Sisters of Charity Hospital

Rhinosinusitis is a significant and increasing health problem which results in a large financial burden on society. This evidence based position paper describes what is known about rhinosinusitis and nasal polyps, offers evidence based recommendations on diagnosis and treatment, and considers how we can make progress with research in this area. Rhinitis and sinusitis usually coexist and are concurrent in most individuals; thus, the correct terminology is now rhinosinusitis. Rhinosinusitis (including nasal polyps) is defined as inflammation of the nose and the paranasal sinuses characterised by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), +/- facial pain/pressure, +/- reduction or loss of smell; and either endoscopic signs of polyps and/or mucopurulent discharge primarily from middle meatus and/or; oedema/mucosal obstruction primarily in middle meatus, and/or CT changes showing mucosal changes within the ostiomeatal complex and/or sinuses. The paper gives different definitions for epidemiology, first line and second line treatment and for research. Furthermore the paper describes the anatomy and (patho)physiology, epidemiology and predisposing factors, inflammatory mechanisms, evidence based diagnosis, medical and surgical treatment in acute and chronic rhinosinusitis and nasal polyposis in adults and children. Evidence based schemes for diagnosis and treatment are given for the first and second line clinicians. Moreover attention is given to complications and socio-economic cost of chronic rhinosinusitis and nasal polyps. Last but not least the relation to the lower airways is discussed.

EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. no immunosuppressants IV D no nasal saline irrigation Ib, no data in single use D yes for symptomatic relief topical antibiotics no data D no anti-IL-5 no data D unclear phytotherapy no data D no decongestant topical / oral no data in single use D no mucolytics no data D no oral antihistamine in allergic patients no data D no antimycotics -topical Ia (-) ** A(-) no antimycotics -systemic Ib (-)# A(-) $ no anti leukotrienes Ib (-) A(-) no anti-IgE Ib (-) A(-) no * Some of these studies also included patients with CRS with nasal polyps. % short term antibiotics shows one positive and one negative study. Therefore recommendation C. oral antibiotic short term <4 weeks Ib(-) # A(-)* no intravenous antibiotics III(-) ## C(-) ** no # Ib (-): Ib study with a negative outcome.

Diagnostic accuracy relates to the ability of a test to discriminate between the target condition and health. This discriminative potential can be quantified by the measures of diagnostic accuracy such as sensitivity and specificity, predictive values, likelihood ratios, the area under the ROC curve, Youden's index and diagnostic odds ratio. Different measures of diagnostic accuracy relate to the different aspects of diagnostic procedure: while some measures are used to assess the discriminative property of the test, others are used to assess its predictive ability. Measures of diagnostic accuracy are not fixed indicators of a test performance, some are very sensitive to the disease prevalence, while others to the spectrum and definition of the disease. Furthermore, measures of diagnostic accuracy are extremely sensitive to the design of the study. Studies not meeting strict methodological standards usually over- or under-estimate the indicators of test performance as well as they limit the applicability of the results of the study. STARD initiative was a very important step toward the improvement the quality of reporting of studies of diagnostic accuracy. STARD statement should be included into the Instructions to authors by scientific journals and authors should be encouraged to use the checklist whenever reporting their studies on diagnostic accuracy. Such efforts could make a substantial difference in the quality of reporting of studies of diagnostic accuracy and serve to provide the best possible evidence to the best for the patient care. This brief review outlines some basic definitions and characteristics of the measures of diagnostic accuracy.

EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. no immunosuppressants IV D no nasal saline irrigation Ib, no data in single use D yes for symptomatic relief topical antibiotics no data D no anti-IL-5 no data D unclear phytotherapy no data D no decongestant topical / oral no data in single use D no mucolytics no data D no oral antihistamine in allergic patients no data D no antimycotics -topical Ia (-) ** A(-) no antimycotics -systemic Ib (-)# A(-) $ no anti leukotrienes Ib (-) A(-) no anti-IgE Ib (-) A(-) no * Some of these studies also included patients with CRS with nasal polyps. % short term antibiotics shows one positive and one negative study. Therefore recommendation C. oral antibiotic short term <4 weeks Ib(-) # A(-)* no intravenous antibiotics III(-) ## C(-) ** no # Ib (-): Ib study with a negative outcome.

Rheumatoid arthritis (RA) is a heterogeneous, prevalent, chronic autoimmune disease characterized by painful swollen joints and significant disabilities. Symptomatic relief can be achieved in up to 50% of patients using biological agents that inhibit tumor necrosis factor (TNF) or other mechanisms of action, but there are no universally effective therapies. Recent advances in basic and preclinical science reveal that reflex neural circuits inhibit the production of cytokines and inflammation in animal models. One well-characterized cytokine-inhibiting mechanism, termed the "inflammatory reflex," is dependent upon vagus nerve signals that inhibit cytokine production and attenuate experimental arthritis severity in mice and rats. It previously was unknown whether directly stimulating the inflammatory reflex in humans inhibits TNF production. Here we show that an implantable vagus nerve-stimulating device in epilepsy patients inhibits peripheral blood production of TNF, IL-1β, and IL-6. Vagus nerve stimulation (up to four times daily) in RA patients significantly inhibited TNF production for up to 84 d. Moreover, RA disease severity, as measured by standardized clinical composite scores, improved significantly. Together, these results establish that vagus nerve stimulation targeting the inflammatory reflex modulates TNF production and reduces inflammation in humans. These findings suggest that it is possible to use mechanism-based neuromodulating devices in the experimental therapy of RA and possibly other autoimmune and autoinflammatory diseases.

STUDY QUESTION: What are the European trends and developments in ART and IUI in 2014 as compared to previous years? SUMMARY ANSWER: The 18th ESHRE report on ART shows a continuing expansion of both treatment numbers in Europe and more variability in treatment modalities resulting in a rising contribution to the birth rates in most participating countries. WHAT IS KNOWN ALREADY: Since 1997, ART data generated by national registries have been collected, analysed by the European IVF-monitoring (EIM) Consortium and reported in 17 manuscripts published in Human Reproduction. STUDY DESIGN, SIZE, DURATION: Continuous collection of European data by the EIM for ESHRE. The data for treatments performed in 2014 between 1 January and 31 December in 39 European countries were provided by national registries or on a voluntary basis by clinics or professional societies. PARTICIPANTS/MATERIALS, SETTING, METHODS: From 39 countries and 1279 institutions offering ART services, a total of 776 556 treatment cycles, involving 146 148 with IVF, 362 285 with ICSI, 192 027 with frozen embryo replacement (FER), 15 894 with PGT, 56 516 with egg donation (ED), 292 with IVM and 3404 with frozen oocyte replacement (FOR) were reported. European data on IUI using husband/partner's semen (IUI-H) and donor semen (IUI-D) were reported from 1364 institutions offering IUI in 26 countries and 21 countries, respectively. A total of 120 789 treatments with IUI-H and 49 163 treatments with IUI-D were included. MAIN RESULTS AND THE ROLE OF CHANCE: In 14 countries (17 in 2013), where all institutions contributed to their respective national registers, a total of 291 235 treatment cycles were performed in a population of ~208 million inhabitants, corresponding to 1925 cycles per million inhabitants (range: 423-2978 per million inhabitants). After treatment with IVF the clinical pregnancy rates (PR) per aspiration and per transfer were marginally higher in 2014 than in 2013, at 29.9 and 35.8% versus 29.6 and 34.5%, respectively. After treatment with ICSI the PR per aspiration and per transfer were also higher than those achieved in 2013 (28.4 and 35.0% versus 27.8 and 32.9%, respectively). After FER with own embryos the PR continued to rise, from 27.0% in 2013 to 27.6% in 2014. After ED a similar trend was observed with PR reaching 50.3% per fresh transfer (49.8% in 2013) and 48.7% for FOR (46.4% in 2013). The delivery rates (DR) after IUI remained stable at 8.5% after IUI-H (8.6% in 2013) and at 11.6% after IUI-D (11.1% in 2013). In IVF and ICSI together, 1, 2, 3 and ≥4 embryos were transferred in 34.9, 54.5, 9.9 and in 0.7% of all treatments, respectively (corresponding to 31.4%, 56.3, 11.5% and 1% in 2013). This evolution in embryo transfer strategy in both IVF and ICSI resulted in a singleton, twin and triplet DR of 82.5, 17.0 and 0.5%, respectively (compared to 82.0, 17.5 and 0.5%, respectively, in 2013). Treatments with FER in 2014 resulted in a twin and triplet DR of 12.4 and 0.3%, respectively (versus 12.5 and 0.3% in 2013). Twin and triplet DR after IUI were 9.5 and 0.3%, respectively, after IUI-H (in 2013:9.5 and 0.6%) and 7.7 and 0.3% after IUI-D (in 2013: 7.5 and 0.3%). LIMITATION, REASONS FOR CAUTION: The method of data collection and reporting varies among European countries. The EIM receives aggregated data from various countries with variable levels of completeness. Registries from a number of countries have failed to provide adequate data about the number of initiated cycles and deliveries. As long as incomplete data are provided, the results should be interpreted with caution. WIDER IMPLICATIONS OF THE FINDINGS: The 18th ESHRE report on ART shows a continuing expansion of treatment numbers in Europe. The number of treatments reported, the variability in treatment modalities and the rising contribution to the birth rates in most participating countries point towards the increasing impact of ART on reproduction in Europe. Being the largest data collection on ART, the report gives detailed information about ongoing developments in the field. STUDY FUNDING/COMPETING INTEREST(S): The study has no external funding and all costs are covered by ESHRE. There are no competing interests.

Nasty/Rzany An evidence-based guideline has been defined as 'a systematically developed statement that assists clinicians and patients in making decisions about appropriate treatment for a specific condition'.1 A guideline will never encompass therapy specifications for all medical decision-making situations. Deviation from the recommendations may, therefore, be justified in specific situations. This is not a textbook on acne, nor a complete, all-inclusive reference on all aspects important to the treatment of acne. The presentation on safety in particular is limited to the information available in the included clinical trials and does not represent all the available and necessary information for the treatment of patients. Additional consultation of specific sources of information on the particular intervention prescribed (e.g. product information sheet) is necessary. Furthermore, all patients should be informed about the specific risks associated with any given topical and/or systemic therapy. Readers must carefully check the information in this guideline and determine whether the recommendations contained therein (e.g. regarding dose, dosing regimens, contraindications, or drug interactions) are complete, correct, and up-to-date. The authors and publishers can take no responsibility for dosage or treatment decisions. Improvement in the care of acne patients The idea behind this guideline is that recommendations based on a systematic review of the literature and a structured consensus process will improve the quality of acne therapy in general. Personal experiences and traded therapy concepts should be critically evaluated and replaced, if applicable, with the consented therapeutic recommendations. In particular, a correct choice of therapy should be facilitated by presenting the suitable therapy options in a therapy algorithm, taking into account the type of acne and the severity of the disease. Reduction of serious conditions and scarring As a result of the detailed description of systemic therapies for patients with severe acne, reservations about these interventions should be overcome to ensure that patients receive the optimal therapy. With the timely introduction of sufficient therapies, the development of serious post-acne conditions and severe scarring should be reduced. Promotion of adherence Good therapeutic adherence is key to treatment success. Adherence is facilitated by knowledge of the product being used, for example treatment duration, the expected onset of effect, the sequence of the healing process, the maximal achievable average effect, expected adverse events and the benefit to quality of life. Reduction of antibiotic resistance The use of topical and systemic antibiotics should be optimized by using appropriate combinations for a predefined duration, to reduce the development of antibiotic resistance. Health care professionals This guideline has been developed to help health care professionals provide optimal therapy to patients with mild, moderate or severe acne. The primary target groups are dermatologists and other professionals involved in the treatment of acne, such as paediatricians and general practitioners. The target group may vary with respect to national differences in the distribution of services provided by specialists or general practitioners. Patients The recommendations of the guideline refer to patients who suffer from acne. These are mainly adolescents treated in outpatient clinics. The appropriate therapy option is presented according to the type of acne that is present. The primary focus is the induction therapy of facial acne (see Chapter 1.6). Non-primary target groups are patients with special forms of acne, such as, occupational acne, chloracne, acne aestivalis, acne neonatorum, acne inverse (hidradenitis suppurativa). European guidelines are intended for adaptation to national conditions. It is beyond the scope of this guideline to take into consideration the specific costs and reimbursement situations in every European country. Differences in prices, reimbursement systems, willingness and ability to pay for medication among patients and the availability of generics are too large. Therefore, pharmacoeconomic considerations will have to be taken into account when guidelines are developed at national and local levels. The personal financial and health insurance situation of a patient may necessitate amendments to the prioritization of treatment recommendations. However, if financial resources allow, the suggested ranking in the therapeutic algorithm should be pursued. The skin type and stage of disease has to be taken into consideration when choosing the vehicle for topical treatments. The efficacy and safety/tolerability of topical treatments are largely influenced by the choice of vehicle. The face is the primary region of interest for the treatment of acne. Appearance, scarring, quality of life and social stigmatization are important considerations when dealing with facial dermatological diseases. The recommendations of this guideline apply primarily to the treatment of facial acne. More widespread involvement will certainly favour earlier use of a systemic treatment due to the efficacy and practicability of such treatments. Layton/Finlay Acne (synonym 'acne vulgaris') is a polymorphic, inflammatory skin disease most commonly affecting the face (99% of cases). Less frequently it also affects the back (60%) and chest (15%).2 Seborrhoea is a frequent feature.3 The clinical picture embraces a spectrum of signs, ranging from mild comedonal acne, with or without sparse inflammatory lesions (IL), to aggressive fulminate disease with deep-seated inflammation, nodules and in some cases associated systemic symptoms. Clinically non-inflamed lesions develop from the subclinical microcomedo which is evident on histological examination early in acne development.2 Non-inflamed lesions encompass both open (blackheads) and closed comedones (whiteheads). Comedones frequently have a mid-facial distribution in childhood and, when evident early in the course of the disease, this pattern is indicative of poor prognosis.4 Closed comedones are often inconspicuous with no visible follicular opening. Most patients have a mixture of non-inflammatory (NIL) and inflammatory lesions.5 Inflammatory lesions arise from the microcomedo or from non-inflammatory clinically apparent lesions and may be either superficial or deep.6 Superficial inflammatory lesions include papules and pustules (5 mm or less in diameter). These may evolve into deep pustules or nodules in more severe disease. Inflammatory macules represent regressing lesions that may persist for many weeks and contribute markedly to the general inflammatory appearance.5 Small nodules are defined as firm, inflamed lesions >5 mm diameter, painful by palpation. Nodules are defined as larger than 5 mm, large nodules are >1 cm in size. They may extend deeply and over large areas, frequently resulting in painful lesions, exudative sinus tracts and tissue destruction. Conglobate acne is a rare but severe form of acne found most commonly in adult males with few or no systemic symptoms. Lesions usually occur on the trunk and upper limbs and frequently extend to the buttocks. In contrast to ordinary acne, facial lesions are less common. The condition often presents in the second to third decade of life and may persist into the sixth decade. Conglobate acne is characterized by multiple grouped comedones amidst inflammatory papules, tender, suppurative nodules which commonly coalesce to form sinus tracts. Extensive and disfiguring scarring is frequently a feature. There are several severe and unusual variants or complications of acne as well as other similar diseases. These include acne fulminans, gram-negative folliculitis, rosacea fulminans, vasculitis, mechanical acne, oil/tar acne, chloracne, acne in neonates and infants and late onset, persistent acne, sometimes associated with genetic or iatrogenic endocrinopathies. The current guidelines do not lend themselves to comprehensive management of all these variants. Finlay/Layton Acne can be largely assessed from two perspectives: objective disease activity (based on measurement of visible signs) and quality of life impact. There are other aspects of measurement, such as sebum excretion rate, scarring development or economic impact. There are inherent difficulties in objectively measuring acne. Over 25 different methods have been described7 but there is no consensus as to which should be used. Most methods are non-validated and consequently the results of separate trials cannot be directly compared. There are detailed reviews on this subject by Barratt et al.,8 Witkowski et al.,9 Thiboutot et al.,10 and Gollnick et al.11 Proper lighting, appropriate patient positioning and prior facial skin preparation (gentle shaving for men, removal of make-up for women) are helpful in facilitating accurate assessment. Palpation in addition to visual inspection may also help define lesions more accurately. Many methods for measuring acne have been described, ranging from global assessments to lesion counting.7, 9 Despite a range of methods being used to measure acne in the 1960's and 1970's, it was the Leeds technique12 that dominated acne measurement for the next two decades. The Leeds technique included two methods; the grading technique and the counting technique. The grading technique allocated patients a grade from 0 to 10, with seven subgroups between 0 and 2. Photographic guides illustrating each grade are given, but the importance of palpating lesions is also stressed. The experience on which this system was based stemmed from the pre-isotretinoin era, and acne of the severity described by grades above 2 is now rarely seen. The counting technique involves the direct counting of non-inflamed and inflamed lesions, including superficial papules and pustules, deep inflamed lesions and macules. The revised Leeds acne grading system13 includes numerical grading systems for the back and chest as well as for the face. The Echelle de Cotation des Lesions d'Acne (ECLA) or 'Acne Lesion Score Scale' system has demonstrated good reliability.14 However, ECLA scores do not correlate with quality of life scores and the use of both disease and quality of life scores is suggested.15 Global assessment scales incorporate the entirety of the clinical presentation into a single category of severity. Each category is defined by either a photographic repertoire with corresponding numeric scale or descriptive text. Grading is a subjective task, based on observing dominant lesions, evaluating the presence or absence of inflammation, which is particularly difficult to capture, and estimating the extent of involvement. Global methods are much more practically suited to clinical practice. In clinical investigations, they should be combined with lesion counts as a co-primary endpoint of efficacy.16 A simple photographic standard-based grading method using a 0–8 scale has been successfully employed in a number of clinical trials.17 In 2005, the US FDA proposed an IGA (investigator global assessment) that represented a static quantitative evaluation of overall acne severity. To accomplish this, they devised an ordinal scale with five severity grades, each defined by distinct and clinically relevant morphological descriptions that they hoped would minimize inter-observer variability. Indeed, the more detailed descriptive text has resulted in this system being considered to provide even greater reliability than previous global assessments.16 A very simple classification of acne severity was described in the 2003 report from the Global Alliance for better outcome of acne treatment.11 This basic classification was designed to be used in a routine clinic, and its purpose was to map treatment advice onto common clinical presentations. For each acne descriptor a first-choice therapy is advised, with alternatives for female patients and maintenance therapy. There are five simple descriptors: mild comedonal, mild papulopustular, moderate papulopustular, moderate nodular and severe nodular/conglobate. A series of eight photographs span and overlap these five descriptors. Different facial views and different magnifications are used, reducing the comparability of the images. To give treatment recommendations based on disease activity, the EU Guidelines group has considered how best to classify acne patients. It has used the following simple clinical classification: Comedonal acne Mild–moderate papulopustular acne Severe papulopustular acne, moderate nodular acne Severe nodular acne, conglobate acne Other already existing systems are very difficult to compare with one another. The group has tried to map the existing systems to the guidelines' clinical classification. However, in many cases the systems do not include corresponding categories and often it has to be considered an approximated narrowing rather than a precise mapping (Table 1). Simpson and Cunliffe25'consider the use of quality of life and psychosocial questionnaires essential to adequately understanding just how the disease is affecting the patient, and to better understand the progress of the disease'. The impact of acne on quality of life can be measured using general health measures, dermatology-specific measures or acne-specific measures. In order for quality of life measures to be used more frequently in the routine clinical work, they need to be easy to use, the scores need to be meaningful and they need to be readily accessible. Clinicians must be convinced that the information gained from using them is of benefit in guiding them to make optimum clinical decisions for their patients, and they need to become aware that the use of these measures may help to justify their clinical decisions. Quality of life measures can influence the choice of therapy. In patients with a severe impact on their quality of life, a more aggressive therapy may be justified. A number of prognostic factors relating to more severe disease should be considered when assessing and managing acne. These are outlined and evidenced in review papers published by Holland and Jeremy 200526 and Dreno et al. 200827 and include family history, course of inflammation, persistent or late-onset disease, hyperseborrhoea, androgenic triggers, truncal acne and/or psychological sequelae. Previous infantile acne may also correlate with resurgence of acne at puberty and early age of onset with mid-facial comedones, early and more severe seborrhoea and earlier presentation relative to menarche are all factors that should alert the clinician to increased likelihood of more severe acne. Scarring usually follows deep-seated inflammatory lesions, but may also occur as a result of more superficial inflamed lesions in scar-prone patients. Acne scarring, albeit mild, has been identified in up to 90% of patients attending a dermatology clinic.28 Scars may show increased collagen (hypertrophic and keloid scars) or be associated with collagen loss. The presence of scarring should support aggressive management and therapy should be commenced early in the disease process. (For further details please see the methods report at http://www.acne-guidelines.com.) Nast/Rzany All experts were officially nominated by the European Dermatology Forum (EDF) or the European Academy of Dermatology and Venereology. They were selected according to their clinical expertise, publication record and/or experience in the field of evidence-based medicine and guideline development. None of the experts received any financial incentive other than reimbursement of travel costs. Participation of patients was difficult to realize, since no patient organization exists. Attempts to invite patients currently treated by the involved experts did not succeed. Patients were invited to participate in the external review. Patient preference was considered as an important outcome and trials looking at patient preferences were included. There is a vast array of treatment options available for acne. The options are further extended by the availability of different vehicles and formulations. When choosing a treatment, different skin types, ethnic groups and subtypes of acne must also be considered. The authors of this guideline selected the most relevant treatments in Europe to be included in the guideline. The fact that a certain treatment was not selected as a topic for this guideline, does not mean that it may not be a good treatment for acne. Additional treatment options may be considered for a later update. Fixed-dose combinations were considered as long as they were licensed in a European country (e.g. adapalene + benzoyl peroxide (BPO), clindamycin + BPO, erythromycin + tretinoin, erythromycin + isotretinoin, erythromycin + zinc). Treatment options consisting of more than two topical components were not included because of the likeliness of reduced patient adherence and/or because of a limitation in the feasibility of discussing all possible combinations and sequences. An extensive search of existing guidelines and systematic reviews was performed at the beginning of the project. The search was performed in Medline, Embase, and Cochrane (for search strategies see the methods report at http://www.acne-guidelines.com). The date of the systematic searches was March 10th 2010 for topical and systemic interventions and April 13th 2010 for laser and light therapies. The results were checked for the inclusion criteria and trial quality using a standardized literature evaluation form. Existing systematic reviews (e.g. Cochrane) and other guidelines served as an additional basis for the body of evidence in this guideline. Pooling of the trials was not attempted due to the lack of common outcome measures and endpoints and the unavailability of some primary data (for details of search strategies, standardized evaluation form and references of included reviews see methods report at http://www.acne-guidelines.com). The aim of this guideline is to give recommendations for specific clinical conditions, e.g. the severity of acne, and not to assess the different medications one by one without respect to clinical stage. However, most trials did not look in detail at subtypes but include patients with 'acne vulgaris' in general. Therefore, for some recommendations, 'indirect evidence' was generated from looking at suitable outcome parameters: The percentage 'reduction of non-inflammatory lesions' was the efficacy parameter considered for comedonal acne. Efficacy in papulopustular acne was assessed by 'reduction in inflammatory lesions', 'reduction in total lesion count' and other acne grading scales. The generation of evidence for nodular/conglobate acne was particularly difficult, since very few trials included nodular/conglobate acne. Consequently, treatment recommendations also took into account indirect data from trials of severe papulopustular acne. The evidence from clinical trials almost always focuses on facial acne. Trials that examined acne at other locations (e.g. back), were considered as indirect evidence and the level of evidence was downgraded accordingly. Very little attention has been given during clinical trials to the question of a minimal clinically important difference from the perspective of the patient. It would be helpful to know the extent of reduction in the number of acne lesions required for patients to consider that there has been a clinically important improvement. One study has been identified that empirically validated a non-inferiority margin of 10–15% for facial acne lesion counts as appropriate.356 The consensus view of the authors of this guideline is that a treatment should achieve at least a 10% greater reduction in the number of lesions to demonstrate superior efficacy. for the evaluation of superior or efficacy the evidence generation process, a 10% difference in efficacy was considered Many different grading systems for assessing the quality of evidence are available in the field of guideline development. For this guideline, the authors used the grading system for the European Guidelines with some taken from the The available literature was evaluated with respect to the quality of each single A grade of evidence was given to every trial clinical trial of quality of patient sufficient clinical trial of quality (e.g. limited at least patients trial with severe (e.g. not very no When looking at a specific question (e.g. efficacy of relative to the available evidence was by a level of evidence using the following is very to in the of least two trials are available that were a grade of evidence A and the results are with the results of additional grade or is to have an important impact on in the of and may the least trials are available that were a grade of evidence and the results are with respect to additional grade is very to have an important impact on in the of and is to the evidence or limited of with a grade of evidence of or of is very or no systematic included trials are limited in number and/or All recommendations were in a consensus of the authors using consensus group The consensus was by who is a for the of All of the were to in the consensus In a consensus was In the absence of a this was in the text and for the difference in views were All consensus are in a the text. To the different recommendations, the group a of grade (see The of considered all aspects of the treatment such as patient preference and the reliability of the existing body of evidence of of To grade the a guidelines' was be be considered. not not be used any A for or treatment cannot be at the An extensive external review was dermatological Dermatology Forum (EDF) other general as in the European of and patients were invited to was open and it was possible for to the the The group the guidelines their and performed a trial their clinics. (For further details see the methods report at will be at a national level by local medical such as an a and a therapeutic algorithm will be for evaluation (e.g. assessment of treatment and patient are in preparation and will be at a national Guidelines need to be to the of medical information This guideline will not be In of important in the licensed of drug important an will be The guidelines the of the of evidence-based medicine will the for an by of a Acne is one of the most frequent skin diseases. in the of acne in adolescents to be between and on the method of lesion mild were and moderate or severe were the was Acne is a disease primarily of It is in by the of by the and and it usually the of However, to some acne may persist beyond in a of particularly the disease has acne and are not factors have been there is a among and there is also a severe acne in patients with a family for little is about specific It is that several are involved in an to acne. These include the for and and ethnic factors may also contribute to differences in the clinical presentation and of factors also to be of to the of with a not to develop In particular, has gained with and a between acne and Acne is an of There are primary which to acne sebum by the in the process, follicular and of inflammatory Patients with seborrhoea and acne have a greater number of with Inflammatory occur prior to the of to the development of comedones of the with A relative has also been are by which in with to and as well as the in by and are also involved in activity as are the such as and The also as an in to in and other can of and a Acne factors and the of and induction by 2 of and of the of which and the The understanding of acne development on a level that acne is a disease that involves both and systems and inflammatory are based on available evidence and evidence and to classification of of (Table one trial at patients with comedonal acne. As a of indirect trials including patients with papulopustular acne were used and the percentage in the reduction of non-inflammatory lesions was considered as the relevant outcome of the general lack of direct evidence for the treatment of comedonal acne, the of was downgraded for all considered treatment with of as a of topical systemic treatment to the usually severity of comedonal acne, a topical therapy is efficacy was defined as a difference of in the reduction of non-inflammatory lesions in (see also Chapter efficacy with is demonstrated and the topical (Table the topical

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Nonalcoholic fatty liver disease (NAFLD) is a condition in which excess fat accumulates in the liver of a patient with no history of alcohol abuse or other causes for secondary hepatic steatosis. The pathogenesis of NAFLD and nonalcoholic steatohepatitis (NASH) has not been fully elucidated. The "two-hit" hypothesis is probably a too simplified model to elaborate complex pathogenetic events occurring in patients with NASH. It should be better regarded as a multiple step process, with accumulation of liver fat being the first step, followed by the development of necroinflammation and fibrosis. Adipose tissue, which has emerged as an endocrine organ with a key role in energy homeostasis, is responsive to both central and peripheral metabolic signals and is itself capable of secreting a number of proteins. These adipocyte-specific or enriched proteins, termed adipokines, have been shown to have a variety of local, peripheral, and central effects. In the current review, we explore the role of adipocytokines and proinflammatory cytokines in the pathogenesis of NAFLD. We particularly focus on adiponectin, leptin and ghrelin, with a brief mention of resistin, visfatin and retinol-binding protein 4 among adipokines, and tumor necrosis factor-α, interleukin (IL)-6, IL-1, and briefly IL-18 among proinflammatory cytokines. We update their role in NAFLD, as elucidated in experimental models and clinical practice.

Abstract This EAACI position paper aims at providing a state‐of‐the‐art overview on nonallergic rhinitis ( NAR ). A significant number of patients suffering from persistent rhinitis are defined as nonallergic noninfectious rhinitis ( NANIR ) patients, often denominated in short as having NAR . NAR is defined as a symptomatic inflammation of the nasal mucosa with the presence of a minimum of two nasal symptoms such as nasal obstruction, rhinorrhea, sneezing, and/or itchy nose, without clinical evidence of endonasal infection and without systemic signs of sensitization to inhalant allergens. Symptoms of NAR may have a wide range of severity and be either continuously present and/or induced by exposure to unspecific triggers, also called nasal hyperresponsiveness ( NHR ). NHR represents a clinical feature of both AR and NAR patients. NAR involves different subgroups: drug‐induced rhinitis, (nonallergic) occupational rhinitis, hormonal rhinitis (including pregnancy rhinitis), gustatory rhinitis, senile rhinitis, and idiopathic rhinitis ( IR ). NAR should be distinguished from those rhinitis patients with an allergic reaction confined to the nasal mucosa, also called “entopy” or local allergic rhinitis ( LAR ). We here provide an overview of the current consensus on phenotypes of NAR , recommendations for diagnosis, a treatment algorithm, and defining the unmet needs in this neglected area of research.

Central abdominal fat is a strong risk factor for diabetes and cardiovascular disease. To identify common variants influencing central abdominal fat, we conducted a two-stage genome-wide association analysis for waist circumference (WC). In total, three loci reached genome-wide significance. In stage 1, 31,373 individuals of Caucasian descent from eight cohort studies confirmed the role of FTO and MC4R and identified one novel locus associated with WC in the neurexin 3 gene [NRXN3 (rs10146997, p = 6.4x10(-7))]. The association with NRXN3 was confirmed in stage 2 by combining stage 1 results with those from 38,641 participants in the GIANT consortium (p = 0.009 in GIANT only, p = 5.3x10(-8) for combined analysis, n = 70,014). Mean WC increase per copy of the G allele was 0.0498 z-score units (0.65 cm). This SNP was also associated with body mass index (BMI) [p = 7.4x10(-6), 0.024 z-score units (0.10 kg/m(2)) per copy of the G allele] and the risk of obesity (odds ratio 1.13, 95% CI 1.07-1.19; p = 3.2x10(-5) per copy of the G allele). The NRXN3 gene has been previously implicated in addiction and reward behavior, lending further evidence that common forms of obesity may be a central nervous system-mediated disorder. Our findings establish that common variants in NRXN3 are associated with WC, BMI, and obesity.

INTRODUCTION: Nuclear medicine parathyroid imaging is important in the identification of hyperfunctioning parathyroid glands in primary hyperparathyroidism (pHPT), but it may be also valuable before surgical treatment in secondary hyperparathyroidism (sHPT). Parathyroid radionuclide imaging with scintigraphy or positron emission tomography (PET) is a highly sensitive procedure for the assessment of the presence and number of hyperfunctioning parathyroid glands, located either at typical sites or ectopically. The treatment of pHPT is mostly directed toward minimally invasive parathyroidectomy, especially in cases with a single adenoma. In experienced hands, successful surgery depends mainly on the exact preoperative localization of one or more hyperfunctioning parathyroid adenomas. Failure to preoperatively identify the hyperfunctioning parathyroid gland challenges minimally invasive parathyroidectomy and might require bilateral open neck exploration. METHODS: Over a decade has now passed since the European Association of Nuclear Medicine (EANM) issued the first edition of the guideline on parathyroid imaging, and a number of new insights and techniques have been developed since. The aim of the present document is to provide state-of-the-art guidelines for nuclear medicine physicians performing parathyroid scintigraphy, single-photon emission computed tomography/computed tomography (SPECT/CT), positron emission tomography/computed tomography (PET/CT), and positron emission tomography/magnetic resonance imaging (PET/MRI) in patients with pHPT, as well as in those with sHPT. CONCLUSION: These guidelines are written and authorized by the EANM to promote optimal parathyroid imaging. They will assist nuclear medicine physicians in the detection and correct localization of hyperfunctioning parathyroid lesions.

Background: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated. Methods: The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm 2 with aortic jet velocity &gt;4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries. Results: Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 [95% CI, 0.23–0.90]; P =0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome. Conclusions: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02436655.

AIMS: To determine the global extent of hypoglycaemia experienced by patients with diabetes using insulin, as there is a lack of data on the prevalence of hypoglycaemia in developed and developing countries. METHODS: This non-interventional, multicentre, 6-month retrospective and 4-week prospective study using self-assessment questionnaire and patient diaries included 27 585 patients, aged ≥18 years, with type 1 diabetes (T1D; n = 8022) or type 2 diabetes (T2D; n = 19 563) treated with insulin for >12 months, at 2004 sites in 24 countries worldwide. The primary endpoint was the proportion of patients experiencing at least one hypoglycaemic event during the observational period. RESULTS: During the prospective period, 83.0% of patients with T1D and 46.5% of patients with T2D reported hypoglycaemia. Rates of any, nocturnal and severe hypoglycaemia were 73.3 [95% confidence interval (CI) 72.6-74.0], 11.3 (95% CI 11.0-11.6) and 4.9 (95% CI 4.7-5.1) events/patient-year for T1D and 19.3 (95% CI 19.1-19.6), 3.7 (95% CI 3.6-3.8) and 2.5 events/patient-year (95% CI 2.4-2.5) for T2D, respectively. The highest rates of any hypoglycaemia were observed in Latin America for T1D and Russia for T2D. Glycated haemoglobin level was not a significant predictor of hypoglycaemia. CONCLUSIONS: We report hypoglycaemia rates in a global population, including those in countries without previous data. Overall hypoglycaemia rates were high, with large variations between geographical regions. Further investigation into these differences may help to optimize therapy and reduce the risk of hypoglycaemia.

In the clinical laboratory setting, interferences can be a significant source of laboratory errors with potential to cause serious harm for the patient. After hemolysis, lipemia is the most frequent endogenous interference that can influence results of various laboratory methods by several mechanisms. The most common preanalytical cause of lipemic samples is inadequate time of blood sampling after the meal or parenteral administration of synthetic lipid emulsions. Although the best way of detecting the degree of lipemia is measuring lipemic index on analytical platforms, laboratory experts should be aware of its problems, like false positive results and lack of standardization between manufacturers. Unlike for other interferences, lipemia can be removed and measurement can be done in a clear sample. However, a protocol for removing lipids from the sample has to be chosen carefully, since it is dependent on the analytes that have to be determined. Investigation of lipemia interference is an obligation of manufacturers of laboratory reagents; however, several literature findings report lack of verification of the declared data. Moreover, the acceptance criteria currently used by the most manufacturers are not based on biological variation and need to be revised. Written procedures for detection of lipemia, removing lipemia interference and reporting results from lipemic samples should be available to laboratory staff in order to standardize the procedure, reduce errors and increase patient safety.

OBJECTIVE: Glycans attached to the Fc portion of IgG are important modulators of IgG effector functions. Interindividual differences in IgG glycome composition are large and they associate strongly with different inflammatory and autoimmune diseases. IKZF1, HLA-DQ2A/B, and BACH2 genetic loci that affect IgG glycome composition show pleiotropy with systemic lupus erythematosus (SLE), indicating a potentially causative role of aberrant IgG glycosylation in SLE. We undertook this large multicenter case-control study to determine whether SLE is associated with altered IgG glycosylation. METHODS: Using ultra-performance liquid chromatography analysis of released glycans, we analyzed the composition of the IgG glycome in 261 SLE patients and 247 matched controls of Latin American Mestizo origin (the discovery cohort) and in 2 independent replication cohorts of different ethnicity (108 SLE patients and 193 controls from Trinidad, and 106 SLE patients and 105 controls from China). RESULTS: Multiple statistically significant differences in IgG glycome composition were observed between patients and controls. The most significant changes included decreased galactosylation and sialylation of IgG (which regulate proinflammatory and antiinflammatory actions of IgG) as well as decreased core fucose and increased bisecting N-acetylglucosamine (which affect antibody-dependent cell-mediated cytotoxicity). CONCLUSION: The IgG glycome in SLE patients is significantly altered in a way that decreases immunosuppressive action of circulating immunoglobulins. The magnitude of observed changes is associated with the intensity of the disease, indicating that aberrant IgG glycome composition or changes in IgG glycosylation may be an important molecular mechanism in SLE.

Total quality in laboratory medicine should be defined as the guarantee that each activity throughout the total testing process is correctly performed, providing valuable medical decision-making and effective patient care. In the past decades, a 10-fold reduction in the analytical error rate has been achieved thanks to improvements in both reliability and standardization of analytical techniques, reagents, and instrumentation. Notable advances in information technology, quality control and quality assurance methods have also assured a valuable contribution for reducing diagnostic errors. Nevertheless, several lines of evidence still suggest that most errors in laboratory diagnostics fall outside the analytical phase, and the pre- and postanalytical steps have been found to be much more vulnerable. This collective paper, which is the logical continuum of the former already published in this journal 2 years ago, provides additional contribution to risk management in the preanalytical phase and is a synopsis of the lectures of the 2nd European Federation of Clinical Chemistry and Laboratory Medicine (EFLM)-Becton Dickinson (BD) European Conference on Preanalytical Phase meeting entitled "Preanalytical quality improvement: in quality we trust" (Zagreb, Croatia, 1-2 March 2013). The leading topics that will be discussed include quality indicators for preanalytical phase, phlebotomy practices for collection of blood gas analysis and pediatric samples, lipemia and blood collection tube interferences, preanalytical requirements of urinalysis, molecular biology hemostasis and platelet testing, as well as indications on best practices for safe blood collection. Auditing of the preanalytical phase by ISO assessors and external quality assessment for preanalytical phase are also discussed.

By writing scientific articles we communicate science among colleagues and peers. By doing this, it is our responsibility to adhere to some basic principles like transparency and accuracy. Authors, journal editors and reviewers need to be concerned about the quality of the work submitted for publication and ensure that only studies which have been designed, conducted and reported in a transparent way, honestly and without any deviation from the truth get to be published. Any such trend or deviation from the truth in data collection, analysis, interpretation and publication is called bias. Bias in research can occur either intentionally or unintentionally. Bias causes false conclusions and is potentially misleading. Therefore, it is immoral and unethical to conduct biased research. Every scientist should thus be aware of all potential sources of bias and undertake all possible actions to reduce or minimize the deviation from the truth. This article describes some basic issues related to bias in research.

Phospho- and sphingolipids are crucial cellular and intracellular compounds. These lipids are required for active transport, a number of enzymatic processes, membrane formation, and cell signalling. Disruption of their metabolism leads to several diseases, with diverse neurological, psychiatric, and metabolic consequences. A large number of phospholipid and sphingolipid species can be detected and measured in human plasma. We conducted a meta-analysis of five European family-based genome-wide association studies (N = 4034) on plasma levels of 24 sphingomyelins (SPM), 9 ceramides (CER), 57 phosphatidylcholines (PC), 20 lysophosphatidylcholines (LPC), 27 phosphatidylethanolamines (PE), and 16 PE-based plasmalogens (PLPE), as well as their proportions in each major class. This effort yielded 25 genome-wide significant loci for phospholipids (smallest P-value = 9.88×10(-204)) and 10 loci for sphingolipids (smallest P-value = 3.10×10(-57)). After a correction for multiple comparisons (P-value<2.2×10(-9)), we observed four novel loci significantly associated with phospholipids (PAQR9, AGPAT1, PKD2L1, PDXDC1) and two with sphingolipids (PLD2 and APOE) explaining up to 3.1% of the variance. Further analysis of the top findings with respect to within class molar proportions uncovered three additional loci for phospholipids (PNLIPRP2, PCDH20, and ABDH3) suggesting their involvement in either fatty acid elongation/saturation processes or fatty acid specific turnover mechanisms. Among those, 14 loci (KCNH7, AGPAT1, PNLIPRP2, SYT9, FADS1-2-3, DLG2, APOA1, ELOVL2, CDK17, LIPC, PDXDC1, PLD2, LASS4, and APOE) mapped into the glycerophospholipid and 12 loci (ILKAP, ITGA9, AGPAT1, FADS1-2-3, APOA1, PCDH20, LIPC, PDXDC1, SGPP1, APOE, LASS4, and PLD2) to the sphingolipid pathways. In large meta-analyses, associations between FADS1-2-3 and carotid intima media thickness, AGPAT1 and type 2 diabetes, and APOA1 and coronary artery disease were observed. In conclusion, our study identified nine novel phospho- and sphingolipid loci, substantially increasing our knowledge of the genetic basis for these traits.

OBJECTIVE: The aim of this study was to determine whether ultrasonography itself was able to distinguish benign from malignant lymphadenopathy in patients with thyroid cancer. METHODS: We evaluated lymph nodes in a group of patients with thyroid cancer. Nodes were detected and measured by ultrasonography, and their shape, echogenicity, size, and location were noted. Ultrasonographically guided fine-needle aspiration biopsy (FNAB) was performed, and smears were analyzed cytologically. RESULTS: Ultrasonographically guided FNAB was performed in 578 neck nodes in a group of 631 patients with thyroid cancer. In most cases, metastases had a round shape and various echo structures, with a predomination of hypoechoic nodes without a hilum. There were statistical differences in size between metastatic and benign nodes in terms of maximum diameter, minimum diameter, and volume. Among these, minimum diameter and the shape of the nodes seemed to be the most reliable in suggesting malignancy. A round shape with a longitudinal/transverse ratio of less than 2 of hypoechoic nodes indicated the presence of metastases, and we then performed FNAB. The absence of an echogenic hilum and the presence of cystic portions and calcifications were significantly greater in malignancies than in benign lesions (P<.001). In most cases, metastatic nodules were situated in the lower third of the neck. Reactively enlarged nodes occurred more frequently in the upper part of the neck. CONCLUSIONS: Ultrasonography itself cannot distinguish benign from malignant lesions, but an echographic appearance suggests malignancy and helps in the selection of the node to aspirate with ultrasonographically guided FNAB, which is crucial for a final diagnosis.