Incidence and associated premorbid diagnoses of patients with chronic rhinosinusitis

doi:10.1016/j.jaci.2013.02.002

Journal of Allergy and Clinical Immunology

Volume 131, Issue 5, May 2013, Pages 1350-1360

https://doi.org/10.1016/j.jaci.2013.02.002 Get rights and content

Background

Chronic rhinosinusitis (CRS) is a prevalent condition with underexplored risk factors.

Objectives

We sought to determine CRS incidence and evaluate associations with a range of premorbid medical conditions for chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) using real-world clinical practice data.

Methods

Electronic health records data from 446,480 Geisinger Clinic primary care patients were used for a retrospective longitudinal cohort study for data from 2001-2010. By using logistic regression, newly diagnosed CRS cases between 2007 and 2009 were compared with frequency-matched control subjects on premorbid factors in the immediate (0-6 months), intermediate (7-24 months), and entire observed timeframes before diagnosis.

Results

The average incidence of CRS was 83 ± 13 CRSwNP cases per 100,000 person-years and 1048 ± 78 CRSsNP cases per 100,000 person-years. Between 2007 and 2009, 595 patients with incident CRSwNP and 7523 patients with incident CRSsNP were identified and compared with 8118 control subjects. Compared with control subjects and patients with CRSsNP, patients with CRSwNP were older and more likely to be male. Before diagnosis, patients with CRS had a higher prevalence of acute rhinosinusitis, allergic rhinitis, chronic rhinitis, asthma, gastroesophageal reflux disease, adenotonsillitis, sleep apnea, anxiety, and headaches (all P < .001). Patients with CRSsNP had a higher premorbid prevalence of infections of the upper and lower airway, skin/soft tissue, and urinary tract (all P < .001). In the immediate and intermediate timeframes analyzed, patients with CRS had more outpatient encounters and antibiotic prescriptions (P < .001), but guideline-recommended diagnostic testing was performed in a minority of cases.

Conclusions

Patients who are given a diagnosis of CRS have a higher premorbid prevalence of anxiety, headaches, gastroesophageal reflux disease, sleep apnea, and infections of the respiratory system and some nonrespiratory sites, which results in higher antibiotic, corticosteroid, and health care use. The use of guideline-recommended diagnostic testing for confirmation of CRS remains poor.

Section snippets

Study overview

We used longitudinal data from the EHRs of patients with a Geisinger Clinic primary care provider to first calculate annual incidence rates from 2001-2009 and then complete a nested case-control analysis. The goals were as follows: (1) describe the epidemiology of CRS; (2) compare the prevalence and timing of premorbid illnesses preceding incident CRSwNP and CRSsNP compared with those in control subjects; (3) compare health care and antibiotic use among patients with CRSwNP and CRSsNP compared

Description of study population and annual incidence

Data on 307,381 patients who received care at any time in the years 2007, 2008, and 2009 were analyzed to identify 595 incident CRSwNP cases, 7523 incident CRSsNP cases, and 8118 matched control subjects (Table I). The average incidence rate from 2007-2009 was 83 ± 13 CRSwNP cases per 100,000 person-years and 1048 ± 78 CRSsNP cases per 100,000 person-years. Comparing the study time period 2007-2009 with 2001-2006, the incidence of CRSsNP was stable, whereas the incidence of CRSwNP appeared to

Discussion

In this study we used 10 years of data from a large cohort of primary care patients from the EHRs of the dominant health care provider serving an expansive geographic region to evaluate the epidemiology of CRS, test several previously proposed hypotheses regarding the pathobiology of CRS, and examine how CRS is being treated and diagnosed in the community. To our knowledge, this study has provided the first estimate of the incidence of physician-diagnosed CRS. Our study shows a remarkable

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The Management of Chronic Rhinosinusitis With Nasal Polyps (CRSwNP) With Biologics
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Chronic rhinosinusitis with nasal polyps affects a significant portion of the worldwide population. This illness is associated with several chronic conditions and has an important impact on patient quality of life, leading to a great societal economic burden. In recent years, biologic medications have been developed and found to be effective in the treatment of chronic rhinosinusitis with nasal polyps. This review focuses on these treatment options and their ability to improve patient outcomes, including quality of life. It also reviews available evidence with regards to patient selection, monitoring of patients after treatment initiation, and comparison of different biologics and with other treatment options such as sinus surgery.
Real-world evidence for the effectiveness and safety of dupilumab in patients with CRSwNP after 1 year of therapy
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For nearly 3 years, the monoclonal antibody dupilumab has been approved in Germany for the treatment of patients with chronic rhinosinusitis with nasal polyps (CRSwNP). Although efficacy has been demonstrated in large double-blind, placebo-controlled clinical trials, few reports of real-world data on this therapy have been published to date.
Patients with an indication for treatment with dupilumab for CRSwNP were included in the study and followed up every 3 months for a period of 1 year. At the baseline visit, demographic data, medical history, comorbidities, nasal polyp score, disease-related quality of life (SNOT-22), nasal congestion, and sense of smell (VAS and Sniffiń Sticks test) were recorded. In addition, total blood eosinophil counts and serum total IgE were measured. During follow-up, all of the described parameters and possible adverse events were recorded.
Eighty-one patients were enrolled in the study, of whom 68 patients were still receiving dupilumab after 1 year of follow-up. Eight patients discontinued therapy, with only 1 patient discontinuing due to severe side effects. The Polyp score decreased substantially during follow-up, and parameters for disease-related quality of life and sense of smell increased significantly. Total IgE levels decreased significantly, and eosinophils leveled off at baseline after an initial increase after three months of therapy. No clinical data could be identified to a priori predict a treatment response.
Dupilumab shows effectiveness and safety in the treatment of CRSwNP under real-world conditions. More research on systemic biomarkers and clinical parameters to predict treatment response is necessary.
Significance of leukocyte-specific transcript 1 levels in nasal mucosal tissue to predict recurrence of nasal polyps
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Chronic Rhinosinusitis with Polyps (CRSwNP) is characterized by high heterogeneity and postoperative recurrence rate. This study aims to explore the clinical significance of tissue Leukocyte-Specific Transcript 1 (LST1) in predicting CRSwNP recurrence.
We enrolled 62 CRSwNP patients including 30 primary CRSwNP and 32 recurrent CRSwNP patients, and 40 Healthy Controls (HC). Tissue samples were collected. Tissue LST1 expression was assessed by Reverse Transcription-Polymerase Chain Reaction (RT-PCR), Western Blotting (WB) and Immunofluorescence (IF) staining. The predictive values of LST1 expression for CRSwNP postoperative recurrence were assessed through the Receiver Operating Characteristic (ROC) curves.
The tissue levels of LST1 were significantly increased in the CRSwNP group than the HC group, especially in the recurrent group, and the elevated LST1 mRNA levels were positively correlated with the peripheral eosinophil percentages, tissue eosinophil counts and percentages. IF staining results showed that the LST1 protein levels were higher in CRSwNP patients, especially in the recurrent patients than in the HC group. ROC curves highlighted that tissue LST1 levels were associated with recurrent CRSwNP and exhibited a higher predictive ability for postoperative CRSwNP recurrence.
This was the first report suggesting that LST1 expression was upregulated and associated with mucosal eosinophil infiltration and CRSwNP recurrence. Tissue LST1 could be a promising biomarker for predicting postoperative recurrence in CRwNP patients.
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The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.
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: Supported by National Institutes of Health grants K23DC012067 (to B.K.T.), R01 HL068546, R01 HL078860, and R01 AI072570, as well as the Ernest S. Bazley Trust (to R.P.S.).

: Disclosure of potential conflict of interest: B. K. Tan has been supported by one or more grants from the National Institutes of Health (NIH), has received one or more grants from or has one or more grants pending with the Triological Society, and has received one or more payments for travel/accommodations/meeting expenses from the Foundation for Innovation, Education, and Research in Otorhinolaryngology. J. Pollak is employed by Johns Hopkins Bloomberg School of Public Health. A. T. Peters has provided expert testimony regarding Stevens-Johnson syndrome and has received one or more payments for lecturing from or is on the speakers' bureau for Baxter. R. P. Schleimer has been supported by one or more grants from the NIH and has consultancy arrangements with Intersect ENT, GlaxoSmithKline, and Allakos. B. S. Schwartz has been supported by one or more grants from Northwestern University. The rest of the authors declare that they have no relevant conflicts of interest.

View full text

Rhinitis, sinusitis, and upper airway diseaseIncidence and associated premorbid diagnoses of patients with chronic rhinosinusitis

Background

Objectives

Methods

Results

Conclusions

Section snippets

Study overview

Description of study population and annual incidence

Discussion

EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists

Rhinology

Rhinosinusitis: establishing definitions for clinical research and patient care

J Allergy Clin Immunol

Summary health statistics for U.S. adults: National Health Interview Survey, 2008

Vital Health Stat 10

Clinical practice guideline: adult sinusitis

Otolaryngol Head Neck Surg

EPOS primary care guidelines: European position paper on the primary care diagnosis and management of rhinosinusitis and nasal polyps 2007—a summary

Prim Care Respir J

Chronic rhinosinusitis: epidemiology and medical management

J Allergy Clin Immunol

Diseases associated with chronic rhinosinusitis: what is the significance?

Curr Opin Otolaryngol Head Neck Surg

Perspectives on the etiology of chronic rhinosinusitis

Curr Opin Otolaryngol Head Neck Surg

Pathophysiology of chronic rhinosinusitis

Proc Am Thorac Soc

The epidemiology of chronic rhinosinusitis in Canadians

Laryngoscope

Prevalence and risk factors of chronic sinusitis in Korea: results of a nationwide survey

Eur Arch Otorhinolaryngol

The severity-dependent relationship of infant bronchiolitis on the risk and morbidity of early childhood asthma

J Allergy Clin Immunol

Response to infections in patients with asthma and atopic disease: an epiphenomenon or reflection of host susceptibility?

J Allergy Clin Immunol

Allergic vs nonallergic rhinitis: which is more predisposing to chronic rhinosinusitis?

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Int Forum Allergy Rhinol

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J Allergy Clin Immunol

Chronic rhinosinusitis and asthma

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Rhinosinusitis in severe asthma

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Ann Otol Rhinol Laryngol

EAACI position paper on rhinosinusitis and nasal polyps executive summary

Allergy

Rhinitis, sinusitis, and upper airway disease
Incidence and associated premorbid diagnoses of patients with chronic rhinosinusitis