International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Reusable vs disposable nasopharyngolaryngoscopes: Cost analysis and resident survey

OBJECTIVE

Assess the quality of a new disposable nasopharyngolaryngoscope (NPL) through resident feedback at multiple academic institutions and provide a cost analysis of reusable and disposable NPLs at a single academic center.

STUDY DESIGN

An online survey was distributed to residents at institutions throughout the United States that have implemented use of a disposable NPL (Ambu aScope 4 Rhinolaryngo).

SETTING

Cost analysis performed at a single academic center. Resident survey distributed to multiple residency programs throughout the United States.

SUBJECTS AND METHODS

The survey collected demographic information and asked residents to rate the new disposable NPL and other reusable NPLs using a 5-point Likert scale. A cost analysis was performed of both reusable and disposable NPLs using information obtained at a single academic center.

RESULTS

The survey was distributed to 109 residents throughout the country and 37 were completed for a response rate of 33.9%. The disposable NPL was comparable to reusable NPLs based on ergonomics and maneuverability, inferior in imaging quality (P < .001), and superior in setup (P < .001), convenience (P < .001), and rated better overall (P < .04). The disposable NPL was found to be cheaper per use than reusable NPLs at $171.82 and $170.36 compared to $238.17 and $197.88 per use for the reusable NPL if the life span is 1 year and 5 years respectively.

CONCLUSION

Disposable NPLs may offer an alternative option and initial feedback obtained from resident physicians is favorable. Cost analysis favors disposable NPLs as the cost-effective option.

LEVEL OF EVIDENCE

NA.

Reduction of CD19 autoimmunity marker on B cells of paediatric SLE patients through repressing PU.1/TNF-α/BAFF axis pathway by miR-155

microRNA-155 (miR-155) is implicated in regulating B-cell activation and survival that is important in systemic lupus erythematosus (SLE) pathogenesis. PU.1, a target for miR-155, is a crucial regulator of B-cell development and enhances Tumour-Necrosis-factor-alpha (TNF-α) expression. TNF-α induces the expression of B-cell-activating-factor (BAFF). BAFF is reported to increase the expression of the autoimmunity marker; CD19. This study aimed to investigate the regulation of expression of PU.1 in pediatric-systemic-lupus-erythematosus (pSLE) patients by miR-155, and hence evaluate its impact on TNF-α/BAFF/CD19 signalling pathway. Screening revealed that PU.1 is upregulated in PBMCs and B-cells of pSLE patients. PU.1 expression directly correlated with systemic-lupus-erythematosus disease-activity-index-2 K SLEDAI-2K. Ectopic expression of miR-155 and knockdown of PU.1 suppressed PU.1, TNF-α and BAFF. Finally, miR-155 decreased the proportion of BAFF-expressing-B-cells and CD19 protein expression. These findings suggest that miR-155 suppresses autoimmunity through transcriptional repression of PU.1 and TNF-α, which in turn suppresses BAFF and CD19 protein expression.

The utility of nasopharyngeal culture in the management of chronic adenoiditis

OBJECTIVES

To examine the utility of nasopharyngeal culture in the management of children with chronic adenoiditis to determine if it results in a change in antibiotic therapy.

METHODS

Retrospective chart review of pediatric patients managed for chronic adenoiditis, being defined as cough, postnasal drip, and congestion for over three months with endoscopic evidence of nasopharyngeal purulence with normal anterior rhinoscopy and middle meati. Standard treatment was defined as amoxicillin clavulanate or amoxicillin clavulanate ES-600 in non-penicillin allergic patients, and cefuroxime or clarithromycin for penicillin allergic patients. Nasopharyngeal culture results and antibiotic prescriptions were reviewed to look for a change from the standard.

RESULTS

Of 207 patients diagnosed with chronic adenoiditis, 198 had nasopharyngeal cultures (119 male, 79 female, mean age 3.7 years). The most common organisms isolated were Streptococcus pneumoniae sensitive to penicillin in 40 cultures (20.2%), S. pneumoniae intermediate or resistant to penicillin in 26 (13.1%), Moraxella catarrhalis in 27 (13.6%), Haemophilus influenzae in 57 (28.8%), and Staphylococcus aureus intermediate or resistant to penicillin in 26 (13.1%). 13.3% of S. aureus isolated was methicillin resistant. 103 (52.0%) children required different antibiotics from the standard, and 26 (13.1%) had no antibiotics prescribed based on a negative culture. Of the 87 children suspected to have upper airway reflux, 25 (28.7%) had negative cultures. Of the 135 patients with follow-up, 50 (37.0%) reported resolution and 50 (37.0%) reported improvement of their symptoms.

CONCLUSION

Nasopharyngeal culture has significant utility in the choice of antibiotics for children with chronic adenoiditis.

The new aromatase inhibitor CGS-16949A suppresses aldosterone and cortisol production by human adrenal cells in vitro

CGS-16949A is a new orally active nonsteroidal aromatase inhibitor which is more than 100-fold more potent than aminoglutethimide. This compound is an imidazole derivative, and therefore, its possible effect on cytochrome P-450-dependent enzyme activities in the adrenal gland was evaluated. In vitro investigations with dispersed normal and hyperplastic human adrenocortical cells showed that CGS-16949A at 10(-7)-10(-6) M is a potent 11 beta-hydroxylase inhibitor, which inhibits ACTH-stimulated cortisol release to a similar extent as an equimolar concentration of metyrapone (IC50 for both compounds, 10(-7)-5 X 10(-7) M). Etomidate was a more potent 11 beta-hydroxylase inhibitor (IC50, approximately 10(-8) M), while 10(-7)-10(-6) M ketoconazole caused (via 17 alpha-hydroxylase inhibition) a similar inhibition of cortisol release as 10(-7) M CGS-16949A (IC50, 10(-7)-5 X 10(-7) M). The 11 beta-hydroxylase inhibition by CGS-16949A was accompanied by a dose-dependent increase in the release of precursor steroids by the adrenocortical cells in vitro, including deoxycortisol, 17-hydroxyprogesterone, and androstenedione. Aldosterone release was suppressed 50% by 10(-9) M CGS-16949A, while the IC50 for cortisol in the same cells was 10(-7) M. Aldosterone release by the dispersed adenoma cells obtained from a patient with primary aldosteronism was also significantly suppressed by CGS-16949A. We concluded that 1) the new nonsteroidal aromatase inhibitor CGS 16949A is an inhibitor of 11 beta-hydroxylase which is equipotent to metyrapone. At present it is unclear whether the compound at the dose that causes complete aromatase inhibition in vivo also affects stress-induced cortisol release in man. 2) CGS-16949A exerts a very potent inhibitory effect on normal aldosterone release (IC50, 10(-9) M) and on tumorous aldosterone secretion. CGS-16949A might, therefore, be a drug that can be used in the treatment of primary hyperaldosteronism.