Incorporation of antibiotics and systemic steroids by sinus surgeons: is there widespread consensus?

BACKGROUND: The objective of this work was to evaluate factors associated with antibiotic and oral corticosteroid (OCS) prescription among otolaryngologists regularly performing sinus surgery. METHODS: Fellowship-trained rhinologists, including fellowship directors, were identified via the American Rhinologic Society (ARS) website. Non-fellowship-trained otolaryngologists performing ≥25 balloons (frontal/maxillary) or ≥25 functional endoscopic sinus surgeries (FESSs) (frontal/maxillary/ethmoids) were also included in "balloon surgeons" and "sinus surgeon" cohorts, respectively. Prescribing data for Medicare Part D beneficiaries was obtained for 2015. RESULTS: Otolaryngologists included in this analysis wrote a median of 54 scripts for antibiotics, with a 15.1% antibiotic prescription rate. The overall script length per antibiotic was 11.1 days. Of fellowship-trained rhinologists, 90.2% wrote fewer than 100 scripts, compared to 25.6% and 32.5% of sinus surgeons and balloon surgeons, respectively. Fellowship-trained rhinologists wrote lengthier antibiotic scripts (14.1 vs 10.3 days, p < 0.05). Clinicians who have been in practice longer prescribed antibiotics significantly more frequently. Fellowship-trained rhinologists had a greater OCS rate (8.9%) than balloon and sinus surgeons (7.1%), also writing lengthier courses (15.0 vs 8.1 days). Early-career otolaryngologists wrote lengthier steroid prescriptions than those with 11 to 20 years and >20 years in practice. CONCLUSION: Antibiotic and OCS utilization varies by type of training, as non-fellowship-trained sinus surgeons and balloon surgeons tend to utilize antibiotics more aggressively, and fellowship-trained rhinologists utilize OCS more frequently. Otolaryngologists with more years in practice are more likely to incorporate antibiotics in the management of sinus disorders, although these conclusions must be considered in the context of this resource's limitations. Further clarification of guidelines may be helpful for minimizing divergent practices and maintaining a consensus.

High-volume steroid isotopic standards developed as working standards for gas chromatography-combustion-isotope ratio mass spectrometry.

High-precision carbon isotope ratio analysis of urinary steroids by gas chromatography-combustion-isotope ratio mass spectrometry (GC-C-IRMS) is the official test to detect illicit doping of synthetic versions of endogenous steroids, such as testosterone. Our group created the first steroid isotopic standards (SIS) specifically for World Anti-Doping Agency (WADA) accredited laboratories. The standards contain mixtures of steroids as acetates or free steroids at ~400 µg each per ampoule and have been widely distributed to anti-doping laboratories to facilitate comparability of inter-laboratory results. Here we report on the creation and characterization of 3 new high-volume single component SIS suitable for use as working standards. They contain ~50 times more steroid mass per ampoule than previous SIS. The new SIS, coded CU/PCC 40-1, CU/PCC 41-1, & CU/PCC 42-1, contain ~20 mg of androsterone, androsterone-AC, and 5α-cholestane, with determined isotopic values of -27.09 ± 0.07 mUr, -32.82 ± 0.01 mUr, -25.03 ± 0.01 mUr, respectively. We used our previously developed protocol to calibrate the isotopically uniform steroids against the isotopic standard gases methane and ethane in NIST RM 8559 that are traceable to the international standard Vienna PeeDee Belemnite (VPDB). Two sets of data, acquired 7 months apart, of absolute δ13 CVPDB and ∆Δδ13 CVPDB values from 8 randomly selected ampoules of all 3 SIS indicate uniformity of steroid isotopic composition within measurement reproducibility, SD(δ13 C) < 0.2 mUr Our results show that protocols for SIS extend to creation of high volume working standards that can also be used as internal standards under appropriate GC conditions.

Gas chromatography tandem mass spectrometry offers advantages for urinary steroids analysis.

Gas chromatography mass spectrometry has been the lynchpin of clinical assessment of steroid profiles for ∼3 decades. The improvements in assay performance offered by tandem mass spectrometry were assessed. Across the spectrum of glucocorticoid and androgen analytes tested, limits of detection and quantitation were ∼20 fold lower with triple than single quadrupole systems, but the more noticeable improvement was that signal to noise was substantially improved and the linear range wider. These benefits allowed more reliable and concomitant measurement of steroids with substantially different abundances and in smaller volumes of urine.

[Diagnosis and treatment of sarcoidosis. Current standards]. / Diagnostik und Therapie der Sarkoidose. Was ist gesichert?

Sarcoidosis is a granulomatous disease that mainly affects the lungs and intrathoracic lymph nodes; however, virtually any organ can be affected. As an orphan disease, recommendations are mainly based on observational or small randomized studies as well as experts' opinion. Diagnosing sarcoidosis requires proof of non-necrotizing granulomas in patients with a compatible symptomatic pattern and the exclusion of other granulomatous diseases. Granulomas can be detected best in the lungs or intrathoracic lymph nodes. Therefore, bronchoscopy and endobronchial ultrasound with biopsies of lymph nodes are the major tools to diagnose sarcoidosis. Frequently, close follow-up and symptomatic therapy are sufficient to allow for spontaneous resolution. In case of functional organ impairment, cardial or CNS involvement, or other complications, steroid therapy is necessary with a starting dose of 0.5 mg/kg body weight that should be tapered-off over 6-12 months. Steroid-refractory disease can be treated by adding methotrexate or azathioprine, two drugs long known in sarcoidosis treatment. Monoclonal antibodies against TNF and lung transplantation are further therapeutic options.

Development of criteria for the detection of adrenosterone administration by gas chromatography-mass spectrometry and gas chromatography-combustion-isotope ratio mass spectrometry for doping control.

Adrenosterone (androst-4-ene-3,11,17-trione, 11-oxoandrostenedione) is an endogenous steroid hormone that has been promoted as a dietary supplement capable of reducing body fat and increasing muscle mass. It is proposed that adrenosterone may function as an inhibitor of the 11beta-hydroxysteroid dehydrogenase type 1 enzyme (11beta-HSD1), which is primarily responsible for reactivation of cortisol from cortisone. The urinary metabolism of adrenosterone was investigated, after a single oral administration in two male subjects, by gas chromatography-mass spectrometry (GC-MS) and gas chromatography-combustion-isotope ratio mass spectrometry (GC-C-IRMS). Substantially increased excretion of 11beta-hydroxyandrosterone, 11beta-hydroxyetiocholanolone, 11-oxoandrosterone and 11-oxoetiocholanolone was observed. Minor metabolites such as 3alpha,17beta-dihydroxy-5beta-androstan-11-one, 3alpha-hydroxyandrost-4-ene-11,17-dione and 3alpha,11beta-dihydroxyandrost-4-en-17-one were also identified. The exogenous origin of the most abundant adrenosterone metabolites was confirmed by GC-C-IRMS according to World Anti-Doping Agency criteria. Through analysis of a reference population data set obtained from urine samples provided by elite athlete volunteers (n = 85), GC-MS doping control screening criteria are proposed: 11beta-hydroxyandrosterone concentration greater than 10 000 ng/mL (specific gravity adjusted to 1.020) or 11beta-hydroxyandrosterone/11beta-hydroxyetiocholanolone ratio greater than 20.Urine samples fulfilling these screening criteria may be subjected to GC-C-IRMS analysis for confirmation of adrenosterone administration.

Reference intervals of urinary steroid metabolites using gas chromatography-mass spectrometry in Chinese adults.

BACKGROUND: Urinary steroid profiling by GC or GC-MS are established clinical tools to complement other biochemical tests in the diagnosis and investigation of a wide range of adrenocortical disorders, but normative data on adults using the more specific GC-MS are lacking. Our objective was to set up the reference intervals of commonly detected urinary steroid metabolites as well as marker metabolites seen in disease states. METHOD: Apparently healthy adult Chinese males and females were recruited by completing health questionnaires. A 24-h urine specimen was collected from all the participants for urinary steroid profiling by GC-MS in cyclic scan mode. The analyzer was calibrated by using authentic steroid standards. Statistical methods recommended by the National Committee for Clinical Laboratory Standards were followed for setting up the reference intervals of various steroid metabolites. After outliers were excluded, the data were tested for the necessity to partition into sex-, menopausal status- and age-specific reference intervals. RESULTS: 83 males and 89 females were recruited for the study. Necessity to partition into sex-specific reference intervals was demonstrated for almost all steroid metabolites. Menopausal status and age also had a significant impact on steroid metabolite excretion, making separate reference intervals necessary. CONCLUSIONS: We have set up the normative data on the levels of urinary steroid metabolite excretion in Chinese adults for future reference in patient management and research in steroid metabolism.