You Do Not Rise to the Level of Your Goals;You Fall to the Level of Your Systems

It is a distinct honor to be the guest editor for this issue of the American Journal of Rhinology and Allergy, and I express my gratitude to the esteemed editor and editorial board for entrusting me with this opportunity.

January signifies a juncture for new beginnings, prompting contemplation on past achievements and future aspirations. Each January 1st, my ambitious self eagerly formulates new goals spanning various facets of life, encompassing fitness, diet, relationships, and career advancement. However, through years marked by many setbacks and some triumphs, the wisdom eloquently summarized by author James Clear has crystallized: “You do not rise to the level of your goals; you fall to the level of your systems.” The pivotal role of our daily systems, encapsulated in our habits, becomes apparent in the success of our endeavors. Perseverance begets consistency, consistency begets habits, habits beget systems, and systems pave the way for successful goals and projects, both in the immediate and distant future.

The landscape of research programs has undergone a transformation, historically reliant on subsidies from clinical care margins. The shift toward managed care, reductions in fee-for-service reimbursements worsened by inflation, and the adoption of value-based payment models compel American (and international) academic centers to rethink their research systems. This reevaluation is imperative for forging a sustainable and productive trajectory that benefits our patients. Consequently, researchers find themselves confronting heightened challenges in realizing the fruition of their projects. Against this backdrop, I commend the authors of this issue for their leadership and contributions that delve into various critical aspects of our field. These insights are invaluable as we navigate the evolving terrain of academic research and strive for excellence and continued progress in improving rhinological health in the face of changing paradigms.

Healthcare disparity has been shown to impact care delivery and outcomes. Hentati and colleagues conducted a retrospective matched cohort study analyzing the impact of race and socioeconomic status on presentation and outcomes in patients with chronic rhinosinusitis (CRS) undergoing endoscopic sinus surgery. ¹ They found that nonwhite patients have worse outcomes, higher revision rates, less consistent follow up, and present from areas with fewer resources compared to white patients. Therefore, acknowledging the socioeconomic status is essential when treating patients with CRS in order to mitigate disparity-related outcomes.

Biological therapy is revolutionizing our field and helping many patients suffering from CRS with nasal polyps. Tsunemi and colleagues retrospectively reviewed patients with refractory eosinophilic CRS experiencing polyp recurrence following endoscopic sinus surgery and undergoing dupilumab for more than 1 year. ² They found that the nasal polyp scores and computed tomography (CT) scores improved in the short and long term. Olfaction measured using a T&T olfactometer and olfactory cleft opacification on CT showed improvement only in the long term. These findings suggest continuation of dupilumab for over a year for optimal smell improvement.

Lv et al examined the histopathological process following mucosal resection and bone drill-out, assessing the effects of shielding exposed bone with mucosal flaps. ³ Utilizing a rabbit model of CRS, they contrasted it with a non-CRS group. Additionally, they compared the inflammatory reactions in subgroups with and without mucosal flaps. The results indicate that bone drilling triggers an inflammatory response, causing mucosal scarring and new bone formation, which can be mitigated by repairing with pedicled mucosal flaps.

Zhao and colleagues investigated the genetic associations between allergic rhinitis (AR) and 8 immune-related diseases using 2-sample Mendelian randomization and data from the Genome-Wide-Association-Studies. ⁴ Their results indicated a causal relationship between the risk of AR and atopic dermatitis, asthma, and Crohn's disease, while Grave's disease and systemic lupus erythematosus appeared to be protective factors.

Gong and colleagues assessed the Epistaxis Severity Score (ESS) in patients with hemorrhagic telangiectasia (HHT) focusing on internal consistency and test–retest reliability. ⁵ The ESS was found to have low internal consistency but excellent test–retest reliability thus highlighting the necessity to acknowledge epistaxis severity from different dimensions and consider individual ESS items separately for a comprehensive understanding.

Aldajani and colleagues conducted a meta-analysis assessing the association between reflux diseases (laryngopharyngeal reflux [LPR] and gastroesophageal reflux [GERD]) and CRS. ⁶ The study revealed a significant association between GERD, LPR, and CRS compared to control groups, along with higher pH values and pepsin detection in CRS patients. Additionally, studies evaluating proton pump inhibitor therapy in CRS patients consistently reported positive outcomes. These findings reinforce the association between reflux diseases and CRS in the existing literature.

In another study performed by the same team, Gong et al performed a scoping review of studies on health-related quality of life in patients with hereditary HHT to identify existing metrics, gaps, and guide future research. ⁷ The heterogeneity in outcomes measures across studies that they found highlights the need for further development of HHT-specific patient-reported outcomes instruments.

I trust that you will find as much enjoyment in this edition of the journal as I did. Wishing all our readers a happy New Year, filled with optimized systems that pave the way to successful goals.