mySinusitisCoach: patient empowerment in chronic rhinosinusitis using mobile technology.

Mobile health technology is emerging to take a prominent position in the management of chronic diseases. These technologies aim at enhancing patient empowerment via education and self-management. To date, of all the different apps available for patients with sinus disease, none were developed by medical experts dealing with chronic rhinosinusitis (CRS). The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) has undertaken a multi-stakeholder approach for designing, developing and implementing a tool to support CRS patients in monitoring their symptoms and to provide patients with a digital support platform containing reliable medical information about their disease and treatment options. mySinusitisCoach has been developed by medical experts dealing with CRS in close collaboration with patients, primary care physicians and community pharmacists, meeting the needs of both patients and health care providers. From a research perspective, the generation of real life data will help to validate clinical studies, patient stratification and improve understanding of the socio-economic impact of CRS, thereby paving the way for better treatment strategies.

Current use of baseline medical treatment in chronic rhinosinusitis: Data from the National Chronic Rhinosinusitis Epidemiology Study (CRES).

OBJECTIVES: According to clinical and comissioning guidelines for chronic rhinosinusitis (CRS), patients being referred to secondary care should have failed primary medical treatment with nasal douching (ND) and intranasal corticosteroids (INCS). The study objectives were to identify the rate of specific medical therapy in CRS patients and establish any differences in medication use, for both CRS and associated medical conditions, between CRS phenotypes. DESIGN AND SETTING: Case-control study in a secondary care setting. METHODS: Participant-reported study-specific questionnaire capturing free text data on current medication use at the time of study entry. Qualitative interviews with 21 participants also explored their experience of CRS and its management. PARTICPANTS: Patients both without (CRSsNPs) and with polyps (CRSwNPs). MAIN OUTCOME MEASURES: Reported use of CRS-related and non-related medications. RESULTS: Within a total of 1243 CRS participants, current INCS usage was low (18% in CRSwNPs, 12% in CRSsNPs); ND was being performed by only 1% of all participants. Bronchodilators and inhaled corticosteroids use was significantly higher in CRSwNPs participants (P < .0001). Antidepressant use was significantly higher in CRSsNPs (14% vs 7%, P < .0002). There were no significant regional variations in rates of INCS use, nor any significant influence of social deprivation. CONCLUSIONS: The current use of baseline medical therapy in CRS appears to be very low, representing a combination of poor patient compliance, possible ineffectiveness of treatment and a lack of familiarity with current guidelines amongst general practitioners and some ENT specialists. Work is needed to disseminate guidelines to all practitioners involved and reduce unnecessary burden on existing healthcare resources for this common condition by ensuring timely referral and definitive management.

Should chronic catarrh patients seen in primary care be referred for further investigations?

BACKGROUND: Chronic catarrh is commonly encountered in primary care, but often presents a quandary to the clinician because the history of postnasal or pharyngeal mucus build-up is frequently at odds with the absence of physical findings. As with certain other medically mysterious syndromes, the value of often costly investigation remains unclear in both the primary and the secondary care settings. Indeed, investigation may reassure the physician more than the patient (1) and could even prove counter-productive through reinforcement of the patient's belief about the presence of significant pathology (2). AIM: To establish the benefit of referral of chronic catarrh patients for specialist investigation. DESIGN: A cross-sectional survey. SETTING: A total of 138 patients referred to secondary care with chronic catarrh, postnasal drip or throat clearing in the north of England. METHODS: Subjects completed three disease-specific symptom-scoring questionnaires (RSI, SNOT-20 and GETS). Investigations performed were saccharin clearance time, nasendoscopy, skinprick allergy testing and CT of sinuses. Results were compared with published values. RESULTS: Catarrh patients scored highly on all three symptom questionnaires. Nasendoscopy was normal in 70% of patients, with the remainder demonstrating mostly simple mucus (20%), lymphoid tissue (6%) or mucopus (2%). Only 6 of the 136 patients tested had a prolonged saccharin clearance time greater than 30 min. The mean score of the 63 sinus CT scans obtained was 2.6 (normal range = 0-5). Of patients undergoing skinprick testing (n = 45), 30% reacted to one or more inhaled allergen. No rhinological investigation yielded results above that expected in the general population. CONCLUSION: Chronic catarrh appears to be related more to pharyngeal symptom awareness than to pathological postnasal drip or mucus over-production. Rhinological investigations have a limited role in the management of chronic catarrh patients. The principal outcome of ENT referral is likely to be reassurance and direction towards patient self-help information.

Catarrh - the patient experience.

BACKGROUND: No study to date has looked at the symptoms of chronic catarrh as defined by the patients themselves. We looked to explore the catarrh experience through the eyes of patients using a qualitative approach. METHODOLOGY/PRINCIPAL: Forty-eight patients referred to Secondary Care with chronic catarrh, postnasal drip or persistent throat clearing completed an open-ended questionnaire from which a comprehensive symptom list was generated. Nineteen of these patients undertook semi-structured interviews to explore symptomatic themes relating to their catarrh using grounded theory analysis. RESULTS: A standardised list of 38 catarrh-related symptoms was generated covering a wide topography. A common theme amongst interviewees was the frustration of being unable to expectorate mucus rather than expelling too much. CONCLUSIONS: Difficulties exist in establishing whether the extensive list of symptoms associated with catarrh is a result of differing experiences for patients or simply differing lexicon describing the same experience. Many of these symptoms are not included in the most commonly used nose/throat symptom instruments. Furthermore a distinction should be made between patients with true rhinitis who expel mucus and those who present with apparent postnasal drip or throat clearing but who cannot expectorate, whose management ought be focused more on symptom-coping strategies rather than medication or investigation.

Night-to-night variation in snoring sound severity: one night studies are not reliable.

OBJECTIVES: To quantify the night-to-night variation in snoring severity; to compare this with inter-subject variation in snoring intensity: to compare multinight mean snoring scores with self-reported subjective scores. DESIGN: Prospective observational study. SETTING: Subjects were recorded during sleep at their own homes. PARTICIPANTS: Twenty patients with socially disruptive snoring awaiting surgery. MAIN OUTCOME MEASURES: Over four consecutive nights using a solid-state sound recording device, the mean, standard deviation and intra-class correlation coefficient were calculated for (a) the loudest 1% of sound, (b) snore frequency and (c) total snore duration. Results were correlated with Snoring Symptom Inventory scores assessed immediately prior to these recordings. RESULTS: Overall mean and intrasubject standard deviation for the loudest 1% of sound was 65.0 (+/-4.1) dB, for snore frequency was 245 (+/-104) per hour and for total snore duration was 4.3% (+/-2.1). Intraclass correlation coefficients were 0.78, 0.74 and 0.67, respectively, suggesting only moderate reliability of these outcome measures. No significant correlation was found between objective and subjective scores for either endpoint. CONCLUSION: Natural night-to-night variation in snoring severity represents a significant proportion of overall snoring variance, thus one night studies of snoring are not reliable. The random error associated with one-night studies exceeds the expected effect size of snoring interventions and so multi-night studies of at least four nights are recommended to reduce the error. However, even multi-night objective measurements correlate poorly with subjective scores of snoring.

A new approach to template purification for sequencing applications using paramagnetic particles.

A new method using traditional hybridization methodology, coupled with the new magnetic particle technology, has been developed for DNA purification, specifically for sequencing applications. The method is similar to the reverse hybridization blot system; however, a specific oligonucleotide probe was attached to the paramagnetic particle instead of a sheet membrane. The target DNA containing the complementary sequence of the probe hybridizes to the probe that is attached to the bead and is then magnetically removed from solution, washed and collected. This system eliminates the need of organic extractions and precipitation/concentration steps. The entire hybridization-purification system can be done in a 1.5-ml microcentrifuge tube making the method ideal for automation. M13 phage clones were purified with this method, both by manual means and by using the CATALYST 800 Molecular Biology LabStation fitted with a prototype magnetic station, and then sequenced. DNA sequencing results obtained with this system were reproducible and gave excellent length of read with low background.

Should drains be used in routine cholecystectomy?

Retrospective analysis failed to demonstrate that drainage in routine cholecystectomy was associated with the reported incidence of wound complications. The overall complication rate was increased in those patients in whom drains were used. This is believed to be due to the patient selection rather than the use of drains in that the most difficult operative cases received drains. Those patients who did not have drainage did not experience related problems, but drains may diagnose and treat the occasional bile leak. Incidental appendectomy increased the incidence of wound infection.

Nonreflux complications of hiatal hernia.

Patients with massive incarcerated hiatal hernia and no appreciable esophagitis present with a distinctly different clinical picture from those with hiatal hernia and reflux peptic esophagitis. In a recent review, 17 patients were encountered with this problem. The patients were often elderly and presented with the following grave complications: upper gastrointestinal obstruction; upper gastrointestinal bleeding, both acute and chronic, from gastric ulcerations; and perforated gastric ulcerations. In these patients, the surgical approach is better accomplished through the abdominal route. These patients should be distinguished from those with a shortened esophagus resulting from chronic reflux peptic esophagitis who often require thoracotomy for surgical correction.

A unique function for ascorbate.

Vitamin C is a reducing substance, an electron donor. When vitamin C donates its two high-energy electrons to scavenge free radicals, much of the resulting dehydroascorbate is re-reduced to vitamin C and therefore used repeatedly. Conventional wisdom is correct in that only small amounts of vitamin C are necessary for this function because of its repeated use. The point missed is that the limiting part in nonenzymatic free radical scavenging is the rate at which extra high-energy electrons are provided through NADH to re-reduce the vitamin C and other free radical scavengers. When ill, free radicals are formed at a rate faster than the high-energy electrons are made available. Doses of vitamin C as large as 1-10 g per 24 h do only limited good. However, when ascorbate is used in massive amounts, such as 30-200+ g per 24 h, these amounts directly provide the electrons necessary to quench the free radicals of almost any inflammation. Additionally, in high concentrations ascorbate reduces NAD(P)H and therefore can provide the high-energy electrons necessary to reduce the molecular oxygen used in the respiratory burst of phagocytes. In these functions, the ascorbate part is mostly wasted but the necessary high-energy electrons are provided in large amounts.

The vitamin C treatment of allergy and the normally unprimed state of antibodies.

I previously described that bowel tolerance (the amount that almost causes diarrhea) to oral ascorbic acid, increases in a person somewhat proportionally to the "toxicity" of his disease. Ascorbic acid ameliorates symptoms and sometimes cures certain diseases at high threshold levels near bowel tolerance. High concentrations of ascorbate cause the redox potential of the redox couple (ascorbate/dehydroascorbate, AA/DHA) to become reducing in diseased tissues. Allergic and sensitivity reactions are frequently ameliorated and sometimes completely blocked by massive doses of ascorbate. I now hypothesize that one mechanism in blocking of allergic symptoms is the reducing of the disulfide bonds between the chains in antibody molecules making their bonding antigen impossible. I further hypothesize that antibodies seek to match antigens only in areas where stray free radicals or a relatively oxidizing redox potential exists. The redox state of normal, healthy tissue does not allow for the bonding of antibodies to antigen. When antioxidant, free radical scavenging systems are overwhelmed, inflammatory, hypersensitivity, and "autoimmune" conditions may result.

Vitamin C in the treatment of acquired immune deficiency syndrome (AIDS).

My previous experience with the utilization of ascorbic acid in the treatment of viral diseases led me to hypothesize that ascorbate would be of value in the treatment of AIDS (acquired immune deficiency syndrome). Preliminary clinical evidence is that massive doses of ascorbate (50-200 grams per 24 hours) can suppress the symptoms of the disease and can markedly reduce the tendency for secondary infections. In combination with usual treatments for the secondary infections, large doses of ascorbate will often produce a clinical remission which shows every evidence of being prolonged if treatment is continued. This clinical remission is achieved despite continuing laboratory evidence of helper T-cell suppression. There may be a complete or partial destruction of the helper T-cells during an initial infection that does not necessitate a continuing toxicity from some source to maintain a permanent or prolonged helper T-cell suppression. However, it is possible ascorbate may prevent that destruction if used adequately during that prodrome period. Emphasis is put upon the recognition and treatment of the frequent intestinal parasites. Food and chemical sensitivities occur frequently in the AID syndrome and may aggravate symptoms considered to be part of the AID syndrome. A topical C-paste has been found very effective in the treatment of herpes simplex and, to a lesser extent, in the treatment of some Kaposi's lesions. Increasingly, clinical research on other methods of treating AIDS is being "contaminated" by patients taking ascorbate.

Vitamin C, titrating to bowel tolerance, anascorbemia, and acute induced scurvy.

A method of utilizing vitamin C in amounts just short of the doses which produce diarrhea is described (TITRATING TO BOWEL TOLERANCE). The amount of oral ascorbic acid tolerated by a patient without producing diarrhea increase somewhat proportionately to the stress or toxicity of his disease. Bowel tolerance doses of ascorbic acid ameliorate the acute symptoms of many diseases. Lesser doses often have little effect on acute symptoms but assist the body in handling the stress of disease and may reduce the morbidity of the disease. However, if doses of ascorbate are not provided to satisfy this potential draw on the nutrient, first local tissues involved in the disease, then the blood, and then the body in general becomes deplete of ascorbate (ANASCORBEMIA and ACUTE INDUCED SCURVY). The patient is thereby put at risk for complications of metabolic processes known to be dependent upon ascorbate.

Vitamin C: the nontoxic, nonrate-limited, antioxidant free radical scavenger.

The amount of oral ascorbic acid that a patient can tolerate without diarrhea, increases somewhat proportionately to the "toxicity" of his disease. Clinically, in a disease ameliorated by ascorbate, there is a suppression of symptoms only with very high doses and approximately to that extent which a nonrate-limited, antioxidant free radical scavenger, might be expected to affect that disease process if all harmful free radicals and highly reactive oxidizing substances were quenched. In most pathologic processes, the rate at which free radicals and highly reactive oxidants are produced, exceeds the rate at which the ordinary rate-limited antioxidant free radical scavenging mechanisms can quench those free radicals and oxidants. When ascorbate acts as a scavenger, dehydroascorbate is formed; but if the ascorbate/dehydroascorbate (AA/DHA) ratio is kept high (the redox potential kept reducing) until the unstable dehydroascorbate undergoes hydrolysis or can be reduced back to ascorbate, the dehydroascorbate will do no harm. Since even at very high doses, ascorbate is virtually nontoxic, it may be given in the enormous doses necessary to quench almost all unwanted free radicals and oxidants. The wide spectrum of infectious diseases ameliorated by massive doses of ascorbate indicates some common pathologic processes in these diseases.

Augmentation mammaplasty by means of the transrectus route.

A new operative technique has been developed for augmentation mammaplasty. Through an inframammary incision, the anterior rectus sheath is entered, and the pocket is dissected in an entirely submuscular plane. We have performed this procedure in 112 patients to date. Complications have been few. The capsular contracture rate in 90 patients followed for greater than 1 year is 7 percent. The inframammary crease can be lowered using this technique, making mastopexy unnecessary in most patients with moderate ptosis.

Non-voice-related throat symptoms: comparative analysis of laryngopharyngeal reflux and globus pharyngeus scales.

BACKGROUND: This study calculated the comparability of two throat symptom assessment scales devised to evaluate either laryngopharyngeal reflux or globus. SETTING: United Kingdom hospital out-patient departments. METHOD: A total of 334 subjects, with and without throat symptoms, completed the Reflux Symptom Index and/or the Glasgow and Edinburgh Throat Scale. The following were calculated for the resultant data: Cronbach's α coefficient, principal component analysis, Kaiser normalisation, varimax and oblimin rotation, and eigenvalues. RESULTS: Analysis of data from the Reflux Symptom Index and the Glasgow and Edinburgh Throat Scale revealed clearly similar symptom domains regarding (1) coughing and blockage, and (2) globus or postnasal drip or throat-clearing, as did combined analysis of their amalgamated items. Both instruments had good overall internal consistency (α = 0.75 and 0.81, respectively). The 'heartburn or reflux' item in the Reflux Symptom Index mapped poorly to each underlying factor. DISCUSSION: The most commonly used laryngopharyngeal reflux and globus assessment questionnaires appear to detect very similar symptom clusters. The management of throat disorders may previously have been over-reliant on the presenting pattern of throat symptoms. Our findings indicate a need to revisit the traditional clinical classification of throat symptoms.