Athletes Continue to Show Functional Performance Deficits at Return to Sport After Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically review the existing literature on the functional performance of athletes at the time of return-to-sport (RTS) clearance after anterior cruciate ligament reconstruction (ACLR). METHODS: A systematic literature search of the MEDLINE, EMBASE, Scopus, and Web of Science databases was performed. The inclusion criteria were original research reports with study populations of athletes who had undergone ACLR and had undergone objective functional testing immediately after clearance to RTS. Functional testing was stratified by hop tests, strength tests, kinetic assessment, and kinematic assessment, and data were extracted from each study using a standardized template. RESULTS: Of the 937 unique studies identified, 46 met the inclusion criteria. The average time between ACLR and functional testing was 7.9 months among the included studies. In 10 of 17 studies, patients were found to have an average quadriceps strength limb symmetry index of less than 90%. However, only 2 of 12 studies found the average hop test limb symmetry index to be less than 90%. Kinematics included reduced knee flexion angle and increased trunk flexion on landing in ACLR patients compared with matched controls. On evaluation of kinetics, ACLR patients showed reduced peak vertical ground reaction force, lower peak knee extension and knee flexion moments, and altered energy absorption contribution compared with matched controls. CONCLUSIONS: This systematic review suggests that athletes show functional deficits at the time of RTS at an average of 7.9 months after ACLR. Traditional functional tests, such as strength and hop tests, are not able to accurately identify patients who continue to show deficits. The most common biomechanical deficits that persist after RTS clearance include diminished peak knee extension moment, decreased knee flexion angle, increased trunk flexion angle, reduced vertical ground reaction force, and increased hamstring central activation ratio during various functional gait and landing tasks. LEVEL OF EVIDENCE: Level III, systematic review of Level I to III studies.

Functional Return-to-Sport Testing Demonstrates Inconsistency in Predicting Short-Term Outcomes Following Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically review the relationship between functional testing at the time of return to sport (RTS) and short-term outcomes, such as second anterior cruciate ligament (ACL) tear and return to a preinjury level of sport, among athletes who underwent anterior cruciate ligament reconstruction (ACLR). METHODS: A systematic literature search was performed in MEDLINE, EMBASE, Scopus, and Web of Science to identify studies examining athletes who underwent functional RTS testing and were followed for at least 12 months following ACLR. Studies were screened by 2 reviewers. A standardized template was used to extract information regarding study characteristics, ACLR information, functional test results, and risk factors associated with retear or reduced RTS. RESULTS: Of the 937 studies identified, 22 met the inclusion criteria. The average time between ACLR and RTS testing was 8.5 months. Single leg hop for distance performance had no association with retear risk in any study and no association with RTS rates in most studies. Quadriceps strength had conflicting results in relation to retear risk, whereas it had no relationship with RTS rates. Rates of reinjury and RTS were similar between patients who passed and did not pass combined hop and strength batteries. Asymmetric knee extension and hip moments, along with increased knee valgus and knee flexion angles, demonstrated increased risk of retear. CONCLUSIONS: Individual hop and strength tests that are often used in RTS protocols following ACLR may have limited and inconsistent value in predicting ACL reinjury and reduced RTS when used in isolation. Combined hop and strength test batteries also demonstrate low sensitivity and negative predictive value, highlighting conflicting evidence to suggest RTS testing algorithm superiority. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Meteorological and environmental factors that impact pollen counts, allergenicity, and thresholds: A scoping review.

Background: Pollen is a key source of aeroallergens responsible for allergic rhinitis, conjunctivitis, and asthma. Objective: The goal of this scoping review was to summarize current available literature on the factors that affect pollen counts, allergenicity, and thresholds that induce symptoms in individuals who were sensitized. Methods: Several databases showed no published articles with a similar scope as of January 2022. A search of these data bases yielded 373 articles for assessment. These were then reviewed for relevance, and articles were selected to demonstrate the breadth of available data on pollen counts, allergenicity, and thresholds that induce symptoms in individuals who were sensitized. Additional articles were identified through examination of bibliographies of search-identified articles. Results: Several environmental factors have shown a correlation with pollen counts and allergen load, including the distance from the source, wind characteristics, pollen size, terrain, urban environments, air composition (particulate matter, CO2 levels, ozone, NO2), and weather conditions (humidity, thunderstorms, precipitation). Pollen thresholds at which symptoms were induced varied by study, pollen type, symptom, disease, and location. In addition, there was heterogeneity in study designs, threshold definition, and outcome measures. Conclusion: This scoping review demonstrates the plethora of variables that influence the relationship between pollen and the symptoms of allergic diseases. Analysis of the available data sheds light on the complex interaction between environmental and biologic factors that affect pollen's role in allergic diseases and provides guidance on multiple areas for further investigation.

Topical corticosteroids for chronic rhinosinusitis with nasal polyposis: GRADE systematic review and network meta-analysis.

BACKGROUND: Chronic rhinosinusitis with nasal polyposis (CRSwNP) is associated with a significant disease burden. The optimal use of and administration route for intranasal corticosteroids (INCS) when managing CRSwNP are unclear. OBJECTIVE: We systematically synthesized the evidence addressing INCS for CRSwNP. METHODS: We searched studies archived in Medline, Embase, and Central from database inception until September 1, 2021, for randomized controlled trials comparing INCS using any delivery method to placebo or other INCS administration types. Paired reviewers screened records, abstracted data, and rated risk of bias (CLARITY revision of Cochrane Risk of Bias version 1 tool) independently and in duplicate. We synthesized the evidence for each outcome using random effects network meta-analyses. We critically appraised the evidence following the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) approach. RESULTS: We analyzed 61 randomized controlled trials (7176 participants, 8 interventions). Sinusitis-related quality of life might improve with INCS rinse (mean difference [MD] -6.83, 95% confidence interval [CI] -11.94 to -1.71) and exhalation delivery system (EDS) (MD -7.86, 95% CI -14.64 to -1.08) compared to placebo (both low certainty evidence). Nasal obstruction symptoms are likely improved when receiving INCS via stent/dressing (MD -0.31, 95% CI -0.54 to -0.08), spray (MD -0.51, 95% CI -0.61 to -0.41), and EDS (MD -0.35, 95% CI -0.51 to -0.18) (all moderate to high certainty) compared to placebo. We found no important differences in adverse effects among interventions (moderate certainty for INCS spray, very low to low certainty for others). CONCLUSIONS: Multiple delivery forms of INCS are viable therapeutic options for CRSwNP, resulting in improvement of patient-important outcomes. INCS via stent, spray, and EDS appear to be beneficial across the widest range of considered outcomes.

Listening to Learners to Prepare for the Future: A Mayo Clinic College of Medicine and Science Benchmarking Survey.

In 2022, a benchmarking survey was completed to gage learner satisfaction with library services, spaces, and resources across 10 Mayo Clinic Libraries. The discussion for this project began around a previously published survey of what medical students wanted from their library. Librarians were asked if Mayo Clinic Libraries could do a similar survey, as a full survey of the Mayo Clinic College of Medicine and Science had not been done. Overall, the findings were positive and provide a baseline for future surveys.

Use of the Electronic Health Record During Clinical Encounters: An Experience Survey.

PURPOSE: Use of the electronic health record (EHR) during face-to-face clinical encounters affects communication, and prior research has been inconclusive regarding its effect. This survey study assessed health care practitioner use of EHR-specific communication skills and patient and practitioner experiences and attitudes regarding EHR use during clinical encounters. METHODS: For this US-based study, we distributed previously validated surveys to practitioners and adult patients (aged >18 years) at academic primary care practices from July 1, 2018 through August 31, 2018. The electronic practitioner survey was completed first; a paper survey was administered to patients after appointments. Descriptive statistics were calculated, and the Cochran-Armitage test was used to assess for associations between key variables. RESULTS: The practitioner response was 72.9% (43/59); patient response, 45.2% (452/1,000). Practitioners reported maintaining less eye contact (79.1%), listening less carefully (53.5%), focusing less on patients (65.1%), and visits feeling less personal (62.8%). However, patients reported that practitioners provided sufficient eye contact (96.8%) and listened carefully (97.0%); they disagreed that practitioners focused less on them (86.7%) or that visits felt less personal (87.2%). Patients thought EHR use was positive (91.7%); only one-third of practitioners (37.2%) thought that patients would agree with that statement. Practitioners reported stress, burnout, and a lack of sufficient time for EHR documentation. CONCLUSIONS: A discrepancy existed in this study between patient and practitioner experiences and attitudes about EHR use, which appeared to negatively affect the experience of health care practitioners but not patients. Organizations should adopt formal strategies to improve practitioner experiences with EHR use.

Using a teach-back intervention significantly improves knowledge, perceptions, and satisfaction of patients with Nurses' discharge medication education.

BACKGROUND: Evidence indicates that patients desire medication information, but clinicians often fail to teach this information in an understandable way. Teach-Back promotes effective clinician-patient communication and enhances medication adherence, satisfaction with education, and hospital experiences. AIMS: This study examined effects of a nurse-led Teach-Back intervention, Teaching Important Medication Effects (TIME), compared with usual care on patients' knowledge, experiences, and satisfaction with medication education before and after discharge. The aims were to examine patients' priority learning needs, group differences in new medication knowledge before and after discharge, and post-discharge experience and satisfaction with medication instruction. METHODS: A longitudinal pretest/post-test, 2-group design was used with 107 randomly selected medical-surgical patients from an academic hospital. After receiving medication instructions, patients were interviewed before and within 72 h after discharge. Bivariate analyses were used to assess group differences in demographic and outcome variables. RESULTS: Usual care (n = 52) and TIME (n = 55) groups' characteristics were equivalent. Knowing new medication names and side effects were top learning priorities. Medication side effect knowledge was better in TIME versus usual care groups at discharge (94.3% vs. 72.5%, p = .003) and follow-up (93.9% vs.75.8%, p = .04). TIME positively influenced patients' medication education experiences; specifically, nurses always explained why a new medication was needed and its side effects. TIME was associated with patients being very satisfied with nurses' education versus usual care (97% vs. 46.9%, p < .001). LINKING EVIDENCE TO ACTION: TIME was significantly and positively associated with knowledge of new medication side effects over time and experiences and satisfaction with nurses' medication education. Teach-Back was effective in educating patients about new medications. It is an essential approach for patient education, requiring clinicians to confirm patients' retention and understanding of new information with each encounter.

Intra-articular therapy with methotrexate or tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic review.

BACKGROUND: Persistent monoarthritis in otherwise well-controlled rheumatoid arthritis presents a therapeutic challenge. Intra-articular (IA) steroids are a mainstay of treatment, though some have queried whether IA disease modifying anti-rheumatic drugs (DMARD) and biologics can be used in those who fail steroid injections. METHODS: A systematic literature review was conducted using four medical databases to identify randomized, controlled trials assessing IA therapies in RA patients. Included studies underwent Cochrane Risk of Bias 2 assessment for quality. RESULTS: Twelve studies were included, 6 of which examined intra-articular (IA) TNF inhibitors (TNFi), and 6 studies evaluating IA methotrexate. Of those evaluating IA TNFi, one study reported statistical improvement in TNFi therapy when compared with placebo. The remaining 5 studies compared IA TNFi therapy with steroid injections. IA TNFi had statistically improved symptom scores and clinical assessments comparable with IA steroid treatments. In the 6 studies evaluating IA methotrexate, the addition of methotrexate to steroid intra-articular therapy was not found to be beneficial, and singular methotrexate injection was not superior to the control arms (saline or triamcinolone). Risk-of-bias (ROB) assessment with the Revised Cochrane ROB tool indicated that 2 of 6 TNFi studies were at some risk or high risk for bias, compared with 5 out of 6 methotrexate studies. CONCLUSION: For persistent monoarthritis in rheumatoid arthritis, IA methotrexate was not found to have clinical utility. Intra-articular TNFi therapy appears to have equal efficacy to IA steroids, though the optimal dose and frequency of injections is yet unknown.

Gastroesophageal reflux disease and head and neck cancers: A systematic review and meta-analysis.

PURPOSE: Gastroesophageal reflux disease (GERD) has been associated with head and neck cancer (HNC), including laryngeal and pharyngeal anatomical sites. A systematic review and meta-analysis was performed to examine these associations. METHODS: Articles were retrieved from the Medline, Web of Science, Scopus, and Embase databases using keywords "gastroesophageal reflux disease", "laryngopharyngeal reflux", "head and neck cancer", and associated variants. Inclusion criteria were English language publications, human subjects, and controlled studies with described development of head and neck cancer among individuals with GERD. 13 studies with a total of 39,824 patients were included. RESULTS: Overall, presence of GERD was associated with an increased risk of developing HNC (OR = 1.86, 95% Confidence Interval [CI] = 1.27-2.74). This association remained significant with laryngeal cancers (OR = 1.95, 95% CI = 1.33-2.86), but not pharyngeal cancers (OR = 1.56, 95% CI = 0.86-2.83). Subgroup analyses of hypopharyngeal (OR = 2.26, 95% CI = 0.67-7.68) and oropharyngeal subsites (OR = 1.39, 95% CI = 0.51-3.84) were not statistically significant. Meta-analysis of studies that objectively assessed reflux, such as pH monitor placement, showed statistical significance (OR = 2.81, 95% CI = 1.36-5.81), while studies that used subjective reporting or chart review of GERD were not significant (OR = 1.46, 95% CI = 0.89-2.40). Association between H. pylori infection and head and neck cancers was not statistically significant (OR = 2.66, 95% CI = 0.59-11.97). CONCLUSION: A diagnosis of GERD is associated with a later diagnosis of HNC, but this association is not significant for pharyngeal cancers. Associations of GERD with HNC may be specific to laryngeal cancers. LEVEL OF EVIDENCE: Systematic review and meta-analysis of case control studies (3a).

CSF Pressure, Volume, and Post-Dural Puncture Headache: A Case-Control Study and Systematic Review.

OBJECTIVES: (1) To perform a systematic literature review to evaluate associations between post-dural puncture headache (PDPH) and opening pressure (OP), closing pressure (CP), and volume of cerebrospinal fluid (V) removed. (2) To perform a case-control study to evaluate pressure-volume index (PVI) as a novel risk factor for PDPH. BACKGROUND: According to the International Classification of Headache Diagnoses, 3rd Edition (ICHD-3), the diagnosis of PDPH requires documentation of intracranial hypotension. However, this remains an unproven concept. METHODS: A systematic literature review was conducted, searching Cochrane Database of Systematic Reviews, Ovid EMBASE, OVID MEDLINE, Scopus, and Web of Science. Study inclusion required a comparison of headache incidence following a LP as a function of OP, CP, and/or V. A retrospective, case-control study with 1:1 matching was conducted utilizing ICHD-3 criteria. Patients with factors that could influence CSF pressure were excluded. RESULTS: In our case-control study, we did not identify a paired difference in either median (95% CI) elastance (0.05 [-0.09, 0.11], P = .503) or PVI (4.53 [-7.98, 19.97], P = .678). We identified 22 references, evaluating V (n = 14), OP (n = 11), and/or CP (n = 4). There was no convincing evidence for an association of PDPH with either OP or CP. A minority of studies documenting an association with V included patients with high-volume CSF removal, and/or stratified patients by the timing of the headache onset. CONCLUSIONS: The overall risk of PDPH does not appear to be influenced by OP, CP, V or PVI. PDPH may be related to V in instances of high-volume removal, and depend on the timing of outcome assessment. Future revision of criteria should consider the existence of immediate and delayed PDPH subtypes, and not presume intracranial hypotension as a mandatory feature.

Hospital library closures and consolidations: a case series.

BACKGROUND: Health sciences libraries are being closed or are under threat of closure, but little is published that looks at context and causes or alternative library service delivery models such as affiliations or consolidations. There is also very little research about the effect of these changes on health care provider satisfaction, patient care, or hospital quality indicators. Preventing library closures is not always possible, but understanding some of the circumstances leading to the decision and implementation of a closure or consolidation could inform best practice management. CASE PRESENTATIONS: At a recent Medical Library Association joint chapter meeting, a panel of six librarians presented their cases of navigating a library closure or reorganization. Background information was given to highlight reasons that the decisions to reorganize or close were made. Following the case presentations, participants took part in discussion with audience members. Cases and discussion points were recorded for further research, publication, and advocacy. CONCLUSIONS: Several points from the cases are highlighted in the discussion section of the paper. An accurate reporting of US health sciences libraries and librarian staffing is needed. More needs to be written about new library service models and best practices for centralizing and maintaining library services. After a consolidation, remaining librarians will be expected to manage the effects of staff loss and site closures and so should be involved in planning and implementing these decisions. It remains to be determined how hospitals with librarians compare in patient care and other quality indicators against hospitals without librarians.

Elevating Evidence-Based Practice: A Multi-Site Workshop Pilot for Nurses.

Leveraging an established evidence-based practice (EBP) workshop at the Mayo Clinic campus in Arizona, the manager of Nursing Research asked local library staff to discuss the research process and to demonstrate to the attendees how to use literature databases to support their research projects and EBP practices on their units. The EBP workshop was presented via video conference from the originating location to two remote locations within the organization. Each remote site had a librarian in attendance to support the librarian at the originating campus. This method allowed the librarians at each site to guide and assist patrons and establish a face-to-face connection with attendees.

Minimally invasive biomarker studies in eosinophilic esophagitis: A systematic review.

BACKGROUND: Eosinophilic esophagitis (EoE) is a chronic, inflammatory disease of the esophagus that currently requires repeated endoscopic biopsies for diagnosis and monitoring because no reliable noninvasive markers have been identified. OBJECTIVE: To identify promising minimally invasive EoE biomarkers and remaining gaps in biomarker validation. METHODS: We performed a systematic review of EMBASE, Ovid MEDLINE, PubMed, and Web of Science from inception to June 6, 2017. Studies were included if patients met the 2007 consensus criteria for EoE diagnosis, a minimally invasive biomarker was assessed, and the study included at least 1 control for comparison. RESULTS: The search identified 2094 studies, with 234 reviewed at full-text level, and 49 included in the analysis (20 adult, 19 pediatric, 7 pediatric and adult, and 3 not stated). Most (26 of 49) were published after 2014. Thirty-five studies included healthy controls, 9 analyzed atopic controls, and 29 compared samples from patients with active and inactive EoE. Minimally invasive biomarkers were obtained from peripheral blood (n = 41 studies), sponge or string samples (n = 3), oral or throat swab secretions (n = 2), breath condensate (n = 2), stool (n = 2), and urine (n = 2). The most commonly reported biomarkers were peripheral blood eosinophils (n = 16), blood and string eosinophil granule proteins (n = 14), and eosinophil surface or intracellular markers (n = 12). EoE biomarkers distinguished active EoE from healthy controls in 23 studies, atopic controls in 2 studies, and inactive EoE controls in 20 studies. CONCLUSION: Several promising minimally invasive biomarkers for EoE have emerged; however, few are able to differentiate EoE from other atopic diseases.

Alcohol use at midlife and in menopause: a narrative review.

Alcohol use disorder stands as a prevalent global issue, contributing to 140,000 annual deaths in the United States and causing numerous adverse health and socioeconomic outcomes. Despite being a natural physiological process, menopause often leads to troublesome symptoms that affect women's quality of life and exposes them to increased health risks. Our review delves into the intricate relationship between alcohol use disorder and the menopausal experience. We examine the impact of heightened alcohol consumption on the onset, severity, and burden of menopausal symptoms, particularly vasomotor symptoms. Additionally, we explore its effects on commonly experienced menopausal symptoms such as mood disturbances, sleep problems, and sexual dysfunction. Considering the chronic health conditions associated with both menopause and alcohol use disorder, our study also investigates the influence of alcohol use disorder on bone density. This is especially important due to the elevated risks and mortality linked to bone mineral density loss in menopausal women.

Clinical Significance of Mottling Rashes in Diving Decompression Sickness.

INTRODUCTION: Decompression sickness (DCS) is a medical condition caused by outgassing of dissolved nitrogen following rapid ascent by divers and aviators. Cutaneous DCS, historically termed cutis marmorata (CM), presents as a predominantly truncal reticular violaceous-to-dusky eruption. The prevailing theories for its pathogenesis include: localized cutaneous outgassing, paradoxical embolism across a right-to-left shunt (RLS), and brainstem emboli disrupting autonomic control of cutaneous microcirculation.METHODS: We conducted a systematic review of reports of cutaneous DCS to investigate relationships among CM, RLS, and neurological sequelae to better elucidate the mechanism of CM. A literature search examining reports of cutaneous DCS yielded 31 eligible studies, comprising a pooled total of 128 patients.RESULTS: Of the patients with documented workup, 84% showed evidence of RLS with CM. Subsequently 18 patients underwent percutaneous closure of intracardiac RLS with no recurrence of DCS. Of the patients with documented neurological evaluations, 57% experienced both CM and neurological DCS manifestations. The coexistence of RLS and neurological symptoms with CM was noted in numerous cases; exact percentages of overlap cannot be stated due to data unavailability.DISCUSSION: Our results indicating the striking coexistence of RLS and neurological sequelae in CM patients is supportive of the paradoxical embolism theory of pathogenesis. The frequent coincidence of CM with RLS and neurological symptoms raises concern that CM may signify vulnerability to devastating systemic gas emboli. CM has historically been considered trivial and self-limiting; however, our results support reappraisal of its clinical significance and potential reclassification to the more severe subtype.Breen ID, Stepanek J, Marks L, Yale K, Mesinkovska N, Swanson D. Clinical significance of mottling rashes in diving decompression sickness. Aerosp Med Hum Perform. 2024; 95(9):695-702.

Mental Health in Elite Athletes: A Systematic Review of Suicidal Behaviour as Compared to the General Population.

BACKGROUND AND OBJECTIVE: Previous systematic reviews on mental health in athletes have found athletes to be at a potentially increased risk for mental health diagnoses compared to the public. Multiple cross-sectional studies have examined suicide behaviour within different athlete populations, but there is a need for a comprehensive review to synthesize and identify risk factors and epidemiology regarding suicide behaviour in the elite athlete population, especially as it compares to the general population. METHODS: A systematic literature search was performed in MEDLINE, EMBASE, Scopus, and Web of Science from 1990 to January 2023. Inclusion criteria included original peer-reviewed research articles examining suicidal ideation, suicide attempt, or suicide completion within elite athlete populations. Exclusion criteria included athletes participating in high-school or Paralympic level sports, studies that did not report results regarding elite athletes and non-athletes separately, and non-peer reviewed work. All studies were screened for inclusion by two independent reviewers. The primary outcome variables extracted from included studies included rates, risk factors, and protective factors for suicide behaviour. The study quality and risk of bias was evaluated for each study using the Joanna-Briggs Institute (JBI) critical appraisal tools. RESULTS: Of the 875 unique studies identified, 22 studies, all of which were cross-sectional in nature, met the inclusion criteria. Seven studies evaluated previous athletes, 13 studies evaluated current athletes, and two studies included a combination of previous and current athletes. Seven studies involved varsity college athletes, nine involved professional athletes of various sports, and six focused on international or Olympic level athletes. The rate of suicidal ideation in professional athletes ranged from 6.9 to 18% across four studies, while the rate in collegiate athletes ranged from 3.7 to 6.5% across three studies. Ten studies compared athletes to the general population, the majority of which found athletes to be at reduced risk of suicidal ideation, suicide attempt, and suicide completion. Only one study found athletes to have increased rates of suicide compared to matched non-athletes. Risk factors for suicide behaviour identified across multiple studies included male sex, non-white race, older age, and depression. Player position, athletic level, sport played, and injuries showed trends of having limited effect on suicide behaviour risk. CONCLUSION: This review suggests that elite athletes generally demonstrate reduced risk of suicidal ideation, suicide attempt, and suicide completion compared to the general population. Coaches should remain aware of specific factors, such as male sex, non-white race, and higher athletic level, in order to better identify at-risk athletes. Limitations of this review include the heterogeneity in the methodology and athlete populations across the included studies. Therefore, future targeted research is essential to compare suicide behaviour between sports and identify sport-specific suicide risk factors. TRIAL REGISTRATION: PROSPERO Registration: CRD42023395990.

Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants.

BACKGROUND: Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. OBJECTIVES: To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. METHODS: An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. RESULTS: Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. CONCLUSION: Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

Insights into the epigenetics of chronic rhinosinusitis with and without nasal polyps: a systematic review.

Background: Epigenetics facilitates insights on the impact of host environment on the genesis of chronic rhinosinusitis (CRS) through modulations of host gene expression and activity. Epigenetic mechanisms such as DNA methylation cause reversible but heritable changes in gene expression over generations of progeny, without altering the DNA base-pair sequences. These studies offer a critical understanding of the environment-induced changes that result in host predisposition to disease and may help in developing novel biomarkers and therapeutics. The goal of this systematic review is to summarize the current evidence on epigenetics of CRS with a focus on chronic rhinosinusitis with nasal polyps (CRSwNP) and highlight gaps that merit further research. Methods: A systematic review of the English language literature was performed to identify investigations related to epigenetic studies in subjects with CRS. Results: The review identified 65 studies. These have focused on DNA methylation and non-coding RNAs, with only a few on histone deacetylation, alternative polyadenylation, and chromatin accessibility. Studies include those investigating in vivo and in vitro changes or both. Studies also include animal models of CRS. Almost all have been conducted in Asia. The genome-wide studies of DNA methylation found differences in global methylation between CRSwNP and controls, while others specifically found significant differences in methylation of the CpG sites of the thymic stromal lymphopoietin (TSLP), IL-8, and PLAT. In addition, DNA methyltransferase inhibitors and histone deacetylase inhibitors were studied as potential therapeutic agents. Majority of the studies investigating non-coding RNAs focused on micro-RNAs (miRNA) and found differences in global expression of miRNA levels. These studies also revealed some previously known as well as novel targets and pathways such as tumor necrosis factor alpha, TGF beta-1, IL-10, EGR2, aryl hydrocarbon receptor, PI3K/AKT pathway, mucin secretion, and vascular permeability. Overall, the studies have found a dysregulation in pathways/genes involving inflammation, immune regulation, tissue remodeling, structural proteins, mucin secretion, arachidonic acid metabolism, and transcription. Conclusions: Epigenetic studies in CRS subjects suggest that there is likely a major impact of the environment. However, these are association studies and do not directly imply pathogenesis. Longitudinal studies in geographically and racially diverse population cohorts are necessary to quantify genetic vs. environmental risks for CRSwNP and CRS without nasal polyps and assess heritability risk, as well as develop novel biomarkers and therapeutic agents.

Sclerotherapy for Hereditary Hemorrhagic Telangiectasia-Related Epistaxis: A Systematic Review.

OBJECTIVES: Hereditary hemorrhagic telangiectasia (HHT) is a common inherited condition characterized by mucosal telangiectasias, recurrent epistaxis, and arteriovenous malformations. HHT results in detriment to quality of life. Morbidity and mortality result from severe anemia. Conventional interventions for HHT-related epistaxis include nasal packing, diathermy, lasers, coblation, microdebridement, bevacizumab (topical and systemic), as well as septodermoplasty and nasal closure. Sclerotherapy has been recently described in the literature as a novel approach to HHT-related epistaxis. We hypothesize that sclerotherapy is an effective treatment for HHT-related epistaxis and improves upon the current standard of care for this disease. METHODS: A systematic review was conducted to study sclerotherapy for treating HHT-related epistaxis. Ovid MEDLINE, Ovid EMBASE, Scopus, and Web of Science were searched. Articles were evaluated and excluded according to PRISMA guidelines and reviewed by 2 authors. Reported variables included number of injections, months of follow up, changes in Epistaxis Severity Score, previous treatments used to control epistaxis, and post-injection side effects. RESULTS: Seven studies with a total of 196 patients met inclusion criteria. Three studies reported significant improvement as measured by the Epistaxis Severity Score scale. One reported improvement through subjective patient surveys and others used the Bergler-Sadick scale to measure frequency and intensity of epistaxis. All studies reported improvement in HHT-related epistaxis. The lack of uniform reporting measures however precluded formal meta-analysis. CONCLUSIONS: Based on limited data, sclerotherapy appears to be effective for treating HHT-related epistaxis and offers promise for treating this recalcitrant condition. However, larger, prospective, multi-centered studies using universally validated instruments for epistaxis are needed to definitively evaluate outcomes from sclerotherapy.