Omalizumab therapy for refractory allergic fungal rhinosinusitis patients with moderate or severe asthma.

PURPOSE: 1. To assess the efficacy of omalizumab therapy in improving sinonasal outcomes in refractory allergic fungal rhinosinusitis (AFRS) patients with moderate or severe asthma. 2. To determine if omalizumab therapy reduces the usage of corticosteroids or antifungal therapy in AFRS patients DESIGN: The clinical charts of patients with AFRS with moderate or severe asthma who received at least three subcutaneous injections of omalizumab therapy between 1st January 2012 and 1st May 2014 were retrospectively reviewed. These patients had undergone bilateral functional endoscopic sinus surgery (FESS) and failed adjunct medical treatments (oral or topical corticosteroids and/or antifungal therapy) prior to omalizumab therapy. RESULTS: Seven patients met the inclusion criteria and were included in this study. The mean age of the patients was 48.14. The average number of subcutaneous omalizumab injections was 7.57 (range 6-11) with a mean dosage of 287mg (range 225-375mg). The mean pre-omalizumab treatment Sino-Nasal Outcome Test-22 (SNOT-22) score was 52.14 while the mean post-omalizumab treatment SNOT-22 score was 35.86 (31% improvement). The mean pre-omalizumab therapy Phillpott-Javer endoscopic score (over the last one year before omalizumab therapy) was 36 while the mean post-omalizumab therapy endoscopic score (from the last clinic visit) was 14 (61% improvement). Omalizumab therapy reduced the dependence of AFRS patients on corticosteroid and antifungal treatments. CONCLUSION: Omalizumab therapy can be considered as a potential adjunct for the treatment for patients with refractory AFRS with moderate or severe asthma. However, larger prospective studies to confirm the findings of this study will be required.

Reliability of HEARTSMAP as a Tool for Evaluating Psychosocial Assessment Documentation Practices in Emergency Departments for Pediatric Mental Health Complaints.

OBJECTIVES: The goal of this study was to assess the reliability of HEARTSMAP as a standardized tool for evaluating the quality of psychosocial assessment documentation of pediatric mental health (MH) presentations to the emergency department (ED). In addition, we report on current documentation practices. METHODS: We conducted a retrospective cross-sectional study of pediatric (up to age 17) MH-related visits to four EDs between April 1, 2013, and March 31, 2014. The primary outcome was the inter-rater agreement when evaluating the completeness of pediatric emergency psychosocial assessments using the HEARTSMAP tool. The secondary outcome was to describe the adequacy of documentation of emergency pediatric MH assessments, using HEARTSMAP as a guide for a complete assessment. RESULTS: A total of 400 medical records (100 from each site) were reviewed. We observed near-perfect inter-rater agreement (κ = 0.99-1.00) regarding the presence of documentation and good-to-perfect agreement (κ = 0.71-1.00) regarding whether sufficient information was documented to score a severity level for every component of an emergency psychosocial assessment. Inter-rater agreement regarding whether referrals or resources were documented for identified needs was observed to be good to very good (κ = 0.62-0.98). Current psychosocial documentation practices were found to be inconsistent with significant variability in the presence of documentation pertaining to HEARTSMAP sections between medical centers and initial clinician assessor and whether specialized MH services were involved prior to discharge. CONCLUSIONS: The HEARTSMAP tool can be reliably used to assess pediatric psychosocial assessment documentation across a diverse range of EDs. Current documentation practices are variable and often inadequate, and the HEARTSMAP tool can aid in quality improvement initiatives to standardize and optimize care for the growing burden of pediatric mental illness.

Five-degree, 10-degree, and 20-degree reverse Trendelenburg position during functional endoscopic sinus surgery: a double-blind randomized controlled trial.

BACKGROUND: Using the reverse Trendelenburg position (RTP) during functional endoscopic sinus surgery (FESS) is a safe, simple, and cost-free method that has been found to reduce intraoperative blood loss. However, the critical angle of RTP that produces the least amount of bleeding without compromising surgical technique and safety remains unanswered. The objective of this study was to assess the effects of 5-degree, 10-degree, and 20-degree RTP (5-RTP, 10-RTP, and 20-RTP, respectively) on intraoperative bleeding during FESS. METHODS: This double-blind randomized controlled trial involved 75 patients with chronic rhinosinusitis (CRS) with and without nasal polyposis undergoing FESS. Twenty-five patients were enrolled into each group: 5-RTP, 10-RTP, and 20-RTP. Boezaart endoscopic field-of-view score (BS), total blood loss (TBL), mean arterial blood pressure (MABP), operating time, and blood loss per minute were recorded. An intention-to-treat analysis was used, with a Bonferroni adjustment for multiple comparisons. RESULTS: Intervention groups were comparable in age, sex, nasal polyposis, and disease severity. Mean values of BS and TBL were as follows: 5-RTP (2.0, 231 mL), 10-RTP (1.8, 230 mL), and 20-RTP (1.4, 135 mL). The differences in means were significant for BS (p < 0.01) and TBL (p = 0.03). There was no significant difference in MABP (p = 0.85), operating time (p = 0.10), or blood loss per minute (p = 0.11) between the 3 groups. Pairwise comparison between 5-RTP vs 20-RTP found significant difference in BS (p < 0.01) but not TBL (p = 0.04). Significance was not found in similar comparisons of 10-RTP vs 20-RTP and 5-RTP vs 10-RTP (p > 0.03). CONCLUSION: FESS in 20-RTP produced the best BS and lowest blood loss without compromising surgical technique.