Overall symptom severity as a patient-reported outcome measure for chronic rhinosinusitis: what it reflects and how to measure it.

BACKGROUND: The objective of this study was to identify how - and to what extent - overall symptom severity (OSS) score reflects individual chronic rhinosinusitis (CRS) symptoms and whether it can be measured using alternatives to the standard visual analog scale (VAS). METHODS: CRS patients from four sites across three continents rated their OSS scores, severities of nasal obstruction, nasal drainage, decreased sense of smell, facial pain/pressure and sleep disturbance using a standard VAS, VAS with labeled tick marks at every 1 centimeter, and by writing down their OSS on a scale of 0 - 100 (which was divided by 10), all of which lead to severity scores ranging from 0 - 10 in 0.1 intervals. Quality of life was measured using the SNOT-22 and EQ-5D VAS. RESULTS: In 311 CRS patients, OSS score was significantly correlated with SNOT-22 and EQ-5D VAS. OSS score was most greatly associated with the mean of all individual symptom severity scores. From individual CRS symptoms, OSS was most greatly associated with nasal obstruction followed by nasal drainage and facial pain/pressure severities. These results held true for participants with and without nasal polyps. Measurement of OSS and individual symptom severity scores using a standard VAS, tick-marked VAS, and write-in option had near-perfect consistency. CONCLUSIONS: We demonstrate for the first time that OSS largely reflects the mean of individual CRS symptom severities, although OSS is=== most weighted by nasal obstruction severity. OSS and individual symptom severity scores can be measured using a standard VAS, tick-marked VAS or write-in prompt with near-perfect consistency.

Clinical and technical factors in endoscopic skull base surgery associated with reconstructive success.

BACKGROUND: In this study, we identified key discrete clinical and technical factors that may correlate with primary reconstructive success in endoscopic skull base surgery (ESBS). METHODS: ESBS cases with intraoperative cerebrospinal fluid (CSF) leaks at four tertiary academic rhinology programs were retrospectively reviewed. Logistic regression identified factors associated with surgical outcomes by defect subsite (anterior cranial fossa [ACF], suprasellar [SS], purely sellar, posterior cranial fossa [PCF]). RESULTS: Of 706 patients (50.4% female), 61.9% had pituitary adenomas, 73.4% had sellar or SS defects, and 20.5% had high-flow intraoperative CSF leaks. The postoperative CSF leak rate was 7.8%. Larger defect size predicted ACF postoperative leaks; use of rigid reconstruction and older age protected against sellar postoperative leaks; and use of dural sealants compared to fibrin glue protected against PCF postoperative leaks. SS postoperative leaks occurred less frequently with the use of dural onlay. Body-mass index, intraoperative CSF leak flow rate, and the use of lumbar drain were not significantly associated with postoperative CSF leak. Meningitis was associated with larger tumors in ACF defects, nondissolvable nasal packing in SS defects, and high-flow intraoperative leaks in PCF defects. Sinus infections were more common in sellar defects with synthetic grafts and nondissolvable nasal packing. CONCLUSIONS: Depending on defect subsite, reconstructive success following ESBS may be influenced by factors, such as age, defect size, and the use of rigid reconstruction, dural onlay, and tissue sealants.

Nasal endoscopy score thresholds to trigger consideration of chronic rhinosinusitis treatment escalation and implications for disease control.

BACKGROUND: In the absence of direct evidence supporting how to use nasal endoscopy findings to judge chronic rhinosinusitis (CRS) disease control, experts' practice patterns could provide guidance. METHODOLOGY: Participants consisted of a diverse group of twenty-nine rhinologists. Participants were presented with every possible combination of bilateral nasal endoscopy findings represented by the modified Lund-Kennedy (MLK; range: 0-12) endoscopic scoring system and Nasal Polyp Score (NPS; range: 0-8). Reflecting the practical consequence of CRS disease control assessment, participants were asked whether they would consider CRS treatment escalation based on each scenario in the absence of any CRS symptoms, and how strongly they considered escalating therapy. The same scenarios were then presented in the context of 1 burdensome CRS symptom and participants again were asked whether they would consider treatment escalation. RESULTS: The median threshold total MLK score for considering treatment escalation was ≥4 and 75.9% of participants' MLK thresholds were within 1 point of 4. The median threshold total NPS for considering treatment escalation was ≥3 and 62.5% of participants' NPS thresholds were within 1 point of 3. Endoscopy score thresholds decreased in the presence of 1 burdensome symptom and generally increased when requiring stronger affirmation for considering CRS treatment escalation. CONCLUSION: Reflecting the practice patterns of a diverse group of rhinologists, MLK score ≥4 or NPS ≥3 may serve as thresholds for considering CRS treatment escalation. Alternatively, MLK score.

Preoperative, technical, and postoperative considerations for skull base reconstruction: a practical review of critical concepts.

Despite widespread adoption and advances in endoscopic skull base surgery, with expanding indications and the ability to effectively treat larger and more complex pathologies, skull base reconstruction following tumor resection and prevention of cerebrospinal fluid leak remains a challenge for even the most seasoned of surgical teams. Mounting evidence in all areas have pushed our understanding of skull base reconstruction principles forward. In this narrative review, we summarize critical concepts and provide practical but comprehensive guiding principles on preoperative, intraoperative/technical, and postoperative management principles related to optimizing skull base reconstructive success. The goal is to provide an informative resource for skull base surgeons (both otolaryngologists and neurosurgeons) to reference regarding state-of-the-art evidence surrounding this ever-evolving topic.

Discordance of chronic rhinosinusitis disease control between EPOS guidelines and patient perspectives identifies utility of patient-rated control assessment.

BACKGROUND: The objective of this study was to determine concordance of patient-reported chronic rhinosinusitis (CRS) disease control with CRS disease control assessed according to European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria. METHODS: In 421 participants, CRS disease control was determined using EPOS criteria which include the burden of 5 symptoms measured on a binary scale, use of rescue medications in the prior 6 months and presence of diseased mucosa on nasal endoscopy. Symptom severity was also assessed using a visual analogue scale (VAS). Participants rated their CRS disease control as "controlled","partly controlled" or "uncontrolled". RESULTS: Patient-reported and EPOS-based CRS disease control ratings agreed for 49.6% of participants. Amongst cases of disagreement, EPOS guidelines assessed worse CRS disease control relative to 92.9% of patients. Facial pain/pressure and impaired sense of smell distinctly associated with patient agreement with EPOS guidelines on having "uncontrolled" CRS. Higher VAS symptom scores were associated with worse patient-reported CRS disease control (i.e., agreeing with EPOS guidelines). Removal of the nasal endoscopy criterion improved agreement between patients' and EPOS control assessments, and replacement of this criterion with patient-reported control further aligned EPOS guidelines with patient perspectives. CONCLUSIONS: EPOS guidelines regularly assess worse CRS control than assessed by patients. The lack of more gradated symptom severity criteria and inclusion of nasal endoscopy may contribute to discordance of EPOS guidelines with patient-reported CRS control. Replacement of nasal endoscopy findings with a measure of patient-reported CRS disease control better aligns EPOS CRS disease control guidelines with patients' perspectives.

Individual symptom visual analogue scale severity scores for determining EPOS guideline-based chronic rhinosinusitis disease control.

BACKGROUND: The goal of this study was to determine how to translate visual analogue scale (VAS) symptom scores to the binary, descriptive symptom scales used in the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria for chronic rhinosinusitis (CRS) disease control. METHODS: 309 CRS patients were recruited. All patients rated their burden of 5 symptoms (nasal blockage, rhinorrhea/postnasal drip, facial pain/pressure, smell loss, sleep disturbance or fatigue) using the binary EPOS descriptive symptom scales and a VAS (on a scale of 0 to 10). In addition, participants completed a 22-item Sinonasal Outcome Test (SNOT-22) and rated their overall CRS disease control as "controlled", "partly controlled" or "uncontrolled" Results: Symptom burdens measured by VAS, binary descriptive EPOS scale and SNOT-22 were associated with worsening CRS disease control reported by participants. Each symptom had a distinct VAS score cut-off that strongly predicted the uncontrolled option on the corresponding binary descriptive EPOS symptom scale. However, the predictive ability of VAS for rhinorrhea/ postnasal drip was disparately worse than the other 4 symptoms. When considering all symptom data simultaneously, a VAS score higher than 3.5 strongly predicted the uncontrolled option on the corresponding binary descriptive EPOS symptom scale for all 5 symptoms. CONCLUSIONS: A VAS symptom score of higher than 3.5 translates to the uncontrolled option in the binary, descriptive symptom scale of the EPOS control criteria. The rhinorrhea/postnasal drip descriptive symptom scale translates disparately worse to VAS scores and may be considered for revision in future criteria.

Disease control in chronic rhinosinusitis: a qualitative study of patient perspectives.

BACKGROUND: The definition of disease control in chronic rhinosinusitis (CRS) is an active area of study. However, investigations have not engaged CRS patients in how they think about disease control. This study seeks to understand the patient perspective on CRS disease control. METHODS: Qualitative phenomenological study using constant comparative methodology was applied. The research team conducted 10, one-on-one interviews with CRS patients ranging from 22 to 55 minutes in length. The content of the interview protocol was determined through iterative discussion amongst all authors. Two authors served as coders to identify recurrent themes. Themes were analyzed for meaning and conclusions were summarized. RESULTS: Three recurring themes determined from patients were that (1) use of the terminology control adequately represents this phenomenon, (2) components of control could be classified into four main themes relating to CRS symptomatology, exacerbation of comorbid disease, quality of life and acute exacerbations of CRS, and (3) when patients deem their CRS is uncontrolled they are more willing to escalate their treatment to include escalating their daily maintenance regimen, seeking otolaryngology referral, taking rescue medication or undergoing endoscopic sinus surgery. CONCLUSIONS: CRS patients consider their daily symptoms, the severity and frequency of CRS exacerbations, impact on quality of life as well as exacerbation of comorbid disease when thinking about their disease control. Disease control is a goal of treatment for patients and uncontrolled disease motivates patients to seek further treatment. Physicians should explore all components of CRS control when considering disease status and need for further treatment.

Patient-reported chronic rhinosinusitis disease control is a valid measure of disease burden.

BACKGROUND: Disease control is an important treatment goal for chronic uncurable conditions such as chronic rhinosinusitis (CRS). The objective of this study was to determine whether patient-reported CRS disease control is a valid reflection of disease burden. METHODS: Prospective longitudinal study of 300 CRS patients (35% CRS with nasal polyps, 65% CRS without nasal polyps). At enrollment and at a subsequent follow-up timepoint, all participants were asked to rate their CRS disease control as 'not at all', 'a little', 'somewhat', 'very', 'completely' as well as to complete a 22-item Sinonasal Outcome Test (SNOT-22) and the 5-dimension EuroQol general health questionnaire from which the visual analogue scale (EQ-5D VAS) was used. RESULTS: At enrollment and follow-up timepoints, patient-reported CRS disease control was significantly correlated with SNOT-22 and EQ-5D VAS scores. The change in patient-reported CRS disease control was significantly correlated with change in SNOT-22 and change in EQ-5D VAS scores. There was significant cross-sectional and longitudinal correlation between patient-reported control and all SNOT-22 subdomain scores. A SNOT-22 score of ≤25 points or lower, or an EQ-5D VAS score of ≥77 was predictive of having well - (i.e. 'very' or 'completely') controlled CRS. CONCLUSIONS: Patient-reported CRS disease control is a valid measure of CRS disease burden and general QOL. A patient-reported assessment of CRS disease control could be considered as a component of a more comprehensive measure of CRS disease control.

Multi-institutional minimal clinically important difference of the 22-item Sinonasal Outcome Test in medically managed chronic rhinosinusitis.

BACKGROUND: With a rapid proliferation of clinical trials to study novel medical treatments for CRS, the objective of this study was to study the minimal clinically important difference (MCID) of the 22-item Sinonasal Outcome Test (SNOT-22) in medically-managed CRS patients. METHODS: A total of 183 medically-treated CRS patients were recruited. All patients completed a SNOT-22 at enrollment and subsequent follow up visit. Distribution and anchor-based methods were used for MCID calculation. These data were combined with data from a previously published study on SNOT-22 MCID in 247 medically managed CRS patients to determine a final recommended MCID value using the combined cohort of 430 patients. RESULTS: In our cohort, distribution- and anchor-based methods -"using both sinus-specific and general health anchors-"provided greatest support for a 12-point SNOT-22 MCID, which had approximately 55% sensitivity but 81% specificity for detecting patients explicitly reporting improvement in their sinus symptoms and general health. In the combined cohort of 430 patients, we also found greatest support for a 12-point SNOT-22 MCID, which had approximately 57% sensitivity and 81% specificity for detecting patients explicitly reporting improvement in their sinus symptoms and general health. We also find evidence that the MCID value may be higher in CRS patients without nasal polyps compared to those with nasal polyps. CONCLUSIONS: Our results - which include data from patients from two different institutions and regions - confirm a SNOT-22 MCID of 12 in medically managed CRS patients. The SNOT-22 MCID was specific but not sensitive for identifying CRS patients experiencing improvement in symptoms or general health.

Validity of systemic antibiotics and systemic corticosteroid usage for chronic rhinosinusitis as metrics of disease burden.

BACKGROUND: The frequencies of systemic antibiotics and oral corticosteroids taken for chronic rhinosinusitis (CRS) indicate poor CRS disease control. We sought to determine the validity and responsiveness of these metrics as reflections of CRS disease burden. METHODOLOGY: One hundred and eighty-seven patients undergoing medical management for CRS were recruited. Participants were assessed at two time points: enrollment and a follow-up appointment three to nine months later. At each time point, CRS related antibiotic and oral corticosteroid usage in the previous three months was measured, while general and disease-specific quality of life (QOL) was measured using the visual analog scale of the 5-dimension EuroQol questionnaire (EQ-5D VAS) and the 22-item Sinonasal Outcome Test (SNOT-22), respectively. RESULTS: The frequency of CRS-related antibiotics and oral corticosteroids use was cross-sectionally correlated with EQ-5D VAS and SNOT-22 at the corresponding time points. For participants reporting usage of these medications at enrollment, there was a decrease of 1 course per 3 months for both CRS-related antibiotics and oral corticosteroids. Change in CRS-related antibiotics from enrollment to follow-up was correlated with change in both EQ-5D and SNOT-22 over the same timeframe. The change in CRSrelated oral corticosteroids was correlated with change in both EQ-5D VAS and SNOT-22). These correlations were stronger in the subset of patients who had a change in these metrics over the study period. CONCLUSIONS: The frequencies of CRS-related antibiotic use and oral corticosteroid use are valid and responsive measures of CRS disease burden.

Quality of life impairment due to chronic rhinosinusitis in asthmatics is mediated by asthma control.

BACKGROUND: Chronic rhinosinusitis (CRS) and asthma, when comorbid, may influence each other’s disease course and decrease quality of life (QOL). Our objective was to determine if poorer asthma control due to CRS symptoms could be a mechanism for decreased QOL in asthmatic CRS patients. METHODS: A total of 120 asthmatic CRS patients were recruited. CRS symptom burden was measured using the 22-item Sinonasal Outcome Test (SNOT-22) and patient-reported CRS symptom control, general health-related QOL was measured using the visual analog scale of the 5-dimensional EuroQol quality of life survey (EQ-5D VAS), and asthma control was measured using the Asthma Control Test (ACT). Association was sought between these outcome measures. A mediation model was created and validated to show that asthma control mediated the association between CRS symptom burden and decreased general health-related QOL. RESULTS: ACT score was associated with SNOT-22, EQ-5D VAS was associated with SNOT-22 score, and EQ-5D VAS was associated with ACT score. A statistically significant mediation effect for ACT score in the association between SNOT-22 and EQ-5D VAS), which represented 22.1% of the total effect of SNOT-22 on EQ-5D VAS, was identified. Similar findings were made for patientreported CRS symptom control instead of SNOT-22 score. CONCLUSIONS: In asthmatic CRS patients, a sizeable portion of CRS impact on QOL is indirectly mediated through the effect of CRS on poorer asthma control which may then drive decreased QOL.

Responsiveness and minimal clinically important difference for the EQ-5D in chronic rhinosinusitis.

BACKGROUND: The 5-dimensional EuroQol questionnaire (EQ-5D) is validated to measure general health-related quality of life (QOL). Our objective was to determine the responsiveness and minimal clinically important difference (MCID) of the EQ-5D health utility value (EQ-5D HUV) and visual analog scale (EQ-5D VAS) in chronic rhinosinusitis (CRS). METHODS: 203 adults undergoing medical management for CRS were prospectively recruited. General health-related QOL (using EQ-5D HUV and EQ-5D VAS) and CRS-specific QOL (using the 22-item Sinonasal Outcome Test [SNOT-22]) were measured at enrollment and a subsequent follow-up time point 2-12 months later. At follow-up, participants also rated change in general health as Much worse, A little worse, About the same, A little better or Much better compared to enrollment. The EQ-5D HUV and EQ-5D VAS MCIDs were calculated using distribution-based, anchor-based, and receiver operator characteristic (ROC) curve-based methods. RESULTS: Change in SNOT-22 score was correlated with EQ-5D HUV and EQ-5D VAS change. Using the different methods of calculating MCID, we find the EQ-5D HUV MCID to be 0.04 and EQ-5D VAS MCID to be 8.0. The calculated EQ-5D MCIDs had approximately a sensitivity of 40-50% and specificity of 80% in detecting patients experiencing noticeable improvement in general health. CONCLUSIONS: The EQ-5D responds well to changing CRS symptomatology. We propose MCIDs for EQ-5D HUV of 0.04 and EQ-5D VAS of 8 in CRS patients, which although specific, are not sensitive for detecting patients experiencing improvement in general health.

Depressed mood is associated with loss of productivity in allergic rhinitis.

Allergic rhinitis (AR) is associated with significant decreases in quality of life and productivity losses. We hypothesized that symptoms of AR may differentially associate with lost productivity due to AR. We performed a cross-sectional cohort study of 105 prospectively recruited patients with persistent AR. AR control, severity of depressed mood, and sinonasal symptoms were assessed with the Rhinitis Control Assessment Test (RCAT), Patient Health Questionnaire (PHQ-2), and the 22-item Sinonasal Outcome Test (SNOT-22), respectively. Lost productivity was assessed by asking the number of days of work/school missed due to AR in the last 3 months. Patients missed a mean of 1.5 days (SD:2.9) of work or school. Lost productivity was associated with PHQ-2 (adjusted linear regression coefficient [ß] = .68, 95% CI: 0.20-1.15, P = .007) analysis but not SNOT-22 or RCAT scores. Productivity losses due to AR are associated with severity of depressed mood rather than classic nasal or extra-nasal symptoms of AR.

Chronic rhinosinusitis exacerbations are differentially associated with lost productivity based on asthma status.

BACKGROUND: The frequency of chronic rhinosinusitis (CRS) exacerbations is an independent predictor of quality of life. The objective of this study was to evaluate if increased CRS exacerbations predict decreased productivity. METHODS: Cross-sectional study of adult CRS patients. Number of patient-reported CRS-related antibiotic and oral corticosteroids courses and sinus infections in the past three months were used as metrics for acute exacerbations of CRS (AECRS). Productivity loss was measured by asking participants the number of lost days of work or school due to CRS in the past three months. Associations were sought between lost productivity and AECRS, controlling for clinical and demographic characteristics. RESULTS: 371 participants were recruited. 28.8% of study participants had comorbid asthma. The mean number of lost days of productivity due to CRS in the last three months was 1.5 for asthmatic participants and 2.4 for non-asthmatic participants. In asthmatics, CRS-related lost productivity was significantly associated with number of CRS-related antibiotics used (and oral corticosteroids used, with a trend for sinus infections. No AECRS metric was significantly associated with lost productivity in non-asthmatics. However, when focusing on non-asthmatics reporting missed days of work or school due to CRS, we found statistically significant associations between AECRS metrics and lost productivity. CONCLUSIONS: The frequency of AECRS is associated with CRS-related lost productivity in asthmatics and in the subset of non-asthmatics with moderate CRS-related productivity losses.

Chronic rhinosinusitis severity is associated with need for asthma-related systemic corticosteroids.

BACKGROUND: Chronic rhinosinusitis (CRS) is highly prevalent in patients with asthma. However, no study has evaluated the effect of CRS severity on asthma-related oral corticosteroid use - a marker of poor asthma control and prognosis. We therefore sought to evaluate the association between CRS severity and asthma-related oral corticosteroid use. METHODOLOGY: Prospective cross-sectional study of 110 adult asthmatic CRS patients. CRS severity was measured using the 22-item Sinonasal Outcomes Test (SNOT-22) and Lund-Kennedy endoscopy score. Number of asthma-related courses of oral corticosteroids in the past year was queried at enrollment. Association was sought between metrics for CRS severity and asthma-related oral corticosteroids use in the last year. Receiver operating characteristic (ROC) curves defined whether SNOT-22 or endoscopy scores could be used for detecting asthma-related oral corticosteroid use. RESULTS: The mean SNOT-22 score was 44.9 (standard deviation [SD] : 23.3) and mean endoscopy score was 4.1 (SD: 3.0). The mean number of asthma-related oral corticosteroid courses taken in the last year was 1.1 (SD: 1.9). SNOT-22, but not endoscopy score, was associated with requiring at least one course of asthma-related oral corticosteroids in the last year (odds ratio = 1.03, 95%CI: 1.02 - 1.06, p=0.003), which translates to an odds ratio of 2.0 for a 21-point increase in SNOT-22. ROC analysis identified equally optimal SNOT-22 scores of greater than 32 (sensitivity: 88.1%, specificity: 41.2%) or greater than 65 (sensitivity: 38.1%, specificity: 91.2%) for detecting the need for at least one course of oral corticosteroids within the past year. CONCLUSIONS: CRS symptom severity is associated with past asthma-related oral corticosteroid use. SNOT-22 scores may be used as a versatile tool to screen for past asthma-related oral corticosteroid use in asthmatic CRS patients - i.e. those at greatest risk from their asthma - with either high sensitivity or high specificity.

Patient-reported control of chronic rhinosinusitis symptoms is positively associated with general health-related quality of life.

OBJECTIVE: In chronic rhinosinusitis (CRS), although patient-reported severity of sinonasal symptoms is significantly associated with diminishment of patients' general health-related quality of life (QOL), it remains unclear whether patient-perceived control of CRS symptomatology is associated with patients' QOL. In this study, we sought to determine the association between patient-perceived control of CRS symptomatology and QOL. DESIGN: Prospective cross-sectional study. SETTING: Academic, tertiary care centre. PARTICIPANTS: A cohort of 166 adults with CRS who were asked to categorise their level of CRS symptom control as "Not at all," "A little," "Somewhat," "Very" and "Completely." MAIN OUTCOME MEASURE: General health-related QOL, as reflected by the five-dimensional EuroQol quality of life survey-derived visual analogue scale (EQ5D-VAS) and health utility values (EQ5D-HUV). RESULTS: We found that higher EQ5D-VAS scores were associated with CRS patients who classified their symptom control as "Very" (adjusted ß=15.74, 95% CI: 5.44 to 26.04, P=.003) and "Completely" (adjusted ß=14.24, 95% CI: 2.98 to 25.52, P=.014) compared to patients who classified their symptom control as "Not at all." This was also true for higher EQ5D-HUV which was associated with patient-reported CRS symptom control of "A little" (adjusted ß=0.10, 95% CI: 0.01 to 0.18, P=.024), "Somewhat" (adjusted ß=0.08, 95% CI: 0.00 to 0.17, P=.049), "Very" (adjusted ß=0.13, 95% CI: 0.05 to 0.21, P=.002) and "Completely" (adjusted ß=0.18, 95% CI: 0.09 to 0.27, P<.001). CONCLUSIONS: Higher levels of patient-reported CRS symptom control are therefore associated with better QOL. These findings suggest that CRS symptom control should be targeted for improving patients' QOL.

[The association between allergic rhinitis control and sleep quality]. / Assoziation zwischen Kontrolle der allergischen Rhinitis und Schlafqualität.

BACKGROUND: Allergic rhinitis (AR) is the most common form of atopic disease, comprising 50% of atopic diseases. Recently, this disease has increasingly been the focus of intensive research. Previous work has shown that AR has a significant impact on sleep quality. To date there are no published studies demonstrating a quantitative association between the extent of control of AR and the severity of compromised sleep quality. METHODS: Patients with AR were prospectively recruited into our cross-sectional study. Sleep quality was assessed using five of the sleep subdomain questions from the 22-item Sinonasal Outcome Test (SNOT-22). Control of AR was assessed using the Rhinitis Control Assessment Test (RCAT). Association was sought between the degree of allergic rhinitis control (RCAT) as independent variable and sleep quality as dependent variable using linear regression. RESULTS: A total of 104 patients (54.8% female and 45.2% male) with an average age of 41.4 years (SD: 15.9 years) were included in the study. There were statistically significant associations between the RCAT score and the score of each of the five SNOT-22 questions used to assess decreased sleep quality (p < 0.001). These associations remained significant (p < 0.001) even after controlling participants' clinical and demographic characteristics. CONCLUSION: This is the first study showing that level of control of AR correlates with the severity of subjectively perceived sleep quality detriment. These results indicate that an improvement in AR control could lead to improved subjective sleep quality but a prospective interventional study is needed to confirm these results.

Symptoms of chronic rhinosinusitis differentially impact general health-related quality of life.

BACKGROUND: The degree to which different sinonasal symptoms contribute to the overall quality of life (QOL) detriment in chronic rhinosinusitis (CRS) patients remains unknown. In this study we sought to characterize the effect of different CRS symptoms on the general health-related QOL in patients. METHODOLOGY: We performed a prospective cross-sectional study of 131 adult patients with CRS. Sinonasal symptoms were evaluated using the 22-item Sinonasal Outcomes Test (SNOT-22) and general health-related QOL was evaluated using the EuroQol 5-Dimensional general health-related QOL survey (EQ5D) and visual analog scale (EQ5D-VAS). Health utility values (HUV) were determined using responses to the EQ5D. SNOT-22 scores were broken down into subdomain scores for sleep, nasal, otologic/facial pain and emotional function symptoms. RESULTS: The otologic/facial pain subdomain score consistently had the largest impact on EQ5D-VAS and HUV. After otologic/facial pain, the sleep subdomain score had the second largest effect while the nasal subdomain score had the least impact on general health-related QOL. CONCLUSIONS: Different types of CRS symptoms - most prominently otologic/facial pain and sleep-related symptoms - and their underlying pathophysiologic mechanisms may differentially affect the general health-related QOL detriment associated with CRS. These findings raise the possibility that treatment of the various symptoms associated with CRS may lead to differential improvement in general-health related QOL.

Vitamin D content and variability in fluid milks from a US Department of Agriculture nationwide sampling to update values in the National Nutrient Database for Standard Reference.

This study determined the vitamin D(3) content and variability of retail milk in the United States having a declared fortification level of 400 IU (10 µg) per quart (qt; 1 qt=946.4 mL), which is 25% daily value per 8 fluid ounce (236.6 mL) serving. In 2007, vitamin D(3) fortified milk (skim, 1%, 2%, whole, and 1% fat chocolate milk) was collected from 24 statistically selected supermarkets in the United States. Additionally, 2% milk samples from an earlier 2001 USDA nationwide collection were reanalyzed. Vitamin D(3) was determined using a specifically validated method involving HPLC with UV spectroscopic detection and vitamin D(2) as an internal standard. Quality control materials were analyzed with the samples. Of the 120 milk samples procured in 2007, 49% had vitamin D(3) within 100 to 125% of 400 IU (10 µg)/qt (label value), 28% had 501 to 600 IU (12.5-15 µg)/qt, 16% had a level below the label amount, and 7% had greater than 600 IU (15 µg)/qt (>150% of label). Even though the mean vitamin D(3) content did not differ statistically between milk types, a wide range in values was found among individual samples, from nondetectable [<20 IU (0.5 µg)/qt] for one sample to almost 800 IU (20 µg)/qt, with a trend toward more samples of whole milk having greater than 150% of the labeled content. On average, vitamin D(3) in 2% milk was higher in 2007 compared with in 2001 [473 vs. 426 IU (11.8 vs. 10.6 µg)/qt].