Chronic rhinosinusitis in adults

There is no consensus on diagnostic criteria for chronic rhinosinusitis. By convention, the symptoms of chronic rhinosinusitis are similar to those of acute rhinosinusitis but last more than 8 weeks. Diagnosis is based on history, physical examination, and computed tomography scan of the sinuses or rhinoscopy. Treatment options are numerous and, for the most part, not evidence based. They include antibiotics, nasal or oral corticosteroids, antihistamines, naval lavage, decongestants, immunotherapy, and surgery. Which diagnostic and therapeutic options to exercise when, is the focus of this article.     

Judicious antibiotic use and intranasal corticosteroids in acute rhinosinusitis

Most patients with symptoms of acute rhinosinusitis are treated with antibiotics. However, many cases of rhinosinusitis are secondary to viral infections and unlikely to benefit from antibiotic therapy. Inappropriate use of antibiotics in patients with acute nonbacterial rhinosinusitis contributes to the increase in bacterial antibiotic resistance. Consequently, safe and effective alternatives to antibiotics are needed in the treatment of acute rhinosinusitis caused by viral infections. Recent results from controlled trials have shown that intranasal corticosteroids, used in combination with antibiotics or as monotherapy in selected cases, provide significant symptom relief and resolution of acute rhinosinusitis. The use of intranasal corticosteroids in acute rhinosinusitis therefore might reduce the inappropriate use of antimicrobial therapy in acute rhinosinusitis.     

慢性阻塞性肺疾病稳定期的治疗进展

慢性阻塞性肺疾病是临床上常见的疾病之一,其发病率和病死率逐年升高,是一种不可逆转且进行性加重的呼吸系统疾病.本文综述慢性阻塞性肺疾病治疗的新进展.     

Amazing results with hydroxyurea therapy in chronic hepatitis B: a preliminary report

Background and Aims

To introduce the possible role of hydroxyurea (HU), a well-characterized antineoplastic drug with established antiviral effects, in the treatment of chronic hepatitis B.

Methods

Four antiretroviral-naïve patients with chronic hepatitis B were enrolled in this limited pilot trial, and given 1000 mg/day of hydroxyurea for 4 weeks; then, the administration of the drug was suspended for 4 weeks. A clinical study and laboratory safety assessments and measurements of viral load were made at baseline, after drug therapy, and after one month suspension of the treatment

Results

All 4 patients showed a significant decrease in viral load after 4 weeks of hydroxyurea therapy and the viral load of 2 patients increased again after a 4-week suspension of hydroxyurea

Conclusions

Our data demonstrate that the old low-cost antineoplastic drug, hydroxyurea, efficiently blocks hepatitis B virus (HBV) replication. We suggest that HU will play an important role in the treatment of chronic hepatitis in the fore- seeable future. Further studies including those that evaluate optimal dosing in long-term use will continue to define the role of HU in the treatment of HBV infection alone or in combination with other antiviral drugs     

Antimicrobial therapy in chronic rhinosinusitis

Antimicrobial therapy has been a mainstay of treatment for chronic rhinosinusitis (CRS). The roles of bacterial and fungal infection in the primary pathogenesis of CRS recently have been called into question. Although many different bacteria and fungi can be isolated from CRS patients, antimicrobial treatment directed at their eradication has met with mixed clinical results. Overall, macrolide antibiotics hold the most promise before surgery. Topical antibiotics are safe, efficient, and effective for treating acute bacterial exacerbations of CRS after endoscopic sinus surgery and may prevent the development of subsequent bacterial resistance. Topical treatment of CRS with antifungal agents both before and after sinus surgery is of limited benefit and should not be considered as a primary treatment modality before surgery. Further research into the role of bacterial and fungal infection in the pathophysiology of CRS may offer better insights into appropriate antimicrobial choices, dosing, and treatment duration.     

Topical anal fissure treatment: placebo-controlled study of mononitrate and trinitrate therapies

Aim  The present study aims to evaluate and compare the efficacy of two nitrate gels, containing isosorbide-5-mononitrate (ISMN) or glyceryl trinitrate (GTN), in the therapy of chronic anal fissure. Materials and methods  The patients were randomly assigned to three groups: 0.1% ISMN gel (21 patients), 0.1% GTN gel (21 patients) and a placebo group (ten patients). The ethic committee of our hospital approved the protocol and informed consent was obtained from all participants. All patients underwent clinical examination, visual inspection of the fissure and anal manometry prior to and after therapy. Results  The chronic anal fissure was completely healed in 71% of the patients treated with ISMN, 67% with GTN and in 30% from the placebo group. One patient in the ISMN group reported mild headache. Three patients in the GTN group had anal burning. Conclusion  Both topical nitrate treatments (ISMN and GTN) were effective for chronic anal fissures. The reduction of the anal pressure was slightly higher after ISMN treatment (28%) than the treatment with GTN (23%). However, the statistical difference was not significant (p > 0.05).     

Topical ampicillin in addition to a systemic antibiotic prophylaxis in elective colorectal surgery

Prophylactic use of topical ampicillin in addition to intravenous ampicillin and metronidazole was studied in a randomized trial including 203 consecutive patients undergoing elective colorectal surgery. All received ampicillin, 1g×3, and metronidazole, 0.5g×3, intravenously for at least three days from induction of anesthesia, and 105 also received topical ampicillin, 1g, in each of the surgical wounds. Deep wound infection or dehiscence was seen in 12 of 105 having both administrations of antibiotics, and in nine of 98 having only intravenous antibiotics. The two groups were similar according to distribution of sex, age, type of surgery, and efficiency of bowel preparation. Topical ampicillin should be omitted in elective colorectal surgery when systemic prophylaxis with ampicillin and metronidazole is used.     

乙型肝炎抗病毒治疗2014年国内外进展

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Fibrate therapy: an update

Fibrates are a class of lipid-lowering medication primarily used as second-line agents behind statins. Acting via the peroxisome proliferators-activated receptor-alpha, their main lipoprotein effects are to lower serum triglyceride levels and to raise high-density lipoprotein-cholesterol, with modest effects on low-density lipoprotein-cholesterol. However, many clinical trials indicate that fibrates may have benefits beyond simply altering one's lipid profile. Several angiographic studies show retardation in the progression of atherosclerotic lesions in coronary vessels. Although clinical trials have failed to show a reduction in mortality with fibrates, several post hoc analyses indicate that there may be a mortality benefit in patients with features of the metabolic syndrome. Given that fibrates are often used as second-line agents, it is essential they are safe to be given in combination with other agents, particularly statins and ezetimibe. Although the side-effect profile of fibrates includes gastrointestinal symptoms, increased liver function tests, a reversible rise in creatinine and myositis, in general, fibrates seem to be safe to use in combination with other lipid lowering medications. Thus far, fibrates have not shown a mortality benefit in randomized clinical trials; as a result, they cannot be considered first-line medication for the primary or secondary prevention of coronary artery disease.     

恩替卡韦治疗慢性乙型肝炎病毒携带者近期疗效观察

目的 观察恩替卡韦治疗慢性HBV携带者的近期疗效与安全陛,探讨慢性HBV携带者抗病毒治疗的临床意义. 方法 慢性HBV携带者47例,慢性乙型肝炎患者46例,诊断均符合“慢性乙型肝炎防治指南(2010年版)”.两组患者均给予恩替卡韦分散片0.5 mg/d口服治疗,观察两组患者治疗第4、12、24、48周血清学应答率、生物化学应答率与突破率的差异,并观察药物相关不良事件发生率.数据均使用SPSS17.0统计分析软件进行,分别采用t检验和x2检验.结果 第4、12、24、48周完全病毒学应答率:慢性HBV携带者组分别为14.9％、51.1％、76.6％和97.9％;慢性乙型肝炎患者组分别为,17.4％、63.0％、89.1％和100.0％,两组间各时间点比较,差异均无统计学意义.第4、12、24、48周部分病毒学应答率:慢性HBV携带者组分别为42.6％、57.4％、85.0％和100.0％;慢性乙型肝炎患者组分别为47.8％、65.2％、89.1％和100.0％,两组间各时间点比较,差异均无统计学意义.第4、12、24、48周HBeAg阴转率:慢性HBV携带者组分别为0、2.1％、4.3％和8.5％;慢性乙型肝炎患者组分别为4.4％、8.7％、13.0％和21.7％,两组间各时间点比较,差异均无统计学意义.第4、12、24、48周HBeAg血清学转换率:慢陛HBV携带者组分别为0、0、2.1％和6.4％;慢性乙型肝炎患者组分别为0、4.4％、10.9％和17.4％,两组间各时间点比较,差异均无统计学意义.HBsAg阴转率与血清学转换率,两组各观察时段均为0.慢性乙型肝炎患者组第4、12、24、48周ALT复常率分别为26.1％、65.2％、91.3％和97.8％.两组患者均无病毒学突破和生物化学突破病例.两组患者均未观察到肾毒性、骨髓抑制、横纹肌溶解或其他药物相关不良事件.结论 采用恩替卡韦分散片治疗慢性HBV携带者近期疗效好、安全.     

Iron-chelation therapy: an update

Chronically transfused patients develop iron overload that leads to organ damage and ultimately to death. The introduction of the iron-chelating agent, desferrioxamine mesylate, dramatically improved the life expectancy of these patients. However, the very demanding nature of this treatment (subcutaneous continuous infusion via a battery-operated portable pump) has been the motivation for attempts to develop alternative forms of treatment that would facilitate the patients' compliance. In this review, we describe the most important advances in iron-chelating therapy. In particular, we analyze a new method of administering desferrioxamine mesylate (twice daily subcutaneous bolus injections) and a novel, orally active iron chelator (ICL670A). We also present a meta-analysis of the largest trials on the oral iron chelator deferiprone and the results of combined therapy (deferiprone and desferrioxamine).     

Acute rhinosinusitis during Hajj season 2014: Prevalence of bacterial infection and patterns of antimicrobial susceptibility

BackgroundThe presence of large number of pilgrims during Hajj in Makkah region increases the risk of respiratory diseases. In this study, we aimed to assess the bacteriology of acute rhinosinusitis (ARS) during Hajj season and to demonstrate the antimicrobial susceptibility patterns that should guide the clinicians towards more appropriate antibiotic use.MethodsPatients with ARS presenting during Hajj season of 2014 were prospectively enrolled. According to EPOS2012 criteria. Sampling of sinus secretions was performed from the middle meatus adjacent to the maxillary sinus ostium via endoscopic guidance. Over all, the study has covered all ENT, emergency and outpatient departments in Hajj.ResultsTwo hundred and twenty six patients with ARS were enrolled in the study. Pathogenic bacteria were identified in 93 (41.2%) patients. Of the 93 patients with bacterial ARS, Staphylococcus aureus was isolated in 46 (49.5%) patients, out of which 13 (28.3%) were methicillin-resistant Staphylococcus aureus (MRSA).The second most common group of bacterial isolates was Enterobacteriaceae such as Escherichia coli, and various Klebsiella species. Antibiotic sensitivity showed that methicillin-sensitive Staphylococcus aureus (MSSA) was also sensitive to cephalosporins, quinolones and clindamycin, while exhibiting relatively less sensitivity rates to amoxicillin-clavulinic acid and macrolides.ConclusionOur study demonstrates the importance of assessing the bacteriology of ARS to help implement guidelines for proper treatment and prevention protocols during Hajj season.     

国产阿德福韦酯治疗HBeAg阳性慢性乙型肝炎患者48周的多中心、随机、双盲、安慰剂平行对照临床研究

目的评价国产阿德福韦酯(优贺丁)片10mg/d治疗HBeAg阳性的中国慢性乙型病毒性肝炎患者48周的疗效和安全性。方法采用多中心、随机、双盲、安慰剂平行对照的研究设计。前12周双盲阶段,240例患者按2:1的比例随机进入优贺丁组(160例)或安慰剂组(80例);12～36周,所有患者均接受开放的优贺丁治疗;36～48周原双盲阶段中接受优贺丁治疗的患者重新按1:3的比例随机分入安慰剂组(A组,40例)或继续优贺丁治疗组(B组,120例),而第一阶段服用安慰剂的患者(C组,80例)在此阶段将继续接受优贺丁治疗。主要疗效评估指标为血清HBV DNA的变化情况,次要疗效评估指标包括:丙氨酸转氨酶(ALT)的复常率、HBeAg阴转率和HBeAg的血清转换率。结果12周时,A、B组HBV DNA中位数水平较基线分别降低2.43和2.54log10拷贝/ml,均显著好于C组(P<0.05);36周时,A、B、C组HBV DNA水平中位数较基线分别降低了3.57、3.24和3.29log10拷贝/ml;48周时,B、C组患者HBVDNA中位数水平分别较基线时下降3.58和3.38log10拷贝/ml,而A组则恢复到7.37log10拷贝/ml。12周时,A、B组HBV DNA转阴率分别为17.50%和25.83%,显著高于C组的1.25%(P分别均<0.01);36周时,A、B、C组HB VDNA转阴率分别为37.50%、26.67%和28.75%,三组间无显著差异(P=0.45);48周时,B、C组HBV DNA转阴率持续升高达到34.17%和31.25%,而A组则降为7.50%。48周时,B、C组ALT复常率持续升高达75.25%和64.06%,A组则由36周时的75.68%降为28.57%;B组HBeAg转阴率和血清转换率分别为6.42%和4.55%。安全性方面,研究期间各治疗组血清肌酐及血磷值平均水平同基线相比无变化。结论优贺丁片10mg/d剂量治疗48周HBeAg阳性的中国慢性乙型肝炎患者有效和安全。     

Opioid contracts in chronic nonmalignant pain management: objectives and uncertainties

In this article, we review the principal objectives and ideal elements of opioid contracts, as articulated by proponents of the practice. We examine the limited empirical evidence for the effectiveness of opioid contracts in achieving their intended objectives and identify areas of uncertainty and of ethical concern regarding their implementation. We argue that the challenge in deciding about implementing opioid contracts in clinical practice relates to the multiplicity of potential objectives they might serve, to a lack of empirical evidence regarding their effectiveness, and to ethical concerns over their implementation. Specialty and primary care clinicians contemplating the use of opioid contracts in treating patients with chronic nonmalignant pain need to be sensitive to these considerations, and further debate and research is necessary to establish the proper objectives, elements, effectiveness, and ethical justifications of opioid contracts in clinical practice.     

Topical Treatment of Diabetic Foot Ulcers: an Economic Analysis of Treatment Alternatives and Strategies

In a prospective study, 314 patients with diabetic foot ulcers were followed and 40 patients died before healing occurred. In those patients who healed, a retrospective economic analysis of the costs for topical treatment was performed. The aim of the study was to analyse the costs and discuss how different treatment strategies influence total costs. Data collected for each patient were total time to healing, treatment time for each type of dressing, and the frequency of dressing changes. Material costs for the dressings, labour, and travelling costs were calculated separately. A formula for simulation of economic consequences of different treatment strategies including the introduction of new strategies was designed. The cost for topical treatment was strongly related to the severity of the ulcer and wound healing time. The average weekly cost per patient for topical treatment varied between £40.3 and £385. The dominating costs for topical treatment were expenses for staff and transportation. The most important factor to reduce costs is the frequency of dressing changes. The study emphasizes the need for prospective comparative studies of cost effectiveness in topical treatment strategies.