Academic institution pilot study shows far fewer diagnoses of sinusitis than reported nationally.

OBJECTIVE: To compare the prevalence of acute sinusitis (AS) and chronic sinusitis (CS) diagnosed by primary care and emergency medicine physicians in our academic institution to national data. STUDY DESIGN: Cross-sectional pilot study of institutional census data and a population-based national sample. The setting was primary care and emergency departments at an academic healthcare institution and community healthcare practices nationally. MATERIALS AND METHODS: We determined the proportion of adults visits at our institution for AS and CS from January 1, 2005, to December 31, 2010. We used the same parameters with the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. As a control comparison, we determined the proportion of visits for epistaxis. RESULTS: The sinusitis prevalence was considerably lower at our academic institution: all sinusitis (AS and CS combined) ranged from 0.8% to 1.0% at our institution compared to 3.1% to 3.7% nationally. There were very small differences between AS rates at the academic institution (0.7%-0.8%) and nationally (0.8%-1.4%, P < 0.001) but very large differences between CS rates at the academic institution (0.1%) and national data (1.7%-2.9%, P < 0.001). Epistaxis rates were nearly identical in both datasets (0.1%-0.2%, P = 0.98-0.99). CONCLUSION: The prevalence of CS is much lower at our academic institution, but the prevalence of AS and epistaxis are similar to national data. This suggests CS is over-diagnosed by primary care and emergency medicine providers and that CS diagnosed outside of an academic institution or a specialty clinic may not hold up to diagnostic scrutiny. For this reason, diagnostic and treatment protocols for CS that have been developed in academic specialty clinics should not be extrapolated to patients diagnosed with CS in the community setting. The most appropriate intervention for the majority of patients diagnosed with CS in primary care and emergency medicine may be education of providers and patients about conditions that may be misdiagnosed as CS.

Quality of consumer-targeted internet guidance on home firearm and ammunition storage.

BACKGROUND AND OBJECTIVES: Four storage practices protect against unintentional and/or self-inflicted firearm injury among children and adolescents: keeping guns locked (1) and unloaded (2) and keeping ammunition locked up (3) and in a separate location from the guns (4). Our aim was to mimic common Google search strategies on firearm/ammunition storage and assess whether the resulting web pages provided recommendations consistent with those supported by the literature. METHODS: We identified 87 web pages by Google search of the 10 most commonly used search terms in the USA related to firearm/ammunition storage. Two non-blinded independent reviewers analysed web page technical quality according to a 17-item checklist derived from previous studies. A single reviewer analysed readability by US grade level assigned by Flesch-Kincaid Grade Level Index. Two separate, blinded, independent reviewers analysed deidentified web page content for accuracy and completeness describing the four accepted storage practices. Reviewers resolved disagreements by consensus. RESULTS: The web pages described, on average, less than one of four accepted storage practices (mean 0.2 (95% CL 0.1 to 0.4)). Only two web pages (2%) identified all four practices. Two web pages (2%) made assertions inconsistent with recommendations; both implied that loaded firearms could be stored safely. Flesch-Kincaid Grade Level Index averaged 8.0 (95% CL 7.3 to 8.7). The average technical quality score was 7.1 (95% CL 6.8 to 7.4) out of an available score of 17. There was a high degree of agreement between reviewers regarding completeness (weighted κ 0.78 (95% CL 0.61 to 0.97)). CONCLUSIONS: The internet currently provides incomplete information about safe firearm storage. Understanding existing deficiencies may inform future strategies for improvement.

A diagnostic dilemma: chronic sinusitis diagnosed by non-otolaryngologists.

BACKGROUND: Ambulatory care visits for chronic sinusitis outnumber visits for acute sinusitis. The majority of these visits are with non-otolaryngologists. In order to better understand patients diagnosed with chronic sinusitis by non-otolaryngologists, we sought to determine if incident cases of chronic sinusitis diagnosed by primary care (PC) or emergency medicine (EM) providers meet diagnostic criteria. METHODS: This was a retrospective cohort study. Patients were identified using administrative data from 2005 to 2006. The dataset was then clinically annotated based on chart review. We excluded prevalent cases. RESULTS: We identified 114 patients with newly diagnosed chronic sinusitis in EM (75) or PC settings (39). Rhinorrhea (EM 61%, PC 59%) and nasal obstruction (EM 67%, PC 64%) were common in both settings but facial fullness (EM 80%, PC 39%) and pain (EM 40%, PC 18%) were more common in the EM setting. Few patients reported symptoms of 90 days or longer (EM 6.0%, PC 24%) and no patient had evidence of inflammation on physical examination. A minority of patients received a sinus computed tomography (CT) scan (22.8%) or nasal endoscopy (1.8%). In total, only 1 patient diagnosed with chronic sinusitis met the diagnostic criteria. CONCLUSION: Most patients diagnosed with chronic sinusitis by non-otolaryngologists do not have the condition. Caution should be used in studying chronic sinusitis using administrative data from non-otolaryngology providers because a large proportion of the patients may not actually have the disease.

Diagnosis and treatment of acute sinusitis in the primary care setting: A retrospective cohort.

OBJECTIVES AND HYPOTHESIS: Our objectives were to characterize the quality of acute sinusitis care and to identify nonclinical factors associated with antibiotic use for acute sinusitis. We hypothesized that we would identify provider-level factors associated with antibiotic use. STUDY DESIGN: Retrospective cohort at a single academic institution. METHODS: We developed and clinically annotated an administrative dataset of adult patients diagnosed with acute sinusitis between January 1, 2005, and December 31, 2006. We used identify factors associated with receipt of antibiotics. RESULTS: We find that 66.0% of patients with mild symptoms of short duration are given antibiotics, and that nonclinical factors, including the individual provider, the provider's specialty, and the presence of a medical trainee, significantly influence antibiotic use. Relative to internal medicine providers, family medicine providers use fewer antibiotics, and emergency medicine providers use more antibiotics for acute sinusitis. CONCLUSIONS: Antibiotics continue to be overused for patients with mild acute sinusitis of short duration. Nonclinical characteristics, including the individual provider, the provider's specialty, and the presence of a medical trainee, significantly influence use of antibiotics for acute sinusitis. LEVEL OF EVIDENCE: 4.

Ultrasound shear wave elastography helps discriminate low-grade from high-grade bowel wall fibrosis in ex vivo human intestinal specimens.

OBJECTIVES: To determine whether bowel wall fibrosis can be detected in freshly resected human intestinal specimens based on ultrasound-derived shear wave speed. METHODS: Seventeen intact (>3-cm) bowel segments (15 small and 2 large intestine) from 12 patients with known or suspected inflammatory bowel disease were procured immediately after surgical resection. Ultrasound shear wave elastography of the bowel wall was performed by two methods (Virtual Touch Quantification [VTQ] and Virtual Touch-IQ [VT-IQ]; Siemens Medical Solutions USA, Inc, Mountain View, CA). Eighteen short-axis shear wave speed measurements were acquired from each specimen: 3 from the 9-, 12-, and 3-o'clock locations for each method. Imaging was performed in two areas for specimens greater than 10 cm in length (separated by ≥5 cm). A gastrointestinal pathologist scored correlative histologic slides for inflammation and fibrosis. Differences in mean shear wave speed between bowel segments with low and high inflammation/fibrosis scores were assessed by a Student t test. Receiver operating characteristic curve analysis was performed. RESULTS: High-fibrosis score (n = 11) bowel segments had a significantly greater mean shear wave speed than low-fibrosis score (n = 6) bowel segments (mean ± SD: VTQ, 1.59 ± 0.37 versus 1.18 ± 0.08 m/s; P= .004; VT-IQ, 1.87 ± 0.44 versus 1.50 ± 0.26 m/s; P= .049). There was no significant difference in mean shear wave speed between high-and low-inflammation score bowel segments (P > .05 for both VTQ and VT-IQ). Receiver operating characteristic curves showed areas under the curve of 0.91 (95% confidence interval, 0.67-0.99) for VTQ and 0.77 (95% confidence interval, 0.51-0.94) for VT-IQ in distinguishing low-from high-fibrosis score bowel segments. CONCLUSIONS: Ex vivo bowel wall shear wave speed measurements increase when transmural intestinal fibrosis is present.

Adrenal Incidentaloma triage with single-source (fast-kilovoltage switch) dual-energy CT.

OBJECTIVE: The purpose of this article is to evaluate single-source dual-energy CT (DECT) for distinguishing benign and indeterminate adrenal nodules, with attention to the effects of phase of IV contrast enhancement. MATERIALS AND METHODS: A retrospective review revealed 273 contrast-enhanced abdominal DECT examinations from November 2009 through March 2012. Fifty adrenal nodules 0.8 cm or larger were identified in 41 patients (22 women and 19 men; average age, 66 years; age range, 36-88 years). CT postprocessing and measurements were independently performed by two radiologists (readers 1 and 2) for each nodule, as follows: attenuation (in Hounsfield units) on true unenhanced images; contrast-enhanced attenuation (in Hounsfield units) on monochromatic spectral images at 40, 75, and 140 keV; and contrast-enhanced material density (in milligrams per milliliter) on virtual unenhanced images. Nodules were classified as benign (< 10 HU) and indeterminate (≥ 10 HU) according to true unenhanced images. RESULTS: Interreader agreement regarding benign and indeterminate nodules was high (κ = 0.92; 95% CI, 0.8-1.0). At 140 keV, the attenuation of benign nodules was significantly lower (reader 1, 7.0 ± 12.5 HU; reader 2, 7.8 ± 9.2 HU) than that of indeterminate nodules (reader 1, 15.7 ± 20.5 HU [p = 0.004]; reader 2, 17.5 ± 13.4 HU [p < 0.0001]). On virtual unenhanced images, benign nodules had significantly lower material density (reader 1, 992.4 ± 9.9 mg/mL; reader 2, 992.7 ± 9.6 mg/mL) than did indeterminate nodules (reader 1, 1001.1 ± 20.5 mg/mL [p = 0.038]; reader 2, 1007.6 ± 13.4 mg/mL [p < 0.0001]). CONCLUSION: DECT tools can mathematically subtract iodine or minimize its effects in high-energy reconstructions, approximating unenhanced imaging and potentially reducing the need for additional studies to triage adrenal nodules detected on contrast-enhanced DECT examinations.

Is venous foot pump effective in prevention of thromboembolic disease after joint arthroplasty: a meta-analysis.

The goal of this meta-analysis was to evaluate the efficacy of venous foot pumps in prevention of venous thromboembolism following joint arthroplasty. Using different databases, we found 13 prospective clinical trials published meeting our inclusion criteria. In total, 1514 patients were included in the final analysis. Venous foot pump devices are effective in prevention of venous thromboembolic disease after total hip and knee arthroplasty compared to chemoprophylaxis. This was especially significant in prevention of major deep vein thrombosis and pulmonary emboli rate. The use of mechanical devices like venous calf or foot pump, either alone or in combination with less potent chemical prophylaxis, on the other hand can reduce the rate of venous thromboembolism and complications of potent chemoprophylaxis like wound hematoma.

Revision total hip arthroplasty in octogenarians. A case-control study.

BACKGROUND: Revision total hip arthroplasty in the very elderly is believed to be associated with a high complication rate. We evaluated the early outcomes and prevalence of complications following revision total hip arthroplasty in patients older than eighty years of age and compared them with those in a younger patient population. METHODS: We retrospectively reviewed the results of 170 revision total hip arthroplasties that had been performed in 159 octogenarians in our institute between 1992 and 1999. The mean patient age at the time of surgery was 83.8 years, and the mean follow-up time was 6.8 years. We then compared these results with those of 170 revision total hip arthroplasties, done with the same surgical technique and prosthesis, in 162 patients who were seventy years old or younger and followed for a mean of six years. The functional outcome and the quality of life following the arthroplasties were assessed with use of the Harris hip score and the Short Form-36 (SF-36), respectively. Risk factors for complications and mortality were identified, and Kaplan-Meier analysis was used to determine survivorship. RESULTS: The octogenarians had a significant improvement in the mean Harris hip score, from 47 points preoperatively to 85 points at the time of the latest follow-up. In the control group, the Harris hip score also improved significantly, from a preoperative mean of 44.3 points to a mean of 87.9 points at the time of the latest follow-up. There was no significant difference between the two groups in the magnitude of improvement of the Harris hip score. There were 100 deaths (a rate of 58.8%) at a mean of 5.3 years postoperatively in the octogenarian group compared with twelve deaths (7.1%) in the control group (p < 0.0001). There were no intraoperative deaths in either group. Of the 100 octogenarian patients who died, 94% had a well-functioning hip at the time of death. Perioperative medical complications developed in thirty patients (thirty-eight hips [22.4%]) in the octogenarian group and in twenty-five patients (twenty-six hips [15.3%]) in the control group (p > 0.05). There were thirteen repeat revisions and four other types of reoperations in the octogenarian group and twenty-three repeat revisions and six other types of reoperations in the control group (p = 0.08). A dislocation was sustained by four patients in the octogenarian group and sixteen patients in the control group (p = 0.01). CONCLUSIONS: Revision total hip arthroplasty can provide substantial clinical benefit to patients over eighty years of age. The medical complication rate for octogenarians may not differ significantly from that for patients seventy years of age or younger, and the prevalence of technical complications and dislocations can be expected to be lower than that for younger patients.