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Journal of Medical Internet Research Nov 2020There has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the...
BACKGROUND
There has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding the safety of remote consultations is inconclusive. The appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed.
OBJECTIVE
This study aimed to summarize evidence on the impact of remote consultation in primary care with regard to antibiotic prescribing.
METHODS
Searches were conducted in MEDLINE, Embase, HMIC, PsycINFO, and CINAHL for literature published since the databases' inception to February 2020. Peer-reviewed studies conducted in primary health care settings were included. All remote consultation types were considered, and studies were required to report any quantitative measure of antibiotic prescribing to be included in this systematic review. Studies were excluded if there were no comparison groups (face-to-face consultations).
RESULTS
In total, 12 studies were identified. Of these, 4 studies reported higher antibiotic-prescribing rates, 5 studies reported lower antibiotic-prescribing rates, and 3 studies reported similar antibiotic-prescribing rates in remote consultations compared with face-to-face consultations. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for patients with sinusitis, but conflicting results were found for patients with acute respiratory infections. Mixed evidence was found for follow-up visit rates after remote and face-to-face consultations.
CONCLUSIONS
There is insufficient evidence to confidently conclude that remote consulting has a significant impact on antibiotic prescribing in primary care. However, studies indicating higher prescribing rates in remote consultations than in face-to-face consultations are a concern. Further, well-conducted studies are needed to inform safe and appropriate implementation of remote consulting to ensure that there is no unintended impact on antimicrobial resistance.
Topics: Adult; Anti-Bacterial Agents; Female; Humans; Male; Primary Health Care; Remote Consultation; SARS-CoV-2; COVID-19 Drug Treatment
PubMed: 33031045
DOI: 10.2196/23482 -
American Journal of Rhinology & Allergy May 2021RARS is a challenging clinical phenomenon that affects many patients, and diagnostic criteria for this condition are not fully characterized in the literature.
BACKGROUND
RARS is a challenging clinical phenomenon that affects many patients, and diagnostic criteria for this condition are not fully characterized in the literature.
OBJECTIVE
To examine diagnostic criteria for recurrent acute rhinosinusitis (RARS).
STUDY DESIGN
Systematic review.
METHODS
Cochrane, PubMed (MEDLINE), clinicaltrials.gov, EMBASE, Google Scholar, and Web of Science databases were queried for articles related to RARS dating from 1990 to present, according to PRISMA statement guidelines. Full text articles pertinent to the diagnostic criteria of RARS were included in this review. Inclusion criteria included articles specifically addressing RARS; studies with 3 or more patients; and articles in English.
RESULTS
A total of 1022 titles/abstracts potentially related to RARS were identified. Of these, sixty-nine full texts were selected for review, and 22 of these ultimately met inclusion criteria. The level of evidence was generally low. Studies and guidelines have used many different definitions for RARS diagnosis over the years based on symptomatology, physical examination, nasal endoscopy, imaging, and laboratory domains. Clinically important RARS has been defined most commonly as 4 or more discrete episodes of ARS per year, but this frequency is typically based on expert opinion. Additionally, radiologic anatomic associations such as concha bullosa, accessory maxillary os, and narrowed infundibular distance may be associated with RARS. Endoscopic visualization and imaging are sometimes used to confirm the presence of sinus disease during exacerbations of RARS, but there is variability in this practice.
CONCLUSION
The diagnostic definition for RARS has developed over time and is currently based on low level 4 and 5 evidence. Because of the migratory definition of RARS, comparing inter-study results of RARS management remains difficult, and future studies should aim to follow current expert guidelines on diagnostic criteria of RARS.
Topics: Acute Disease; Humans; Recurrence; Retrospective Studies; Rhinitis; Sinusitis
PubMed: 32954839
DOI: 10.1177/1945892420956871 -
Current Allergy and Asthma Reports Sep 2020We provide a systematic review of experimental and clinical evidences linking allergy to acute, including common cold, and chronic rhinosinusitis in children....
PURPOSE OF THE REVIEW
We provide a systematic review of experimental and clinical evidences linking allergy to acute, including common cold, and chronic rhinosinusitis in children. Furthermore, we questioned if anti-allergy treatment may prevent the occurrence of rhinosinusitis or improve outcomes of its specific management.
RECENT FINDINGS
Allergic rhinitis is a common childhood disease in industrialized countries that is responsible for a major impact on quality of life and healthcare resources. Over the years many authors tried to correlate allergy with comorbidities and in particular to the onset of rhinosinusitis including common cold, even though conflicting results are frequently reached. We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) process. Our search yielded 7103 that were finally screened. This resulted in 25 publications of which the full texts were assessed and included in a qualitative analysis per different phenotypes of rhinosinusitis. The evidence suggests that allergy may lead to overall impairment of mechanical and immunological defense function of the nasal mucosa against viruses and that anti-allergy treatment may significantly decrease the number and severity of upper respiratory tract infections including common colds in children. It was not possible to perform the analysis for allergy and post-viral acute rhinosinusitis, bacterial acute rhinosinusitis, and recurrent acute rhinosinusitis because of paucity and heterogeneity of data. Although there is no definitive proof of causation linking allergy to chronic rhinosinusitis, studies lead to suppose that anti-allergy treatment may improve outcomes of specific CRS treatments.
Topics: Acute Disease; Allergens; Biomarkers; Child; Chronic Disease; Histamine Antagonists; Humans; Rhinitis; Rhinitis, Allergic; Sinusitis
PubMed: 32889648
DOI: 10.1007/s11882-020-00967-9 -
Journal of Otolaryngology - Head & Neck... Aug 2020Acute exacerbations (AE) in chronic rhinosinusitis (CRS) have been increasingly recognized as an important clinical issue. The purpose of this study is to summarize the...
BACKGROUND
Acute exacerbations (AE) in chronic rhinosinusitis (CRS) have been increasingly recognized as an important clinical issue. The purpose of this study is to summarize the current definitions and evaluation parameters of AE and then identify and quantify the clinical and immunopathologic characteristics of AE in CRS.
METHODS
A systematic review of the literature was performed on PubMed, Scopus, and Cochrane databases from January 1990 through August 2020 to identify studies relating to AE in CRS. Exclusion criteria included non-English and non-human studies, and case reports.
RESULTS
The definitions of AE in CRS among all the studies were based on a description of short-term worsening sinonasal symptoms. Patient-reported sinus infection and exacerbation related medical treatment during the preceding 3 months to 1 year were used to evaluate the frequency of AE in CRS. The average decline in 22-item Sino-Nasal Outcome Test (SNOT-22) score during an exacerbation was 7.83 points relative to baseline. Comorbid asthma, SNOT-22 scores ≥24, allergic rhinitis, eosinophil count ≥150/μL and autoimmune disease were positively associated with an exacerbation-prone CRS phenotype. AE in chronic rhinosinusitis with nasal polyps (CRSwNP) was associated with increased expression of mucus cytokines including myeloperoxidase (percentage increase [PI] = 101%), IL-5 (PI = 125%), and IL-6 (PI = 162%) and could be predicted by the increasing mucus cystatin and periostin.
CONCLUSION
The definition of AE in CRS is largely driven by patient-reported symptoms and is associated with several risk factors. Quantitative changes in mucus cytokines associated with AE in CRSwNP and may be used to predict events. The development of a consistent definition of AE in CRS is critical to help define disease control and treatment efficacy.
Topics: Asthma; Chronic Disease; Humans; Nasal Polyps; Rhinitis; Risk Factors; Sino-Nasal Outcome Test; Sinusitis; Symptom Flare Up
PubMed: 32811568
DOI: 10.1186/s40463-020-00459-w -
International Forum of Allergy &... Feb 2021Immunodeficiency is a risk factor for recalcitrant chronic rhinosinusitis (CRS). Currently, there is no consensus on effective treatment modalities for immunodeficient...
BACKGROUND
Immunodeficiency is a risk factor for recalcitrant chronic rhinosinusitis (CRS). Currently, there is no consensus on effective treatment modalities for immunodeficient CRS patients. This review aims to evaluate the existing evidence on the treatment outcomes and its limitations in patients with CRS and immunodeficiency.
METHODS
MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to April 2019 for studies reporting measurable medical or surgical treatment outcomes for adult patients with CRS and underlying primary or secondary immunodeficiency.
RESULTS
Of the 2459 articles screened, 13 studies met the inclusion criteria: 2 prospective double-blind placebo-controlled trials, 2 prospective case-control studies, 2 prospective cohort studies, and 7 case series. The high degree of study heterogeneity precluded a meta-analysis. Antibiotic monotherapy was not linked with significant improvement in clinical, radiographic, or endoscopic outcomes. Immunoglobulin replacement therapy may potentially reduce the frequency of acute or chronic sinusitis in patients with primary immunodeficiency (PID) but may not improve their sinonasal symptoms. Outcomes from endoscopic sinus surgery (ESS) were reported in 8 studies, which found that surgery was linked with improvement in symptoms, disease-specific quality of life, endoscopy scores, and radiographic scores. The average reported ESS revision rate was 14%.
CONCLUSION
Patients with CRS and immunodeficiency likely benefit from ESS based on the available evidence. Data supporting medical therapy in this targeted population is limited overall, but there may be a potential role for immunoglobulin therapy in patients with PID and CRS.
Topics: Adult; Chronic Disease; Endoscopy; Humans; Prospective Studies; Quality of Life; Randomized Controlled Trials as Topic; Rhinitis; Sinusitis; Treatment Outcome
PubMed: 32668102
DOI: 10.1002/alr.22647 -
Open Forum Infectious Diseases Jun 2020Olfactory dysfunction (OD) has been reported in coronavirus disease 2019 (COVID-19). However, there are knowledge gaps about the severity, prevalence, etiology, and...
BACKGROUND
Olfactory dysfunction (OD) has been reported in coronavirus disease 2019 (COVID-19). However, there are knowledge gaps about the severity, prevalence, etiology, and duration of OD in COVID-19 patients.
METHODS
Olfactory function was assessed in all participants using questionnaires and the butanol threshold test (BTT). Patients with COVID-19 and abnormal olfaction were further evaluated using the smell identification test (SIT), sinus imaging, and nasoendoscopy. Selected patients received nasal biopsies. Systematic review was performed according to PRISMA guidelines. PubMed items from January 1, 2020 to April 23, 2020 were searched. Studies that reported clinical data on olfactory disturbances in COVID-19 patients were analyzed.
RESULTS
We included 18 COVID-19 patients and 18 controls. Among COVID-19 patients, 12 of 18 (67%) reported olfactory symptoms and OD was confirmed in 6 patients by BTT and SIT. Olfactory dysfunction was the only symptom in 2 patients. Mean BTT score of patients was worse than controls ( = .004, difference in means = 1.8; 95% confidence interval, 0.6-2.9). Sinusitis and olfactory cleft obstruction were absent in most patients. Immunohistochemical analysis of nasal biopsy revealed the presence of infiltrative CD68 macrophages harboring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigen in the stroma. Olfactory dysfunction persisted in 2 patients despite clinical recovery. Systematic review showed that the prevalence of olfactory disturbances in COVID-19 ranged from 5% to 98%. Most studies did not assess olfaction quantitatively.
CONCLUSIONS
Olfactory dysfunction is common in COVID-19 and may be the only symptom. Coronavirus disease 2019-related OD can be severe and prolonged. Mucosal infiltration by CD68 macrophages expressing SARS-CoV-2 viral antigen may contribute to COVID-19-related OD.
PubMed: 32548209
DOI: 10.1093/ofid/ofaa199 -
International Journal of Pediatric... Aug 2020Assess characteristics and outcomes of orbital complications of acute bacterial rhinosinusitis (ABRS) in the pediatric population and evaluate trends over time. (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Assess characteristics and outcomes of orbital complications of acute bacterial rhinosinusitis (ABRS) in the pediatric population and evaluate trends over time.
METHODS
A literature search of pediatric orbital complications was performed in the following databases: Ovid MEDLINE, Scopus, and Cochrane Database of Systematic Reviews. Studies reporting data for at least 10 subjects with orbital complications of sinusitis under 18 years old were included. Studies were grouped by publication year; before 2010 and after and including 2010. Studies that only included patients with subperiosteal abscess (SPA) were grouped in a separate category. Data collected include demographics, Chandler class complications, intra-operative culture, treatment, and outcomes. Meta-analysis of proportion was performed to compare data from studies published before 2010 and data published in 2010 and after.
RESULTS
Thirty-five studies met inclusion criteria. No significant difference was observed over time in gender of subjects in the all Chandler complications or SPA only groups (P > 0.72). The proportion of subjects presenting with Chandler IV complications decreased from 6.8% to 2.9% in recent studies (P = 0.019). The proportion of subjects treated surgically decreased from 45.2% to 21.7% in the all Chandler complications group (P < 0.0001) and from 90.0% to 47.9% in the SPA only group, P < 0.0001. The proportion of S. pneumoniae positive cultures decreased from 20.5% to 9.1% (P = 0.02).
CONCLUSION
The demographics of pediatric patients treated for orbital complications of ABRS in published literature has been stable. Patients reported in more recently published studies are less likely to present with orbital abscess and more likely to receive conservative treatment. The proportion of positive Streptococcus pneumoniae cultures have decreased.
Topics: Acute Disease; Adolescent; Bacterial Infections; Child; Child, Preschool; Female; Humans; Infant; Infant, Newborn; Male; Orbital Diseases; Rhinitis; Sinusitis; Treatment Outcome
PubMed: 32408012
DOI: 10.1016/j.ijporl.2020.110078 -
Paediatric Respiratory Reviews Nov 2020Acute upper respiratory tract infections are the most common infections in infants and children. Saline nasal irrigation (SNI) is widely prescribed and recommended. We... (Meta-Analysis)
Meta-Analysis
PURPOSE
Acute upper respiratory tract infections are the most common infections in infants and children. Saline nasal irrigation (SNI) is widely prescribed and recommended. We conducted a systematic review to assess the efficacy and safety of SNI in infants and children with acute rhinopharyngitis.
METHODS
We searched CENTRAL, Medline, Embase and clinicalTrials.gov. Two authors selected randomized control trials (RCTs), including infants ≥3 months and children ≤12 years, comparing the use of isotonic saline solutions, whatever their mode of administration, with one therapeutic abstention, or a therapy deemed less important for nasal lavage. Trial quality was assessed independently by two authors, who, with a third author, extracted and analysed data. Statistical analysis was conducted using Comprehensive Meta-Analysis software. The standard difference in means (SMD) between groups and its 95% confidence interval were estimated.
RESULTS
Four RCTs (569 participants) were included. The analysis showed a benefit of SNI for certain clinical rhinological symptoms (SMD = -0.29 [-0.45; -0.13]) but no significant improvement of respiratory symptoms (SMD = -0.19 [-0.70; 1.08]) or health status (SMD = -0.30 [-0.68; 0.07]). Its use appeared to limit the prescription of other treatments, whether local or systemic, and particularly antibiotics. Long-term use led to a decrease in the incidence of acute rhinosinusitis and its complications. SNI appeared to be a safe treatment.
CONCLUSIONS
SNI is beneficial for rhinological symptoms but not respiratory symptoms. Further research is needed to address the full benefits/risks of this treatment.
Topics: Child; Child, Preschool; Humans; Infant; Nasal Lavage; Pharyngitis; Respiratory Tract Infections; Rhinitis; Saline Solution; Sinusitis
PubMed: 32312677
DOI: 10.1016/j.prrv.2019.11.003 -
The Cochrane Database of Systematic... Apr 2020Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review.
OBJECTIVES
To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain.
SEARCH METHODS
We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field.
SELECTION CRITERIA
We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group.
DATA COLLECTION AND ANALYSIS
Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach.
MAIN RESULTS
We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) -4.93, 95% confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions - that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection.
AUTHORS' CONCLUSIONS
This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.
Topics: Adrenal Cortex Hormones; Adult; Anesthetics, Local; Humans; Injections, Epidural; Lumbosacral Region; Middle Aged; Randomized Controlled Trials as Topic; Sciatica
PubMed: 32271952
DOI: 10.1002/14651858.CD013577 -
International Forum of Allergy &... Apr 2020Sinusitis and rhinitis are common diseases for which patients seek medical attention. Alternative therapies constitute a multibillion-dollar industry despite poorly...
BACKGROUND
Sinusitis and rhinitis are common diseases for which patients seek medical attention. Alternative therapies constitute a multibillion-dollar industry despite poorly established efficacy and safety profiles. This study was designed to identify and grade the evidence for alternative therapies purported to treat sinusitis and rhinitis.
METHODS
A modified Delphi method was used to establish a consensus opinion among rhinology experts of the current evidence for efficacy, potential harm, and future research needs for alternative therapies in sinusitis and rhinitis. Following the initial Delphi round of discussion, a Google search query was performed to identify topics and review online reports of benefit. Subsequent rounds established search criteria and inclusion/exclusion criteria for a systematic literature review utilizing PubMed, EMBASE, and Cochrane databases. Centre for Evidence-Based Medicine (CEBM) and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria were used to assess levels of evidence and recommendations. Final Delphi rounds were performed until consensus opinions could be reached.
RESULTS
Over 60 potential alternative therapies for sinusitis and rhinitis were identified. The literature review included 2066 titles with 220 full-text articles found to be relevant. Most of the therapies had little to no scientific evidence; however, acupuncture, capsaicin, bromelain, and butterbur extract currently have low to moderate-high GRADE rating. Allergic rhinitis was the most common disease studied.
CONCLUSION
Some alternative therapies show promise as potential treatments for sinusitis and rhinitis, mostly compared to placebo. Comparisons to traditional therapies are lacking. For other alternative therapies, many websites included unsubstantiated claims of benefit and ignored potential side effects for which patients should be warned appropriately.
Topics: Administration, Topical; Chronic Disease; Complementary Therapies; Humans; Rhinitis; Rhinitis, Allergic; Sinusitis
PubMed: 32104974
DOI: 10.1002/alr.22488