Excess intra-abdominal adipose tissue accumulation, often termed visceral obesity, is part of a phenotype including dysfunctional subcutaneous adipose tissue expansion and ectopic triglyceride storage closely related to clustering cardiometabolic risk factors. Hypertriglyceridemia; increased free fatty acid availability; adipose tissue release of proinflammatory cytokines; liver insulin resistance and inflammation; increased liver VLDL synthesis and secretion; reduced clearance of triglyceride-rich lipoproteins; presence of small, dense LDL particles; and reduced HDL cholesterol levels are among the many metabolic alterations closely related to this condition. Age, gender, genetics, and ethnicity are broad etiological factors contributing to variation in visceral adipose tissue accumulation. Specific mechanisms responsible for proportionally increased visceral fat storage when facing positive energy balance and weight gain may involve sex hormones, local cortisol production in abdominal adipose tissues, endocannabinoids, growth hormone, and dietary fructose. Physiological characteristics of abdominal adipose tissues such as adipocyte size and number, lipolytic responsiveness, lipid storage capacity, and inflammatory cytokine production are significant correlates and even possible determinants of the increased cardiometabolic risk associated with visceral obesity. Thiazolidinediones, estrogen replacement in postmenopausal women, and testosterone replacement in androgen-deficient men have been shown to favorably modulate body fat distribution and cardiometabolic risk to various degrees. However, some of these therapies must now be considered in the context of their serious side effects. Lifestyle interventions leading to weight loss generally induce preferential mobilization of visceral fat. In clinical practice, measuring waist circumference in addition to the body mass index could be helpful for the identification and management of a subgroup of overweight or obese patients at high cardiometabolic risk.

Pathophysiology of Human Visceral Obesity: An Update

Matrix metalloproteinases (MMPs) are a family of zinc-dependent endopeptidases that are involved in the degradation of various proteins in the extracellular matrix (ECM). Typically, MMPs have a propeptide sequence, a catalytic metalloproteinase domain with catalytic zinc, a hinge region or linker peptide, and a hemopexin domain. MMPs are commonly classified on the basis of their substrates and the organization of their structural domains into collagenases, gelatinases, stromelysins, matrilysins, membrane-type (MT)-MMPs, and other MMPs. MMPs are secreted by many cells including fibroblasts, vascular smooth muscle (VSM), and leukocytes. MMPs are regulated at the level of mRNA expression and by activation of their latent zymogen form. MMPs are often secreted as inactive pro-MMP form which is cleaved to the active form by various proteinases including other MMPs. MMPs cause degradation of ECM proteins such as collagen and elastin, but could influence endothelial cell function as well as VSM cell migration, proliferation, Ca2+ signaling, and contraction. MMPs play a role in tissue remodeling during various physiological processes such as angiogenesis, embryogenesis, morphogenesis, and wound repair, as well as in pathological conditions such as myocardial infarction, fibrotic disorders, osteoarthritis, and cancer. Increases in specific MMPs could play a role in arterial remodeling, aneurysm formation, venous dilation, and lower extremity venous disorders. MMPs also play a major role in leukocyte infiltration and tissue inflammation. MMPs have been detected in cancer, and elevated MMP levels have been associated with tumor progression and invasiveness. MMPs can be regulated by endogenous tissue inhibitors of metalloproteinases (TIMPs), and the MMP/TIMP ratio often determines the extent of ECM protein degradation and tissue remodeling. MMPs have been proposed as biomarkers for numerous pathological conditions and are being examined as potential therapeutic targets in various cardiovascular and musculoskeletal disorders as well as cancer.

/pdf/biochemical-and-biological-attributes-of-matrix-541keac0a1.pdf

Biochemical and Biological Attributes of Matrix Metalloproteinases.

Background The body of knowledge regarding rhinosinusitis(RS) continues to expand, with rapid growth in number of publications, yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS). Methods Evidence-based reviews with recommendations(EBRRs) were developed for scores of topics, using previously reported methodology. Where existing evidence was insufficient for an EBRR, an evidence-based review (EBR)was produced. The sections were then synthesized and the entire manuscript was then reviewed by all authors for consensus. Results The resulting ICAR:RS document addresses multiple topics in RS, including acute RS (ARS), chronic RS (CRS)with and without nasal polyps (CRSwNP and CRSsNP), recurrent acute RS (RARS), acute exacerbation of CRS (AECRS), and pediatric RS. Conclusion As a critical review of the RS literature, ICAR:RS provides a thorough review of pathophysiology and evidence-based recommendations for medical and surgical treatment. It also demonstrates the significant gaps in our understanding of the pathophysiology and optimal management of RS. Too often the foundation upon which these recommendations are based is comprised of lower level evidence. It is our hope that this summary of the evidence in RS will point out where additional research efforts may be directed.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/alr.21695

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis.

I. Executive summary BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. Methods ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. Results ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. Conclusion This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

Metastatic tumours to the oral cavity – Pathogenesis and analysis of 673 cases

The aim of this study was to investigate frequency and degree of ED in patients with severe sleep apnea and to evaluate the results of only continuous positive airway pressure (CPAP) therapy on ED in patients with severe obstructive sleep apnea syndrome (OSAS). This was a prospective clinical trial study. Patients with severe sleep apnea (40) were randomized into two groups. Multiple questionnaire investigation and laboratory evaluation were performed for ED, severity of OSAS and psychological status. Group 1 was treated with CPAP and group 2 was treated with only antidepressant medication for at least 1 month. Patients were evaluated after 1 month of therapy and compared with initial ones. Before CPAP, the International Index of Erectile Function (IIEF)-5 scores were significantly correlated only with body mass index (BMI; P=0.007) and not correlated significantly with Epworth Sleepiness Scale scores (P=0.286), lowest SaO(2) (P=0.182), Beck's Depression Inventory scores (P=0.302) and apnea/hypopnea index (P=0.279). After 1 month of regular CPAP usage, mean value of IIEF-5 score was 15.71+/-5.12 before CPAP and were improved up to 19.06+/-3.94, statistically significant. All subjects responded positively to the CPAP treatment and their erection status was improved positively. We have found a correlation between severe OSAS and ED. CPAP is effective in improvement of sexual performance of these patients.

Erectile dysfunction in severe sleep apnea patients and response to CPAP

The aim of this study was to investigate the effects of four different types of nasal packs on pain, nasal fullness and postoperative bleeding following septoplasty. Prospective randomised double blind study was conducted. The study group included 119 patients who underwent endonasal septoplasty under general anaesthesia. Four types of nasal packing materials were utilized: (1) Merocel standard 8-cm nasal dressing without airway, (2) Doyle Combo splint (DCS), (3) Merocel in a glove finger and (4) Vaseline gauze. All packs were removed at the 48th hour (±3 h) after the surgery. Three different variables were investigated following the surgical procedure: (1) pain, (2) nasal fullness and (3) bleeding after removal of the nasal packing material. DCS produced the greatest pain at the first and sixth postoperative hours. At the first postoperative day, the greatest pain score was reported for Merocel in the glove finger and the least for Merocel. The pain scores during the removal of the nasal packings were highest for Merocel and lowest for Merocel in the glove finger. DCS had the lowest nasal fullness score. Bleeding ratio was highest for Merocel, followed by Vaseline gauze, DCS and Merocel in the glove finger. Many different commercially available packing materials are presently used, each with inherent advantages and disadvantages. We evaluated the pain, nasal fullness and bleeding potential of four nasal packing materials and determined that Merocel had the highest pain potential during removal and the highest rate of bleeding following removal.

Nasal septal packing: which one?

The aim of this study was to investigate the incidence of concha bullosa (CB) in cases with septal deviation (SD), correlation between the angle of deviation and degree of pneumatization and compare these correlations with qualitative and quantitative methods. We retrospectively searched our radiology database for all paranasal sinus computed tomography (CT) findings for 672 patients. All scans were grouped according to the presence and side of SD and/or CB. SD angles and pneumatization degree of the CB were measured with appropriate method. These findings were also classified according to the initial defined qualitative method. Generally, CB and SD incidences were 31.52 and 47.77%, respectively. CB ratio in SD patients was 45.34% whereas ratio in non-SD patients was 18.95%. Mean deviation angle of the isolated SD group (15.24 ± 5.03) was found higher than both deviation angle of the unilateral CB + SD group (13.16 ± 4.19) and bilateral CB + SD group (11.15 ± 3.73) (P = 0.002, P = 0.0001 respectively). In conclusion, CB may tend to develop bilaterally in normal, non-deviated nose. However, the increasing incidence of unilateral CB, especially contralateral ones, in septal deviated patients suggested that SD may prevent the development of ipsilateral CB.

Concha bullosa and septal deviation.

Objective: Currently, the diagnosis of chronic rhinosinusitis (CRS) is a symptom-based definition. This study aims to study, verify and evaluate the predictive value of the symptom-based definition of CRS and compare this with objective tests.



Methods:  Seven hundred and sixty-eight adults, who were referred from primary care centers as patients who met the definition of CRS, were enrolled in the study. The patients were divided into two groups according to their allergic status. The patients were subjected to nasal endoscopy and computed tomography (CT) on the same day.



Results:  The results showed 73.15% of the nonallergic patients with symptom-based diagnosed CRS and 65.34% of the allergic patients with symptom-based diagnosed CRS had no CT and endoscopic pathology (Endoscopic score 0 + CT score 0). Nasal discharge was the most common major symptom in all patients from both groups who had pathologic endoscopic and/or CT scan scores.



Conclusions:  It is well established that symptoms are very important in the diagnosis of CRS. However, two major symptoms are insufficient for diagnosis. Therefore, endoscopy and CT have important differential diagnostic roles. Our study showed that in patients with three major symptoms, CT pathology may be sufficient for definitive diagnosis. However, in patients with two major symptoms such as nasal discharge and/or low grade nasal polyposis, endoscopy becomes considerably more important due to inspective findings. If no endoscopic findings are found, the importance of the CT scans is increased.

The accuracy of symptom-based definition of chronic rhinosinusitis.

SOMMAIRE Objectifs: L'etude avait pour objectifs d'examiner le lien entre la gravite des apnees du sommeil et la resistance a l'insuline ainsi que les taux de leptine, de proteines de liaison aux acides gras dans l'adipose (PLAG-A) et de visfatine, et d'evaluer le role confusionnel de l'obesite. Type d'etude: Il s'agit d'une etude prospective. Methodes: L'etude a ete menee chez des personnes obeses, dirigees au laboratoire de sommeil. Les patients ont ete divises en deux groupes d'apres l'index apnees hypopnees (IAH). Il y a eu mesure du poids, de la taille, de la pression arterielle, du tour de taille (TT) et du tour de cou (TC), le soir de l'etude. Des prelevements sanguins ont ete effectues apres la polysomnographie. La resistance a l'insuline a ete estimee a l'aide de l'indice d'evaluation par le modele homeostatique (EMH). Resultats: Le groupe A comptait 34 patients atteints du syndrome des apnees obstructives du sommeil (SAOS), et le groupe B comptait 19 patients qui en etaient exempts. Ceux qui souffraient du syndrome avaient un taux significativement plus eleve de visfatine que ceux qui n'en souffraient pas, mais les autres parametres etaient similaires. Les taux de leptine et de PLAG-A etaient en correlation etroite avec l'indice de masse corporelle (IMC) dans les deux groupes. Les patients atteints du SAOS presentaient un TC et un TT passablement plus eleves que ceux qui en etaient exempts, et ce, malgre un IMC comparable a celui du groupe B, et de fortes correlations ont ete etablies entre ces deux variables et l'EMH. Le taux de visfatine etait plus eleve dans le groupe A que dans le groupe B. Conclusions: La resistance a l'insuline n'etait pas associee directement a l'IMC ou a l'IAH, mais elle etait aggravee par l'hypoxemie nocturne causee par les apnees. Le tour de cou s'est egalement revele un bon facteur previsionnel de resistance a l'insuline, et on ne devrait pas negliger cet element dans le choix des traitements chez les patients atteints du SAOS. Enfin, la visfatine pourrait jouer un role de marqueur de depistage du SAOS.

Obesity and obstructive sleep apnea syndrome.

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