19 positive composed the experimental group, those who reported being COVID-naïve composed the control group. Mean total score for the UPSIT Smell Test, and the Burghart Taste Strip test were the primary outcome measures.

RESULTS

70 adult subjects (35 former COVID-positive, 35 COVID-naïve) were enrolled, with 21 females and 14 males in each group. 87 % of all subjects were white and were almost distributed evenly between Hispanic and non-Hispanic. Mean UPSIT total score for the experimental group was 30.6 (95 % CI 28.9-32.3), mean UPSIT total score for the control group was 31.2 (95 % CI 29.7-32.8). Mean Burghart total score for the experimental group was 11.3 (95 % CI 10.6-12.0), mean Burghart total score for the control group was 10.7 (95 % CI 9.7-11.8). These showed a significant overlap of the 95 % CI of the mean total score between the control group and the experimental group, suggesting no significant difference between the two groups.

CONCLUSION

These results suggest that COVID-19 patients who experience smell and taste disturbance and recover, regain sensory ability similar to their pre-COVID ability. Further study is needed to validate these findings, but the results are promising in the long-term recovery of COVID-19.

Retrospective Review of Surgical Site Infections after Endoscopic Endonasal Sellar and Parasellar Surgery: Multicenter Quality Data from the North American Skull Base Society

Introduction  Transnasal access to the anterior skull base provides a minimally invasive approach for sellar and parasellar masses compared with its open counterparts. The unique microbiome of the sinonasal mucosa provides distinct challenges not encountered with other cranial approaches. The use of antibiotics in these cases has not been standardized, and data remain scarce regarding infectious outcomes. Methods  We conducted a multicenter retrospective analysis of shared quality data points for the endoscopic endonasal approach (EEA) for pituitary adenomas, along with other sellar and parasellar region masses that were included by participating institutions. Patient and operative characteristics, perioperative and postoperative antibiotic regimens and their durations, intraoperative and postoperative cerebrospinal fluid leak, and onset of postoperative meningitis and sinusitis were compared. Results  Fifteen institutions participated and provided 6 consecutive months' worth of case data. Five hundred ninety-three cases were included in the study, of which 564 were pituitary adenomectomies. The incidences of postoperative meningitis and sinusitis were low (0.67 and 2.87% for all pathologies, respectively; 0.35% meningitis for pituitary adenomas) and did not correlate with any specific antibiotic regimen. Immunocompromised status posed an increased odds of meningitis in pituitary adenomectomies (28.6, 95% confidence interval [1.72-474.4]). Conclusions  The results show no clear benefit to postoperative antimicrobial use in EEA, with further larger studies needed.

Multidisciplinary Postoperative Care Pathway to Reduce Readmissions following Endoscopic Transsphenoidal Pituitary Surgery: Improving Quality of Patient Care

Background  Thirty-day unplanned readmission following endoscopic transsphenoidal pituitary surgery (ETPS) occurs in up to 14% of patients. Delayed hyponatremia is one of the most common causes, accounting for 30% of readmissions and often occurs within 1 week of surgery. The authors' prior retrospective review identified endocrinology follow-up as protective factor. Objectives  Implementation of a multidisciplinary postoperative care (POC) pathway: (1) to reduce 30-day hospital readmissions following ETPS and (2) improve inpatient and outpatient coordination of care with endocrinologist. Methods  This study is a single institution temporal cohort study of patients prior to (control cohort) and after implementation of the POC pathway (intervention cohort). The POC pathway utilized postdischarge 1 to 1.5 L/d fluid restriction, postoperative days 5 to 7 serum sodium, and endocrinology follow-up within 1 week of discharge to stratify patients into tiered hyponatremia regimens. Results  A total of 542 patients were included in the study, 409 (75%) in the control cohort and 133 (25%) in the intervention cohort. All-cause readmission was significantly reduced following implementation of the POC pathway (14 vs. 6%, p  = 0.015). Coordination with endocrinologist significantly increased in the inpatient (96 vs. 83%, p  < 0.001) and outpatient (77 vs. 68%, p  = 0.042) settings. Patients who were not in the POC pathway had the highest risk of readmission (odds ratio: 2.5; 95% confidence interval: 1.1-5.5). Conclusion  A multidisciplinary POC pathway incorporating endocrinologist in conjunction with postdischarge weight-based fluid restriction and postoperative serum sodium levels can safely be used to reduce 30-day readmissions following ETPS.

Opiate vs non-opiate prescription medication for pain control after endoscopic sinus surgery for chronic rhinosinusitis

PURPOSE

Research indicates that most providers give opiates after endoscopic sinonasal surgery. The effectiveness of non-opiate medications after sinonasal surgery is poorly understood and most studies do not assess medication failure. This study compares oral opiate, oral opiate and topical steroid, and oral non-opiate pain control. Patient call-backs are used as a proxy for pain medication failure.

MATERIALS AND METHODS

This study compares three medication regiments after sinonasal surgery for 180 adults with chronic rhinosinusitis. Patients were instructed to take acetaminophen for mild pain. For moderate/severe pain, patients used: 1) oxycodone-acetaminophen, 2) oxycodone-acetaminophen + budesonide nasal rinses, or 3) meloxicam + acetaminophen. Patients were instructed to call clinic if pain was not controlled. Descriptive statistics compared cohorts. Chi-square tests compared call-backs between cohorts. Logistic regression adjusted for baseline differences in covariates, comorbidities, and operative sites.

RESULTS

Cohorts had similar age, sex distribution, disease features, and extent of surgery. The meloxicam cohort had less subjects with pain disorders. The oxycodone cohort had less subjects with diabetes, septoplasty, and turbinate reduction. After adjusting for baseline differences and using oxycodone as the reference group (n = 50), the odds of calling clinic for poorly controlled pain was 0.18 (95% Confidence Interval (CI): 0.05-0.6) in the meloxicam cohort (n = 45) and 0.19 (95% CI:0.07-0.5) in the oxycodone + budesonide rinses cohort (n = 85).

CONCLUSION

In this study, both meloxicam and oxycodone + budesonide rinses were more effective at controlling pain after sinonasal surgery than oxycodone alone.

Chronic Rhinosinusitis Disease Disparity in the South Florida Hispanic Population

OBJECTIVES/HYPOTHESIS

The role of social determinants of health in chronic rhinosinusitis (CRS) is poorly characterized. Limited research examining CRS health disparities indicates that minority status is associated with worse CRS. However, many of these studies are retrospective or performed in populations without substantial ethnic minorities. Rhinologists need to characterize existing CRS disease disparities to develop targeted strategies for improving care in these populations. This prospective study assesses preoperative CRS disease burden in South Florida (SFL) Hispanic and non-Hispanic patients and examines potential factors contributing CRS disease disparities.

STUDY DESIGN

Prospective cohort study.

METHODS

The prospective cohort study included consecutive patients having primary endoscopic sinus surgery (ESS) for CRS between September 2019 and February 2020 with complete preoperative data. Data were collected in clinic and surgery. Descriptive statistics compare Hispanic and non-Hispanic cohorts. Linear regression adjusts for confounders. Relative risk (RR) compared CRS severity markers.

RESULTS

Thirty-eight Hispanic and 56 non-Hispanic patients met inclusion criteria. Age, sex, CT scores, insurance payer, and comorbidities were similar between cohorts. Hispanics presented with worse 22-item Sinonasal Outcome Test (SNOT-22) (55; SD = 18) compared to non-Hispanics (37; SD = 22) (P < .001). Hispanics tended to have a higher risk of severe CRS markers, including nasal polyps RR = 2.5 (95% CI: 1.0-5.9), neo-osteogenesis RR = 1.6 (95% CI: 0.5-4.7), extended procedures (i.e., draft III) RR = 2.97 (95% CI: 1.0-9.1), and tissue eosinophilia RR = 1.46 (95% CI: 0.6-3.5). Hispanics reported longer sinonasal symptom duration.

CONCLUSIONS

SFL hispanic patients presenting for primary ESS have worse sinonasal disease burden. SFL Hispanics have markers of greater CRS severity and report longer delays before receiving CRS care. These factors may contribute to increased sinonasal disease burden in Hispanic patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:2659-2665, 2021.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), oxygen desaturation index (ODI), increase in lowest oxygen saturation (LSAT), sleep quality, and improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI, and increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, ODI, and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggest that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

American Rhinologic Society expert practice statement: Postoperative pain management and opioid use after sinonasal surgery

The goal of this American Rhinologic Society expert practice statement (EPS) is to provide clinically applicable, evidence-based recommendations regarding pain management in sinonasal surgery. This EPS was developed following the recommended methodology and approval process as previously outlined. The topics of interest included preoperative counseling, local anesthesia, use of opioids for postoperative pain, use of nonopioid medication for postoperative pain, nonsteroidal anti-inflammatory drugs and bleeding, and use of gabapentin for pain control. Following a modified Delphi approach, 6 statements were developed, 5 of which reached consensus and 1 that did not. These statements and accompanying evidence are summarized along with an assessment of future needs.

Olfactory and Gustatory Dysfunction as an Early Identifier of COVID-19 in Adults and Children: An International Multicenter Study

OBJECTIVE

To evaluate the prevalence and characteristics of olfactory or gustatory dysfunction in coronavirus disease 2019 (COVID-19) patients.

STUDY DESIGN

Multicenter case series.

SETTING

Five tertiary care hospitals (3 in China, 1 in France, 1 in Germany).

SUBJECTS AND METHODS

In total, 394 polymerase chain reaction (PCR)-confirmed COVID-19-positive patients were screened, and those with olfactory or gustatory dysfunction were included. Data including demographics, COVID-19 severity, patient outcome, and the incidence and degree of olfactory and/or gustatory dysfunction were collected and analyzed. The Questionnaire of Olfactory Disorders (QOD) and visual analog scale (VAS) were used to quantify olfactory and gustatory dysfunction, respectively. All subjects at 1 hospital (Shanghai) without subjective olfactory complaints underwent objective testing.

RESULTS

Of 394 screened subjects, 161 (41%) reported olfactory and/or gustatory dysfunction and were included. Incidence of olfactory and/or gustatory disorders in Chinese (n = 239), German (n = 39), and French (n = 116) cohorts was 32%, 69%, and 49%, respectively. The median age of included subjects was 39 years, 92 of 161 (57%) were male, and 10 of 161 (6%) were children. Of included subjects, 10% had only olfactory or gustatory symptoms, and 19% had olfactory and/or gustatory complaints prior to any other COVID-19 symptom. Of subjects with objective olfactory testing, 10 of 90 demonstrated abnormal chemosensory function despite reporting normal subjective olfaction. Forty-three percent (44/102) of subjects with follow-up showed symptomatic improvement in olfaction or gustation.

CONCLUSIONS

Olfactory and/or gustatory disorders may represent early or isolated symptoms of severe acute respiratory syndrome coronavirus 2 infection. They may serve as a useful additional screening criterion, particularly for the identification of patients in the early stages of infection.

Olfactory and Gustatory Dysfunction as An Early Identifier of COVID-19 in Adults and Children: An International Multicenter Study

OBJECTIVE

Evaluate the prevalence and characteristics of olfactory or gustatory dysfunction in COVID-19 patients Study Design: Multicenter Case Series Setting: 5 tertiary care hospitals (3 in China, 1 in France, 1 in Germany) Subjects and Methods: 394 PCR confirmed COVID-19 positive patients were screened, and those with olfactory or gustatory dysfunction were included. Data including demographics, COVID-19 severity, patient outcome, and the incidence and degree of olfactory and/or gustatory dysfunction were collected and analyzed. The Questionnaire of Olfactory Disorders (QOD) and Visual Analogue Scale (VAS) were used to quantify olfactory and gustatory dysfunction respectively. All subjects at one hospital (Shanghai) without subjective olfactory complaints underwent objective testing.

RESULTS

Of 394 screened subjects, 161 (41%) reported olfactory and/or gustatory dysfunction and were included. Incidence of olfactory and/or gustatory disorders in Chinese (n=239), German (n=39) and French (n=116) cohorts were 32%, 69%, and 49% 138 respectively. The median age of included subjects was 39 years old, 92/161 (57%) were male, and 10/161 (6%) were children. Of included subjects, 10% had only olfactory or gustatory symptoms, and 19% had olfactory and/or gustatory complaints prior to any other COVID-19 symptom. Of subjects with objective olfactory testing, 10/90 demonstrated abnormal chemosensory function despite reporting normal subjective olfaction. 43% (44/102) of subjects with follow-up showed symptomatic improvement in olfaction or gustation.

CONCLUSIONS

Olfactory and/or gustatory disorders may represent early or isolated symptoms of SARS-CoV-2 infection. They may serve as a useful additional screening criterion, particularly for the identification of patients in the early stages of infection.

Somatization, Depression, and Anxiety Disorders in a Rhinology Practice

Background

Patients present to rhinology clinics with various complaints. Symptoms may be attributable to objective findings, some remain unexplained. The objective is to investigate the incidence of psychological disorders in a rhinologic practice and evaluate a correlation of these psychiatric diseases with rhinologic symptoms.

Methods

Patients presenting to a rhinology clinic were administered the Generalized Anxiety Disorder 7 (GAD 7), Patient Health Questionnaire 9 (PHQ 9), and PHQ 15, psychometric instruments that can screen for generalized anxiety, major depression, and somatization disorder, respectively. Patients’ symptoms, endoscopic findings, medication, and psychiatric history were recorded. Multivariable analysis was performed for patients showed moderate-to-severe anxiety, depression, and somatic symptoms via 3 logistic regressions where the outcome was a GAD 7, PHQ 9, or PHQ 15 above 10.

Results

One hundred ninety-six patients were included for this study. There were 109 females and 87 males with a mean age of 49 years. Overall, 9%, 14%, and 21% exhibited moderate-to-severe anxiety, depressive, and somatization symptoms, respectively. Nasal obstruction was the only statistically significant variable that increased the odds of having moderate-to-severe anxiety symptoms. Similarly, headache, nasal obstruction, and anosmia/hyposmia were associated with increased odds of having depressive symptoms, and female gender, headache, and nasal discharge increased the odds of somatic symptom disorder. Edema was the only objective endoscopic finding, which was associated with depression only.

Conclusions

Patients should be counseled about the pathophysiology and psychiatric comorbidities affecting their primary rhinologic complaints. The provider needs to set realistic treatment expectations in order to achieve the desired clinical outcomes.

Revision Functional Endoscopic Sinus Surgery

Refractory chronic rhinosinusitis can be challenging to treat. Initial treatment focuses on medical and nonsurgical treatments. If these treatments fail, revision endoscopic sinus surgery is an option. A plan for revision surgery must address anatomic factors contributing to recurrence. Preoperative imaging and sinonasal endoscopy are systematically reviewed; areas of disease and "danger" zones are identified. Traditional anatomic landmarks are often obscured or absent; thus, a set of consistent landmarks (unchanged despite prior surgery) are used to navigate the revision endoscopic sinus surgery. Wide sinusotomies permit visualization and access to disease intraoperatively. Large sinus openings also facilitate post-operative debridements in clinic, endoscopic disease monitoring, and topical sinus therapy.

Functional Comorbidity Index in chronic rhinosinusitis

BACKGROUND

The Functional Comorbidity Index is a promising tool to predict general health status and adjust for comorbidity confounding in outcomes studies of chronic conditions, but it has been tested as a predictor of general health status only in a sleep apnea cohort. We tested it in a chronic rhinosinusitis cohort with 2 objectives: (1) measure the association between the Functional Comorbidity Index (range, 0 to 18) and general health status (SF-36 Physical Component Score and Mental Component Score); and (2) test if the Functional Comorbidity Index is more strongly associated (a better predictor) than the well-known Charlson Comorbidity Index (range, 0 to 37) with these SF-36 outcome measures.

METHODS

In a cross-sectional study of chronic rhinosinusitis patients, we obtained scores for the Functional Comorbidity Index, Charlson Comorbidity Index, and the SF-36. We calculated Spearman correlations and adjusted coefficients of determination (R(2)) using multiple linear regression, adjusted for demographic covariates. Bootstrapping generated R(2) distributions for statistical comparison.

RESULTS

In the cohort (N = 97), the Functional Comorbidity Index scores (mean ± standard deviation: 2.2 ± 1.9) were more widely distributed than Charlson Comorbidity Index scores (0.6 ± 1.2). The Functional Comorbidity Index significantly correlated with the SF-36 Physical Component Score (-0.49, p < 0.001) and Mental Component Score (-0.37, p < 0.001). The Functional Comorbidity Index was a better predictor than the Charlson Comorbidity Index of SF-36 Physical Component Score (R(2) mean ± standard error: 0.21 ± 0.09 vs 0.15 ± 0.05; p < 0.001) and Mental Component Score (0.16 ± 0.10 vs 0.01 ± 0.06; p < 0.001).

CONCLUSION

The Functional Comorbidity Index is a more robust predictor of general health status than the Charlson Comorbidity Index in chronic rhinosinusitis patients.

Functional comorbidity index in sleep apnea

OBJECTIVES

(1) Measure the association between the Functional Comorbidity Index (range, 0-18) and physical function health status (SF-36 Physical Function domain), general physical health status (SF-36 Physical Component Score), and general mental health status (SF-36 Mental Component Score) outcome measures in a cohort of sleep apnea patients. (2) Test if the Functional Comorbidity Index is more strongly associated (a better predictor) than the well-known Charlson Comorbidity Index (range, 0-37) with these SF-36 outcome measures.

STUDY DESIGN

Cross-sectional study.

SETTING

University of Washington Sleep Center.

SUBJECTS AND METHODS

In a cohort of newly diagnosed obstructive sleep apnea patients (N = 233), we obtained scores for the Functional Comorbidity Index, Charlson Comorbidity Index, and SF-36. We calculated Spearman correlations and adjusted coefficients of determination (R2) with multiple linear regression, adjusted for demographic and health covariates. Bootstrapping generated R2 distributions for statistical comparison.

RESULTS

Functional Comorbidity Index scores (mean ± standard deviation 2.4 ± 1.7) were more widely distributed than Charlson Comorbidity Index scores (0.7 ± 1.4). The Functional Comorbidity Index was significantly correlated with SF-36 Physical Function (-0.53, P < .001), Physical Component Score (-0.44, P < .001), and Mental Component Score (-0.38, P < .001). The Functional Comorbidity Index was a better predictor than the Charlson Comorbidity Index of SF-36 Physical Function (R (2) mean ± standard error 0.27 ± 0.05 vs. 0.17 ± 0.05, P < .001), Physical Component Score (0.23 ± 0.05 vs. 0.17 ± 0.05, P < .001), and Mental Component Score (0.23 ± 0.05 vs. 0.13 ± 0.05, P < .001).

CONCLUSION

The Functional Comorbidity Index is a more robust predictor of general health status than the Charlson Comorbidity Index in obstructive sleep apnea patients.

Development and Validation of a Health-Related Quality-of-Life Comorbidity Index

Objectives:

Comorbidity indexes adjust for comorbidity confounding on a specific outcome, but no index is designed specifically for a quality of life (QOL) outcome. The Functional Comorbidity Index was previously designed to predict physical function. The goals of this study: 1) Develop a Quality of Life Comorbidity Index (QOLI) designed specifically to predict QOL (measured using SF-36 component scores) in sleep apnea patients; 2) Compare the ability to predict QOL between the QOLI, the Functional Comorbidity Index, and another commonly used index.

Methods:

A random sample of 300 subjects, selected from prospectively enrolled sleep apnea patients between 2004-07, was split into a model-development cohort (n=200) and a validation cohort (n=100). Additional comorbidities suspected to impact QOL were selected as candidate variables to add to the Functional Comorbidity Index. Multivariate linear regression using predictive stepwise modeling was applied to determine which candidate variables maximized the ability to predict QOL (adjusted R2). The resultant QOLI was tested in the validation cohort, and the ability to predict QOL was compared to other comorbidity indexes.

Results:

The QOLI model that best predicted QOL added smoking, illicit drug use, migraine, fibromyalgia, allergies, and sinusitis to the Functional Comorbidity Index. The ability to predict QOL (adjusted R2) was better in the QOLI by 10% compared to the Functional Comorbidity Index and by 18% compared to the Charlson Comorbidity Index.

Conclusions:

The QOLI is useful to predict quality of life and is a more robust predictor of QOL than other comorbidity indexes in obstructive sleep apnea patients.

The Functional Comorbidity Index Is Useful to Predict Quality of Life

Objectives:

Comorbidity indexes adjust for comorbidity confounding on a specific outcome, but no index is designed specifically for a quality of life (QOL) outcome. The Functional Comorbidity Index was previously designed to predict physical function-related QOL. The goals of this study: 1) Assess the Functional Comorbidity Index as a predictor of general QOL in sleep apnea patients (measured by SF-36 component scores); 2) Compare the ability to predict general QOL between the Functional Comorbidity Index and the widely used Charlson Comorbidity Index.

Methods:

Between 2004-2007 669 adults with sleep apnea were prospectively enrolled and data collected for the QOL outcome variables and the comorbidity indexes as independent variables. A random sample of 250 was analyzed with Spearman correlations between each index and QOL measures. Multivariate linear regression models calculated the ability to predict QOL (adjusted R2) adjusted for demographics and sleep apnea severity. Bootstrapping generated variances in the regression coefficients to test statistically for a clinically important (10%) difference between indexes.

Results:

Correlations of the Functional and Charlson Comorbidity Indexes with the mental component of QOL were -0.38 ( P < 0.0001) and -0.07 ( P = 0.2946), respectively. The Functional Comorbidity Index was clinically and statistically superior to the Charlson Comorbidity Index for predicting the mental component of QOL (adjusted R2 0.23 and 0.13, respectively, P < 0.001). Similar results were found for predicting the physical component of QOL.

Conclusions:

The Functional Comorbidity Index is useful to predict QOL and is a more robust predictor of QOL than the Charlson Comorbidity Index in sleep apnea patients.

Allergic Rhinitis and Changing Nasal Congestion after Continuous Positive Airwary Pressure

Objective: Among continuous positive airway pressure (CPAP) users, self-reported allergic rhinitis has been associated with relative worsening of subjective nasal congestion. This study’s aims were to test the associations between objective allergic rhinitis status and 1) change in objective nasal congestion after CPAP initiation, or 2) objective CPAP use.

Method: Objective allergic rhinitis status was established by skin-prick test of 17 region-specific aeroallergens in CPAP patients with baseline turbinate hypertrophy. Objective nasal congestion was measured by acoustic rhinometry (combined bilateral minimal cross-sectional area, MCA) at baseline and 3-months later in subjects using CPAP. Objective CPAP use was measured at 12 months.

Results: This cohort study included n = 81 subjects from a larger parent trial on turbinate hypertrophy in CPAP patients. In this cohort, MCA did not change significantly in subjects with allergic rhinitis (n = 51, paired t-test P = .18) or in controls (n = 30, paired t-test P = .67) after initiation of CPAP, and there was no significant difference in change between groups ( t-test P = .28). CPAP use in allergic rhinitis subjects (1.9 ± 2.7 h/night) was not significantly different from controls (2.4 ± 3.0 h/night; Mann-Whitney U test, P = .28), but statistical power was limited for the observed difference (power 12%).

Conclusion: Allergic rhinitis did not predict worsening of objective nasal congestion with CPAP initiation or decreased CPAP use, but confounding, eligibility criteria, limits of objective nasal measurements, and insufficient statistical power may have blunted a true effect. Further studies are needed.

Long-term complications of septal dermoplasty in patients with hereditary hemorrhagic telangiectasia

OBJECTIVE

Septal dermoplasty has been recommended as the treatment of choice for life-threatening epistaxis in patients with hereditary hemorrhagic telangiectasia. This study evaluates the complications of septal dermoplasty in the management of transfusion-dependent epistaxis.

STUDY DESIGN

Consecutive retrospective study.

SUBJECTS AND METHODS

Between 1994 and 2006, septal dermoplasty was performed on 106 consecutive patients with transfusion dependent epistaxis. Of 103 potential patients, 37 either died or were lost to follow-up, which left 66 patients for study. Data on complications and quality of life were collected on 50 (76%) of 66 patients (mean follow-up, 3.75 years) via phone interview.

RESULTS

Seventy-eight percent experienced nasal odor; 72% had nasal crusting; 58% had decreased sense of smell; 30% noted worsened sinus infection; 88% could breathe through their nose; 86% stated improved quality of life.

CONCLUSION

Septal dermoplasty remains an effective way of treating transfusion dependent epistaxis in patients with hereditary hemorrhagic telangiectasia and subjectively improves their quality of life.

Suppression of melanotroph carcinogenesis leads to accelerated progression of pituitary anterior lobe tumors and medullary thyroid carcinomas in Rb+/- mice

Mice with a single copy of the retinoblastoma gene (Rb(+/-)) develop a syndrome of multiple neuroendocrine neoplasia. They usually succumb to fast-growing, Rb-deficient melanotroph tumors of the pituitary intermediate lobe, which are extremely rare in humans. Thus, full assessment of Rb role in other, more relevant to human pathology, neoplasms is complicated. To prevent melanotroph neoplasia while preserving spontaneous carcinogenesis in other types of cells, we have prepared transgenic mice in which 770-bp fragment of pro-opiomelanocortin promoter directs expression of the human RB gene to melanotrophs (TgPOMC-RB). In three independent lines, transgenic mice crossed to Rb(+/-) background are devoid of melanotroph tumors but develop the usual spectrum of other neoplasms. Interestingly, abrogation of melanotroph carcinogenesis results in accelerated progression of pituitary anterior lobe tumors and medullary thyroid carcinomas. A combination of immunologic tests, cell culture studies, and tumorigenicity assays indicates that alpha-melanocyte-stimulating hormone, which is overproduced by melanotroph tumors, attenuates neoplastic progression by decreasing cell proliferation and inducing apoptosis. Taken together, we show that cell lineage-specific complementation of Rb function can be successfully used for refining available models of stochastic carcinogenesis and identify alpha-melanocyte-stimulating hormone as a potential attenuating factor during progression of neuroendocrine neoplasms.

Suppression of Melanotroph Carcinogenesis Leads to Accelerated Progression of Pituitary Anterior Lobe Tumors and Medullary Thyroid Carcinomas in Rb+/− Mice

Mice with a single copy of the retinoblastoma gene (Rb+/−) develop a syndrome of multiple neuroendocrine neoplasia. They usually succumb to fast-growing, Rb-deficient melanotroph tumors of the pituitary intermediate lobe, which are extremely rare in humans. Thus, full assessment of Rb role in other, more relevant to human pathology, neoplasms is complicated. To prevent melanotroph neoplasia while preserving spontaneous carcinogenesis in other types of cells, we have prepared transgenic mice in which 770-bp fragment of pro-opiomelanocortin promoter directs expression of the human RB gene to melanotrophs (TgPOMC-RB). In three independent lines, transgenic mice crossed to Rb+/− background are devoid of melanotroph tumors but develop the usual spectrum of other neoplasms. Interestingly, abrogation of melanotroph carcinogenesis results in accelerated progression of pituitary anterior lobe tumors and medullary thyroid carcinomas. A combination of immunologic tests, cell culture studies, and tumorigenicity assays indicates that α-melanocyte–stimulating hormone, which is overproduced by melanotroph tumors, attenuates neoplastic progression by decreasing cell proliferation and inducing apoptosis. Taken together, we show that cell lineage–specific complementation of Rb function can be successfully used for refining available models of stochastic carcinogenesis and identify α-melanocyte–stimulating hormone as a potential attenuating factor during progression of neuroendocrine neoplasms.

The efficiency of protein compartmentalization into the secretory pathway

Numerous proteins targeted for the secretory pathway are increasingly implicated in functional or pathological roles at alternative cellular destinations. The parameters that allow secretory or membrane proteins to reside in intracellular locales outside the secretory pathway remain largely unexplored. In this study, we have used an extremely sensitive and quantitative assay to measure the in vivo efficiency of signal sequence-mediated protein segregation into the secretory pathway. Our findings reveal that segregation efficiency varies tremendously among signals, ranging from >95 to <60%. The nonsegregated fraction is generated by a combination of mechanisms that includes inefficient signal-mediated translocation into the endoplasmic reticulum and leaky ribosomal scanning. The segregation efficiency of some, but not other signal sequences, could be influenced in cis by residues in the mature domain or in trans by yet unidentified cellular factors. These findings imply that protein compartmentalization can be modulated in a substrate-specific manner to generate biologically significant quantities of cytosolically available secretory and membrane proteins.

New recombinant HLA-B alleles in a tribe of South American Amerindians indicate rapid evolution of MHC class I loci

Evidence suggests that the New World was colonized only 11,000-40,000 years ago by Palaeo-Indians. The descendants of these Palaeo-Indians therefore provide a unique opportunity to study the effects of selection on major histocompatibility complex class I genes over a short period. Here we analyse the class I alleles of the Waorani of South America and the Zuni of North America. Four of the Waorani HLA-B alleles were new functional variants which could be accounted for by intralocus recombination. In contrast, all of the Zuni HLA-A and -B molecules were present in caucasians and orientals. This suggests that the new Waorani HLA-B variants arose in South America. The description of four new HLA-B alleles in the Waorani and another five new HLA-B alleles from two other tribes of South American Amerindians indicates that the HLA-B locus can evolve rapidly in isolated populations. These studies underline the importance of gathering genetic data on endangered native human populations.

A chimpanzee-passaged human immunodeficiency virus isolate is cytopathic for chimpanzee cells but does not induce disease

The human immunodeficiency virus type 1 (HIV-1) readily infects both humans and chimpanzees, but the pathologic outcomes of infection in these two species differ greatly. In attempts to identify virus-cell interactions that might account for this differential pathogenicity, chimpanzee peripheral blood lymphocytes and bone marrow macrophages were assessed in vitro for their ability to support the replication of several HIV-1 isolates. Although the IIIb, RF, and MN isolates did not readily infect chimpanzee peripheral blood lymphocytes, an isolate of HIV-1 passaged in vivo in chimpanzees not only replicated well in both chimpanzee peripheral blood lymphocytes and bone marrow macrophages but also was cytopathic for chimpanzee CD4+ lymphocytes. Because no evidence of HIV-induced disease has been observed in chimpanzees infected with this isolate, in vitro replication to high titers with concomitant loss of CD4+ cells is not, in this instance, a correlate of pathogenicity. These observations, therefore, indicate that caution must be used when making extrapolations from in vitro data to in vivo pathogenesis.

Immunization of simian immunodeficiency virus-infected rhesus monkeys with soluble human CD4 elicits an antiviral response

Since the CD4 molecule is a high-affinity cell-surface receptor for the human immunodeficiency virus (HIV), it has been suggested that a soluble truncated form of CD4 may compete with cell-surface CD4 for HIV binding and thus be of use in the therapy of AIDS. We have utilized the simian immunodeficiency virus of macaques (SIVmac)-infected rhesus monkeys to explore another possible therapeutic application of CD4 in AIDS--the use of recombinant soluble CD4 (rsCD4) as an immunogen. SIVmac-infected rhesus monkeys immunized with human rsCD4 developed not only an anti-human CD4 but also an anti-rhesus monkey CD4 antibody response. Coincident with the generation of this antibody response, SIVmac could not be isolated easily from peripheral blood lymphocytes and bone marrow macrophages of these animals. Furthermore, the decreased number of both granulocyte/macrophage and erythrocyte colonies grown from the bone marrow of these immunized monkeys rose to normal levels. These findings suggest that a modified human CD4 molecule serving as an immunogen might elicit an antibody response in man that could induce a beneficial therapeutic response in HIV-infected individuals.