Stacey T. Gray

Risk factors for development of chronic rhinosinusitis in patients with allergic rhinitis

Chronic rhinosinusitis (CRS) is a heterogeneous inflammatory condition of the sinonasal cavity. CRS may be preceded by other sinonasal inflammatory diseases including allergic rhinitis (AR). It is unclear what factors may predispose patients with AR to develop CRS.

The EQ-5D: a new tool for studying clinical outcomes in chronic rhinosinusitis.

To describe the role and applicability of the EuroQol 5‐Dimension, 5‐Level (EQ‐5D‐5L) questionnaire for the assessment of general health‐related quality of life in patients with chronic rhinosinusitis.

Incidence and survival patterns of cranial chordoma in the United States

To determine trends in survival patterns for cranial chordoma in the United States.

Sinonasal anatomic variants and asthma are associated with faster development of chronic rhinosinusitis in patients with allergic rhinitis

Allergic rhinitis (AR) and chronic rhinosinusitis (CRS) are a major burden to the healthcare system. Although no causal relationship has been established, previous work has demonstrated a strong association of AR with CRS. In this study, we sought to identify risk factors that may influence speed of development of CRS in patients with AR.

Cigarette smoke combined with Toll-like receptor 3 signaling triggers exaggerated epithelial regulated upon activation, normal T-cell expressed and secreted/CCL5 expression in chronic rhinosinusitis

BACKGROUND Chronic rhinosinusitis (CRS) is characterized by persistent mucosal inflammation and frequent exacerbations. OBJECTIVE To determine whether innate epithelial responses to cigarette smoke or bacterial or viral pathogens may be abnormal in CRS leading to an inappropriate inflammatory response. METHODS Primary nasal epithelial cells (PNECs) were grown from middle turbinate biopsies of 9 healthy controls and 11 patients with CRS. After reaching 80% to 90% confluence, PNECs were exposed to medium or cigarette smoke extract (CSE) 5% (vol/vol) for 1 hour, washed, then stimulated with staphylococcal lipoteichoic acid, LPS, or double-stranded RNA (dsRNA). After 24 hours, gene expression was quantified by QRT-PCR. RESULTS At baseline, PNECs revealed elevated TNF-alpha and growth-related oncogene-alpha (a C-X-C chemokine)/CXCL1 (GRO-alpha) (4-fold increase, P = .02; and 16-fold increase, P = .004, respectively) in subjects with CRS compared with controls with normal levels of IL-1beta, IL-6, IL-8/CXCL8, human beta-defensin-2, monocyte chemoattractant protein 2/CCL8, monocyte chemoattractant protein 3/CCL7, and regulated upon activation, normal T-cell expressed and secreted (RANTES)/CCL5. Immunostaining of nasal biopsies, however, revealed comparable epithelial staining for TNF-alpha, GRO-alpha, and RANTES. There were no differences in mRNA induction by CSE, TNF-alpha, lipoteichoic acid, LPS, or dsRNA alone. The combination of CSE+dsRNA induced exaggerated RANTES (12,115-fold vs 1500-fold; P = .03) and human beta-defensin-2 (1120-fold vs 12.5-fold; P = .05) in subjects with CRS. No other genes were differentially induced. Furthermore, CSE+dsRNA induced normal levels of IFN-beta, IFN-lambda1, and IFN-lambda2/3 mRNA in subjects with CRS. CONCLUSION Cigarette smoke extract plus dsRNA induces exaggerated epithelial RANTES expression in patients with CRS. We propose that an analogous response to cigarette smoke plus viral infection may contribute to acute exacerbations and eosinophilic mucosal inflammation in CRS.

Improving Empathy and Relational Skills in Otolaryngology Residents A Pilot Study

Physician empathy and relational skills are critical factors predicting quality of care, patient safety, patient satisfaction, and decreasing malpractice claims. Studies indicate that physician empathy declines throughout medical training, yet little is published about methods to enhance empathy, especially in surgical residency training. The Accreditation Council for Graduate Medical Education requires competencies in 6 areas, including interpersonal skills and communication. To address this important problem, the first author developed an innovative empathy-relational skills training protocol focusing on the underlying neurobiological mechanisms of empathy and the interpersonal processes that positively affect the patient-doctor relationship. The authors tested the effectiveness of this protocol in a pilot study with 11 otolaryngology residents. Results showed that a brief series of 3 empathy training sessions can significantly improve physicians’ knowledge of the neurobiology and physiology of empathy, as well as their self-reported capacity to empathize with patients. A trend toward increased patient satisfaction was observed.

EQ-5D-derived health utility values in patients undergoing surgery for chronic rhinosinusitis.

Health utility value (HUV) is an index used to measure health‐related quality of life for the valuation and comparison of treatments. The Euroqol 5‐Dimension (EQ‐5D) questionnaire is a widely used method for determining HUV, but it has not been applied for this purpose in patients with chronic rhinosinusitis (CRS) who undergo sinus surgery.

Treatment outcomes and prognostic factors, including human papillomavirus, for sinonasal undifferentiated carcinoma: A retrospective review

Sinonasal undifferentiated carcinoma (SNUC) is a high‐grade, aggressive neoplasm. Low incidence and poor outcomes make identification of prognostic factors and treatment standardization difficult. Similarly, little is known regarding the association of human papillomavirus (HPV) with SNUC.

Incidence and survival patterns of sinonasal undifferentiated carcinoma in the United States.

Objective To determine trends in sinonasal undifferentiated carcinoma (SNUC) survival patterns in the United States. Design Retrospective review of national database. Participants All cases of SNUC in the National Cancer Institutes Surveillance Epidemiology and End Results program from 1973 to 2010 were examined. Main Outcome Measures Age-adjusted incidence and survival rates were calculated and stratified by demographic information and treatment modality. Cohort analysis was performed to analyze survival patterns over time. Results A total of 318 SNUC cases were identified. Age-adjusted incidence rate (IR) was 0.02 per 100,000. Incidence was greater in males (IR: 0.03) than females (IR: 0.01; p = 0.03). Overall 5- and 10-year relative survival rate was 34.9% and 31.3%, respectively. Overall median survival was 22.1 months. Median survival following surgery combined with radiation was 41.9 months. Five-year relative survival rate following surgery, radiation, or surgery combined with radiation was 38.7%, 36.0%, and 39.1%, respectively. Median survival from 1973-1986 and 1987-2010 was 14.5 and 23.5 months, respectively. Conclusions This study provides new data regarding survival patterns of SNUC in the United States, confirming survival benefit with surgery and radiation as well as identifying a trend toward improved survival in recent decades.

Long-Term Outcomes in Sinus Surgery: A New Tool for Measuring Health-Related Quality of Life

Objective The 6-question EuroQol 5-Dimension Health Assessment (EQ-5D) is a widely used, simple instrument that monitors general health-related quality of life (HRQoL) in chronic disease. It has not previously been applied to US patients undergoing endoscopic sinus surgery (ESS). Study Design Prospective cohort study. Setting Academic Medical Center. Subjects and Methods The study population consisted of 267 patients with chronic rhinosinusitis (CRS) who completed 2 disease-specific instruments—the Chronic Sinusitis Survey (CSS) and the Sinonasal Outcomes Test-22 (SNOT-22)—and 1 general health-related quality-of-life instrument—the EQ-5D—before and after ESS for CRS. Baseline scores were compared to those collected 3 and 12 months after surgery and to the general US population. Results Surveys were completed at all time points by 186 patients, for a response rate of 69.7%. Patients with CRS, when compared to the US population, reported more problems in the domains of pain/discomfort (73.1% vs 40.8%, P < .01), anxiety/depression (50.5% vs 26.4%, P < .01), and usual activities (30.6% vs 15.0%, P < .01). One year following ESS, there was a significant decrease in patients who reported problems with pain/discomfort (54.3%, P < .001), anxiety/depression (30.6%, P < .001), and usual activities (21.5%, P < .01). After surgery, CRS anxiety/depression scores were no different from those of the US general population. Chronic Sinusitis Survey and SNOT-22 scores demonstrated similar postoperative improvements. Conclusion The EQ-5D assessment provides meaningful general health outcomes data with low patient burden. Application of this instrument demonstrated long-term improvement in the quality of life of patients who undergo sinus surgery.