Jamil Manji

A systematic review of factors associated with health-related quality of life in adolescents and adults with cystic fibrosis.

RATIONALE As the life expectancy for individuals with cystic fibrosis (CF) continues to improve, an emphasis on optimizing health-related quality of life (HRQoL) has become increasingly important. The Cystic Fibrosis Questionnaire-Revised (CFQ-R 14+) is the most widely accepted method to quantify HRQoL in this patient population. OBJECTIVES Our objective was to systematically review the literature to identify sociodemographic and clinical factors associated with HRQoL among adolescents and adults with CF. METHODS Five major literature databases were searched (MEDLINE, EMBASE, CENTRAL, CINAHL, psychINFO) to identify studies published from January 1989 to April 2014 (n=1,921). We included all full-text studies that: (1) focused on individuals 14 years of age or older, and (2) examined the relationship between sociodemographic (age, sex, body-mass index [BMI], socioeconomic status, and employment) and clinical (FEV1 % predicted, pulmonary exacerbation, comorbidities) factors with the CFQ-R 14+. Effect estimates and levels of statistical significance in the association between sociodemographic and clinical factors with each of the 12 CFQ-R 14+ domains were analyzed, if examined in at least two studies. MEASUREMENTS AND MAIN RESULTS Twenty-eight articles met our inclusion/exclusion criteria, but 5 studies were excluded at the data synthesis stage, leaving 23 articles for analysis. In relation to the CFQ-R 14+, 10 candidate factors were examined in at least two studies. The five most commonly studied factors were FEV1 % predicted (57.1% of 28 studies), sex (32.1%), BMI (28.6%), age (17.6%), and pulmonary exacerbations (13%). In studies incorporating multivariable methods, FEV1 % predicted was positively associated with all CFQ-R 14+ domains with the exception of Digestion, Social Functioning, and Emotional Functioning. Male subjects reported higher Physical Functioning and lower Body Image scores than female subjects, BMI was positively correlated with Body Image and Weight, and age was negatively correlated with Treatment Burden. Pulmonary exacerbations were negatively associated with multiple domains, including Respiratory Symptoms, Physical, and Role Functioning. CONCLUSIONS Although several factors have been found to be associated with the CFQ-R in adolescents and adults with CF, FEV1 % predicted and pulmonary exacerbations have the broadest impact on HRQoL. Further research is required to investigate the impact of age-related comorbidities, psychosocial factors, and treatment-related factors on HRQoL in adolescents/adults with cystic fibrosis.

Comparing the Reverse Trendelenburg and Horizontal Position for Endoscopic Sinus Surgery A Randomized Controlled Trial

Objective To determine whether the 15-degree reverse Trendelenburg position (RTP) during functional endoscopic sinus surgery improves endoscopic field of view and reduces intraoperative blood loss when compared with the horizontal position (HP). Study Design A prospective, randomized controlled trial. Setting St Paul’s Sinus Centre, Vancouver, Canada. Subjects Patients with chronic rhinosinusitis (CRS), with or without nasal polyposis, receiving functional endoscopic sinus surgery were included. Patients were excluded if they had severe or uncontrolled hypertension and cardiovascular disease, continued use of anticoagulants, impaired coagulation, or a sinonasal tumor. Methods Sixty-four patients with CRS undergoing functional endoscopic sinus surgery (FESS) were randomized to either 15-degree RTP (experimental arm) or HP (control arm) from October 2011 to February 2012. Boezaart endoscopic field-of-view grading system was the primary outcome measure. Lund-Mackay computed tomography (CT) score, total blood loss, blood loss per minute, mean arterial pressure, heart rate, anesthetic technique, and surgery time were also recorded. Results There was a significant difference in mean Boezaart scoring between RTP and HP: 1.66 vs 2.33 (P < .001), with RTP producing a better endoscopic field of view. There was also a lower total blood loss and blood loss per minute with RTP (P = .01, P = .03). There was no significant difference in disease severity (P > .05), time of surgery (P > .05), or mean arterial pressure (P > .05) between the 2 surgical positions. Conclusion The 15-degree RTP improves the endoscopic field of view and reduces blood loss during FESS. We would therefore recommend its use.

The safety and efficacy of short-term budesonide delivered via mucosal atomization device for chronic rhinosinusitis without nasal polyposis

Budesonide is a potent corticosteroid commonly prescribed for management of inflammation in chronic rhinosinusitis (CRS). The standard for prescribing budesonide is via impregnated nasal saline irrigation (INSI), although recently the mucosal atomization device (MAD) has emerged as a theoretically superior method of distributing medication into the sinuses. The MAD atomizes medication into small droplets and this is thought to enhance absorption and improve bioavailability. However, no studies have shown whether enhanced absorption and improved bioavailability of budesonide via MAD causes adrenal suppression. The objective of this study is to determine whether budesonide via MAD affects the hypothalamic‐pituitary‐adrenal (HPA) axis.

The effect of head position on the distribution of topical nasal medication using the Mucosal Atomization Device: a cadaver study.

The Mucosal Atomization Device (MAD) distributes medication throughout the paranasal sinuses for patients with chronic rhinosinusitis (CRS). Determining the optimal head position is important to ensure maximal delivery of medication to the sinus cavities. The objective of this work was to determine the effect of the lying‐head‐back (LHB) and head‐down and forward (HDF) position, on the distribution of topical nasal medication via MAD in cadaver specimens.

Hemostatic effect of hot saline irrigation during functional endoscopic sinus surgery: a randomized controlled trial.

The endoscopically magnified operative field in functional endoscopic sinus surgery (FESS) makes even a small amount of bleeding a potentially significant hindrance. It is thought that irrigation with hot saline during surgery may improve surgical field of view by producing a hemostatic effect. Our objective was to assess the effectiveness of hot saline irrigation (HSI) compared to room temperature saline irrigation (RTSI) in the control of intraoperative bleeding during FESS.

The Sino-Nasal Outcome Test–22 as a tool to identify chronic rhinosinusitis in adults with cystic fibrosis

Chronic rhinosinusitis (CRS) is becoming increasingly prevalent in adults with cystic fibrosis (CF), as the median age of survival rises for these individuals. Delayed identification of CRS may contribute to worsening health‐related quality of life and increased treatment burden. Our objective was to investigate the utility of the 22‐item Sino‐Nasal Outcome Test (SNOT‐22) as a tool to identify CRS in adults with CF.

Sinonasal Outcomes Test-22 as a Tool to Identify Chronic Rhinosinusitis among Adults with Cystic Fibrosis

Objectives: (1) Investigate the ability of a sinus-specific health-related quality of life questionnaire (HRQoL) to distinguish clinically significant chronic rhinosinusitis (CRS) among adults with cystic fibrosis (CF). (2) Determine an appropriate cutoff score on the Sinonasal Outcomes Test-22 (SNOT-22) with sufficient test sensitivity and specificity, to assist caregivers in identifying adults with CF who may warrant specialist referral and treatment. Methods: Participants were enrolled at an adult-specific CF clinic in a tertiary academic hospital in Vancouver, Canada. Subjects completed the SNOT-22 followed by endoscopic assessment by otolaryngologists. The Canadian Clinical Practice Guidelines for Chronic Rhinosinusitis were used to confirm diagnosis of CRS. Results: To date, 52 of 80 individuals with a confirmed diagnosis of CF have participated in this study. Thirty-nine (75.0%) individuals were identified with CRS, 12 (30.8%) of whom presented with nasal polyposis. Aggregate SNOT-22 scores were significantly higher among individuals with CRS compared to non-CRS counterparts (39.4 ± 20.0 vs 22.7 ± 8.7, P = .007, 95% confidence interval [CI] for mean difference: 4.7, 28.7). A SNOT-22 score >26 was found to have a test sensitivity of 74.4% and specificity of 66.7% for diagnosis of CRS (AUC = 0.77, P < .01). Using SNOT-22 scores related to rhinological symptoms increased the likelihood ratio of a positive test when compared to aggregate scores (8.3 vs 2.2, respectively). Conclusions: The SNOT-22 significantly discriminates between CF adults with and CF adults without CRS. Using rhinological symptom scores increases the likelihood of detecting true CRS cases. The use of this questionnaire may assist specialists in identifying individuals who have clinically significant CRS, warranting specialist referral and treatment.

Comparing the efficacy of Silastic and gloved-Merocel middle meatal spacers for functional endoscopic sinus surgery: a randomized controlled trial: Comparing middle meatal spacers for FESS

Spacers are inserted into the middle meatal space (MMS) following functional endoscopic sinus surgery (FESS) to prevent lateralization of the middle turbinate, scarring, and synechiae. Our objective was to determine if the incidence of postoperative synechiae, facial pain/discomfort, pain during spacer removal, scarring, and discharge differed between nasal cavities receiving Silastic or gloved‐Merocel (GM) spacers following FESS.

Potential risk factors associated with the development of synechiae following functional endoscopic sinus surgery

PurposeSynechiae formation in the middle meatus is the most common complication of functional endoscopic sinus surgery (FESS). Our objectives were to determine the incidence of synechiae occurring in a cohort of patients that have undergone FESS and identify characteristics associated with the development of synechiae postoperatively.MethodsA retrospective chart review was conducted of CRS patients, with or without nasal polyposis, that had undergone bilateral FESS in the past. All patients had received non-absorbable spacers intraoperatively that were left in situ for 6 days. Demographic and preoperative variables were analyzed to identify synechiae risk factors. A multivariable logistic regression model was constructed to estimate the probability of developing synechiae, given demographic and preoperative variables.ResultsTwo hundred cases of bilateral FESS were retrospectively reviewed. Thirty-eight (19.0%, 95% CI 13.6–24.4%) patients developed synechiae. Individuals receiving primary FESS and nasal septal reconstruction (NSR) were strongly associated with the development of synechiae (OR 3.5, 95% CI 1.5–8.5; OR 3.0, 95% CI 1.3–6.9). A multivariable logistic regression model adjusting for NSR, recurrent FESS, concha bullosa, requirement of anterior and posterior ethmoidectomy, Lund-Mackay CT score and gender, identified the likelihood of developing synechiae with a sensitivity of 68%, specificity of 73%, positive predictive value of 38% and likelihood ratio of 2.5.ConclusionPatients undergoing primary FESS and NSR are at greatest odds of developing postoperative synechiae. Methods of assessing risk factors and preventing synechiae formation in this population should be evaluated in future prospective investigations.

A retrospective review of six hundred and nineteen cases to determine the prevalence and factors associated with revision endoscopic sinus surgery in AFRS vs NON-AFRS patients

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