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      Benefits and harm of systemic steroids for short- and long-term use in rhinitis and rhinosinusitis: an EAACI position paper

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          Abstract

          Because of the inflammatory mechanisms of most chronic upper airway diseases such as rhinitis and chronic rhinosinusitis, systemic steroids have been used for their treatment for decades. However, it has been very well documented that—potentially severe—side-effects can occur with the accumulation of systemic steroid courses over the years. A consensus document summarizing the benefits of systemic steroids for each upper airway disease type, as well as highlighting the potential harms of this treatment is currently lacking. Therefore, a panel of international experts in the field of Rhinology reviewed the available literature with the aim of providing recommendations for the use of systemic steroids in treating upper airway disease.

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

          The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 is the update of similar evidence based position papers published in 2005 and 2007. The document contains chapters on definitions and classification, we now also proposed definitions for difficult to treat rhinosinusitis, control of disease and better definitions for rhinosinusitis in children. More emphasis is placed on the diagnosis and treatment of acute rhinosinusitis. Throughout the document the terms chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are used to further point out differences in pathophysiology and treatment of these two entities. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. Last but not least all available evidence for management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is analyzed and presented and management schemes based on the evidence are proposed. This executive summary for otorhinolaryngologists focuses on the most important changes and issues for otorhinolaryngologists. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.
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            Different types of T-effector cells orchestrate mucosal inflammation in chronic sinus disease.

            Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by the accumulation of inflammatory cells; however, an eosinophil predominance is seen in white (Belgian), but not Asian (south Chinese), patients with polyps. We sought to investigate the association of inflammatory cell predominance with regulatory T-cell and T-effector cell patterns. Nasal mucosal tissue was obtained from 26 consecutive Belgian patients with CRSwNP and 21 Belgian control subjects and 29 south Chinese patients with CRSwNP and 29 south Chinese control subjects, who all underwent phenotyping, including nasal endoscopy and computed tomographic scanning. Tissues were investigated for granulocytes and their products and T-effector/regulatory T cells and related cytokines. Both CRSwNP groups were comparable in terms of symptoms, computed tomographic scan results, and nasal endoscopy results, but asthma comorbidity was significantly higher in white patients. Tissue from white patients with CRSwNP was characterized by eosinophilic inflammation (eosinophil cationic protein/myeloperoxidase ratio > 2), whereas samples from Asian patients were biased toward neutrophilic inflammation (eosinophil cationic protein/myeloperoxidase ratio = 0.25). Both CRSwNP groups demonstrated significant upregulation of the T-cell activation marker soluble IL-2 receptor alpha and significant downregulation of Foxp3 expression and TGF-beta1 protein content versus their respective control groups. However, whereas white patients displayed a significant increase in T(H)2 cytokine and related marker levels versus control subjects and versus Asian patients, the latter showed a T(H)1/T(H)17 cell pattern versus control tissue. Nasal polyps (CRSwNP) from white and Asian patients are both characterized by T-cell activation and impaired regulatory T-cell function; however, T-effector cells in the samples from white patients were T(H)2-biased, whereas samples from their Asian counterparts demonstrated a T(H)1/T(H)17 polarization.
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              Taking glucocorticoids by prescription is associated with subsequent cardiovascular disease.

              Glucocorticoids have adverse systemic effects, including obesity, hypertension, and hyperglycemia, that may predispose to cardiovascular disease. The effect of glucocorticoid use on cardiovascular disease has not been quantified. To test the hypothesis that users of exogenous glucocorticoids have an increased risk for cardiovascular disease. A cohort study using a record linkage database. Tayside, Scotland, United Kingdom. 68,781 glucocorticoid users and 82,202 nonusers without previous hospitalization for cardiovascular disease who were studied between 1993 and 1996. The average daily dose of glucocorticoid exposure during follow-up was categorized as low (inhaled, nasal, and topical only), medium (oral, rectal, or parenteral or =7.5 mg of prednisolone equivalent). Poisson regression model, sensitivity analysis, and propensity score methods were used to investigate the association between glucocorticoid exposure and cardiovascular outcome. 4383 cardiovascular events occurred in 257,487 person-years of follow-up for a rate of 17.0 (95% CI, 16.5 to 17.5) per 1000 person-years in the comparator group, and 5068 events occurred in 212,287 person-years for a rate of 23.9 (CI, 23.2 to 24.5) per 1000 person-years in the group exposed to glucocorticoids (22.1, 27.2, and 76.5 in low, medium, and high groups, respectively). The absolute risk difference was 6.9 (CI, 6.0 to 7.7) per 1000 person-years (5.1, 10.1, and 59.4, respectively). After adjustment for known covariates, the relative risk for a cardiovascular event in patients receiving high-dose glucocorticoids was 2.56 (CI, 2.18 to 2.99). Because the data were observational, residual confounding cannot be excluded. Treatment with high-dose glucocorticoids seemed to be associated with increased risk for cardiovascular disease.
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                Author and article information

                Contributors
                Valerie.hox@uclouvain.be
                Journal
                Clin Transl Allergy
                Clin Transl Allergy
                Clinical and Translational Allergy
                BioMed Central (London )
                2045-7022
                3 January 2020
                3 January 2020
                2020
                : 10
                : 1
                Affiliations
                [1 ]ISNI 0000 0004 0461 6320, GRID grid.48769.34, Cliniques Universitaires Saint-Luc Brussels, ; Av. Hippocrate 10, 1200 Brussels, Belgium
                [2 ]ISNI 0000000404654431, GRID grid.5650.6, Department of Otorhinolaryngology, , Amsterdam University Medical Centres, AMC, ; Amsterdam, The Netherlands
                [3 ]ISNI 0000 0004 0626 3303, GRID grid.410566.0, Upper Airway Research Laboratory, Dep. of Otorhinolaryngology, , Ghent University Hospital, ; Ghent, Belgium
                [4 ]ISNI 0000 0000 9350 8874, GRID grid.411702.1, Bispebjerg University Hospital, ; Copenhagen, Denmark
                [5 ]Faculty of Medicine, Transsylvania University, Brasov, Romania
                [6 ]ISNI 0000 0004 1937 0247, GRID grid.5841.8, Hospital Clínic, IDIBAPS, , CEBERES Universitat de Barcelona, ; Catalonia, Spain
                [7 ]ISNI 0000 0004 1769 0319, GRID grid.416936.f, Centro Medico Teknon, ; Barcelona, Spain
                [8 ]ISNI 0000 0000 9241 5705, GRID grid.24381.3c, Department of Ear, Nose and Throat Diseases, , Karolinska University Hospital, ; Stockholm, Sweden
                [9 ]ISNI 0000 0001 2069 7798, GRID grid.5342.0, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, , Ghent University, ; Ghent, Belgium
                [10 ]GRID grid.411457.2, Allergy Unit, , Hospital Regional Universitario of Málaga, IBIMA, ARADyAL, ; Malaga, Spain
                [11 ]ISNI 0000 0004 0626 3338, GRID grid.410569.f, Department of Ear, Nose and Throat Disease, , University Hospitals, ; Louvain, Belgium
                [12 ]GRID grid.425213.3, ENT Department, , Guy’s & St Thomas’ Hospital, ; London, UK
                [13 ]Center of Rhinology and Allergology, Wiesbaden, Germany
                [14 ]ISNI 0000 0000 9950 5666, GRID grid.15485.3d, Skin and Allergy Hospital, , Helsinki University Hospital and University of Helsinki, ; Helsinki, Finland
                [15 ]ISNI 0000 0000 8580 3777, GRID grid.6190.e, University of Cologne, ; Cologne, Germany
                [16 ]London Allergy and Immunology Center, London, UK
                [17 ]GRID grid.439342.b, Royal National Throat, Nose and Ear Hospital, ; London, UK
                [18 ]ISNI 0000 0000 8988 2476, GRID grid.11598.34, Medical University Graz, ; Graz, Austria
                [19 ]ISNI 0000 0001 2176 9917, GRID grid.411327.2, Heinrich-Heine-University, ; Düsseldorf, Germany
                [20 ]ISNI 0000 0004 0407 1981, GRID grid.4830.f, Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), , University of Groningen, ; Groningen, The Netherlands
                Author information
                http://orcid.org/0000-0003-2390-294X
                Article
                303
                10.1186/s13601-019-0303-6
                6941282
                31908763
                83a9ccb1-bc13-4d0c-b0e5-028599ade6df
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 30 November 2019
                : 2 December 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100011824, European Academy of Allergy and Clinical Immunology;
                Award ID: Task Force budget
                Categories
                Review
                Custom metadata
                © The Author(s) 2020

                Immunology
                glucocorticosteroids,rhinitis,rhinosinusitis
                Immunology
                glucocorticosteroids, rhinitis, rhinosinusitis

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