Antibiotics for acute maxillary sinusitis.

BACKGROUND: For adults seeking care in ambulatory medical practices, sinusitis is the most common diagnosis treated with antibiotics. OBJECTIVES: We examined whether antibiotics are indicated for acute sinusitis, and if so, which antibiotic classes are most effective. SEARCH STRATEGY: Relevant studies were identified from searches of MEDLINE and EMBASE in December 2001, contacts with pharmaceutical companies and bibliographies of included studies. SELECTION CRITERIA: Randomized trials were eligible that compared antibiotic to control or antibiotics from different classes, for acute maxillary sinusitis. Additional criteria for inclusion were diagnostic confirmation by radiograph or sinus aspiration, outcomes that included clinical cure or improvement, and a sample size of 30 or more adults. Of 2058 potentially relevant studies, two or more reviewers identified 49 studies meeting selection criteria. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two persons and synthesized descriptively. Some data were analyzed quantitatively using a random effects model. Primary outcomes were: a) clinical cure, and b) clinical cure or improvement. Secondary outcomes were radiographic improvement, relapse rates, and dropouts due to adverse effects. MAIN RESULTS: Forty-nine trials, involving 13,660 participants, evaluated antibiotic treatment for acute maxillary sinusitis. Major comparisons were antibiotic versus control (n of 5); newer, non-penicillin antibiotic versus penicillin class (n of 10); and amoxicillin-clavulanate versus other extended spectrum antibiotics (n of 17), where n is the number of trials. Most trials were conducted in otolaryngology settings. Only 8 trials described adequate allocation and concealment procedures; 20 were double-blind. Compared to control, penicillin improved clinical cures [relative risk (RR) 1.72; 95% CI 1.00 to 2.96]. Treatment with amoxicillin did not significantly improve cure rates (RR 2.06; 95% CI 0.65 to 6.53) but there was significant variability between studies. Radiographic outcomes were improved by antibiotic treatment. Comparisons between classes of antibiotics showed no significant differences: newer non-penicillins versus penicillins (RR for cure 1.07; 95% CI 0.99 to 1.17); newer non-penicillins versus amoxicillin-clavulanate (RR for cure 1.03; 95% CI 0.96 to 1.11). Compared to amoxicillin-clavulanate, dropouts due to adverse effects were significantly lower for cephalosporin antibiotics (RR 0.47; 95% CI 0.30 to 0.73). Relapse rates within one month of successful therapy were 7.7%. REVIEWER'S CONCLUSIONS: For acute maxillary sinusitis confirmed radiographically or by aspiration, current evidence is limited but supports the use of penicillin or amoxicillin for 7 to 14 days. Clinicians should weigh the moderate benefits of antibiotic treatment against the potential for adverse effects.

Antibiotics for acute maxillary sinusitis.

OBJECTIVES: For adults seeking care in ambulatory practices, sinusitis is the most common diagnosis treated with antibiotics. We examined whether antibiotics are indicated for acute sinusitis, and if so, which antibiotic classes are most effective. SEARCH STRATEGY: Relevant studies were identified from searches of MEDLINE and EMBASE in October 1998, contacts with pharmaceutical companies and bibliographies of included studies. SELECTION CRITERIA: Randomized trials were eligible that compared antibiotic to control or antibiotics from different classes for acute maxillary sinusitis. Additional criteria were diagnostic confirmation by radiograph or sinus aspiration, outcomes that included clinical cure or improvement and a sample size of 30 or more adults. Of 1784 potentially relevant studies, two or more reviewers identified 32 studies meeting selection criteria. DATA COLLECTION AND ANALYSIS: Data were abstracted independently by 2 persons and synthesized descriptively. Some data were analyzed quantitatively using a random effects model. Primary outcomes were a) clinical cure and b) clinical cure or improvement. Secondary outcomes were radiographic improvement, relapse rates, and dropouts due to adverse effects. MAIN RESULTS: Thirty-two trials, involving 7,330 subjects evaluated antibiotic treatment for acute maxillary sinusitis. Major comparisons were antibiotic vs. control (n=5); newer, non-penicillin antibiotic vs. penicillin class (n=10); and amoxicillin-clavulanate vs. other extended spectrum antibiotics (n=10). Most trials were conducted in otolaryngology settings. Only 5 trials described adequate allocation and concealment procedures; 10 were double-blind. Compared to control, penicillin improved clinical cures [relative risk (RR) 1.72, 95% CI 1.00 to 2.96]. Treatment with amoxicillin did not significantly improve cure rates (RR 2.06; 95% CI 0.65 to 6.53), but there was significant variability between studies. Radiographic outcomes were improved by antibiotic treatment. Comparisons between classes of antibiotics showed no significant differences: newer non-penicillins vs. penicillins (RR for cure 1.07; 95% CI 0.99 to 1.17); newer non-penicillins vs. amoxicillin-clavulanate (RR for cure 1.01, 95% CI 0.97 to 1.04). Compared to amoxicillin-clavulanate, dropouts due to adverse effects were significantly lower for cephalosporin antibiotics. Relapse rates within one month of successful therapy were 5%. REVIEWER'S CONCLUSIONS: For acute maxillary sinusitis confirmed radiographically or by aspiration, current evidence is limited but supports penicillin or amoxicillin for 7 to 14 days. Clinicians should weigh the moderate benefits of antibiotic treatment against the potential for adverse effects.

Gallstone size and risk of pancreatitis.

BACKGROUND: The treatment of patients with gallstones who have suffered a first episode of acute biliary pain is controversial. Recent guidelines suggest that such patients may choose to observe the "pattern" of their pain over time before deciding about therapy. OBJECTIVE: To determine clinical factors that would identify patients at high risk for 2 important complications: acute biliary pancreatitis and acute cholecystitis. METHODS: We collected sociodemographic and clinical data on patients undergoing cholecystectomy after acute biliary pancreatitis, acute cholecystitis, or uncomplicated biliary pain. The physical characteristics of gallstones recovered at surgery were also recorded. Patients with pancreatitis and patients with cholecystitis were compared with patients with uncomplicated pain. RESULTS: In univariate analyses, patients with acute pancreatitis were significantly more likely to have at least 1 gallstone smaller than 5 mm in diameter, 20 or more gallstones, gallstones described as mulberry shaped, and a lower total gallstone weight than patients with uncomplicated pain. Pancreatitis was unrelated to patient age, sex, race or ethnicity, use of alcohol or tobacco, or clinical comorbidity. In a logistic regression model, acute pancreatitis was associated with a stone diameter of less than 5 mm (odds ratio, 4.51; P = .007) and with mulberry-shaped gallstones (odds ratio, 2.25; P = .04). No sociodemographic, clinical, or gallstone characteristics were consistently associated with acute cholecystitis. CONCLUSIONS: Patients with at least 1 gallstone smaller than 5 mm in diameter have a more than 4-fold increased risk of presenting with acute biliary pancreatitis. A policy of watchful waiting in such cases is unwarranted.

Quantitative assessments from the clinical examination. How should clinicians integrate the numerous results?

OBJECTIVE: To describe strategies for using multiple clinical examination items to estimate disease probabilities; and to evaluate the diagnostic accuracy of each strategy. DESIGN: Prospective observational study. SETTING: Medical preoperative evaluation clinic at a university-affiliated Veterans Affairs Medical Center. PATIENTS: Previously reported consecutive series of patients referred for outpatient medical preoperative risk assessment. MEASUREMENTS AND MAIN RESULTS: Pulmonary clinical examination and spirometry were the measurements. A strategy of using likelihood ratios (LRs) from seven clinical examination items was least accurate (p < .0001). Three alternative strategies were equivalent in diagnostic accuracy (p > or = .2): (1) using the single best clinical examination item and its LR, (2) using the LRs from three clinical examination items chosen by logistic regression, and (3) using the adjusted LRs chosen in strategy 2. When compared with using LRs from all seven items, the strategies of using three LRs chosen by logistic regression or using adjusted likelihood ratios better discriminated patients with airflow limitation from those without (receiver operating characteristic [ROC] areas 0.79 vs 0.69; p = .02). Using the single best clinical finding did not statistically degrade the clinical examination's discriminating ability (ROC areas 0.79 vs 0.75; p = .20). CONCLUSIONS: Describing the rational clinical examination requires evaluating conditional independence of examination components. Conditional independence assumptions were violated when seven clinical examination items were used to estimate posterior probability of airflow limitation. Focusing on clinical examination items identified through logistic models overcame violations of independence; further statistical adjustment did not improve diagnostic accuracy. Clinicians can use the single most predictive clinical examination finding to avoid inaccuracy from violating the independence assumption.

Predicting daily visits to a walk-in clinic and emergency department using calendar and weather data.

We studied the association between calendar and weather variables and daily unscheduled patient volume in a walk-in clinic and emergency department. Calendar variables (season, week of month, day of week, holidays, and federal check-delivery days) and weather variables (high temperature and snowfall) forecasted clinic volume, explaining 84% of daily variance and 44% of weekday variance. Staffing according to predicted volume could have decreased overstaffing from 59% to 15% of days, but would have increased understaffing from 2% to 18% of days. Models using calendar and weather data that forecast local utilization may help to schedule staffing for walk-in clinics and emergency departments more efficiently.

Clinical correlates of gallstone composition: distinguishing pigment from cholesterol stones.

OBJECTIVES: The prevalence of cholelithiasis has been established in population-based surveys employing ultrasonography, and major risk factors have been identified. However, the clinical and epidemiological features that distinguish patients with pigment gallstones from those with cholesterol stones have received little attention. METHODS: We prospectively surveyed 551 patients undergoing cholecystectomy for gallstones at two teaching hospitals. Clinical and epidemiological data were collected during patient interviews and by chart review. Gallstones were collected at surgery; physical measurements were recorded, and stone composition was determined by visual inspection and infrared spectroscopy. RESULTS: Patients with pigment stones were older than patients with cholesterol stones (p < 0.00001). Almost all patients under age 40 yr old had cholesterol stones, but most patients over 70 had pigment stones. Cirrhosis was strongly associated with pigment gallstones (p < 0.00001), although alcohol consumption was unrelated. Univariate analyses suggested associations of stone composition with male sex, diabetes mellitus, educational attainment, and use of thiazides or oral contraceptives, but these were not significant in a logistic regression that adjusted for age, cirrhosis, and other variables. Patients with pigment cholelithiasis had stones that were generally smaller in diameter and fewer in number than those with cholesterol stones. CONCLUSIONS: Compared to patients with cholesterol gallstones, those with pigment stones are older and more likely to have a diagnosis of cirrhosis. In addition, their stones are smaller in size and fewer in number than those from patients with cholesterol cholelithiasis.

Measuring shoulder function with the Shoulder Pain and Disability Index.

OBJECTIVE: To extend the validity of the Shoulder Pain and Disability Index (SPADI) by (1) making it suitable for telephone administration; (2) determining its convergent validity with other health status measures; and (3) assessing the responsiveness of the SPADI to clinical change. METHODS: Consecutive primary care patients with shoulder discomfort were followed for 3 months. At enrollment, a detailed shoulder specific history was obtained by a trained research assistant, and the Health Assessment Questionnaire (HAQ), the Medical Outcomes Study SF-20 (SF-20), and numeric and visual analog versions of the SPADI were completed by the patient. At 2, 4, and 12 weeks the numeric scaled SPADI was administered by telephone and patients rated globally the change in shoulder discomfort. RESULTS: One hundred and two subjects were enrolled; 96 completed at least one followup assessment and 75 completed all followup assessments. Subjects were men (98%), predominantly white (73%), with a median age of 60 years, and the majority had experienced shoulder discomfort for > 3 months (66%). At baseline the visual analog (VAS) and numeric scaled SPADI were highly concordant (intraclass correlation coefficient = 0.86), and the SPADI correlated substantially with the HAQ (r = 0.61) and the physical functioning (r = -0.50) and pain (r = -0.43) domains of the SF-20. The SPADI delta (baseline-followup) discriminated accurately between subjects who improved versus those who stayed the same or worsened [receiver operating characteristic cure, (ROC) = 0.91, likelihood ratio for improvement = 34]. CONCLUSION: The numerically scaled SPADI is highly correlated with the original VAS version of the SPADI and other measures of health status. The SPADI is responsive to change and accurately discriminates among patients who are improved or worsened.

Randomized controlled trial of 3 vs 10 days of trimethoprim/sulfamethoxazole for acute maxillary sinusitis.

OBJECTIVE: To compare 14-day outcomes and relapse and recurrence rates among patients with acute maxillary sinusitis randomized to 3-day (3D) vs 10-day (10D) treatment with trimethoprim/sulfamethoxazole (TMP/SMX). SETTING: University-affiliated Veterans Affairs general medical and acute care clinics. PATIENTS: Consecutive patients with sinus symptoms and radiographic evidence of maxillary sinusitis (complete opacity, air-fluid level, or > or = 6 mm of mucosal thickening). Patients were excluded for antibiotic use within the past week, TMP/SMX allergy, symptoms for more than 30 days, or previous sinus surgery. METHODS: All subjects (n = 80) received oxymetazoline nasal spray 0.05%, two sprays twice daily for 3 days. Subjects were randomly assigned to TMP/SMX double strength: one tablet twice daily for 10 days or one tablet twice daily for 3 days followed by 7 days of placebo. At 7 and 14 days, patients rated their overall sinus symptoms on a Likert scale. Radiographs were scored at baseline and 14 days by radiologists masked to clinical symptoms and treatment assignment. The primary outcome was number of days to "cure" or "much improvement" in sinus symptoms. Patients who were clinical successes by day 14 were assessed for symptomatic relapse or recurrence at 30 and 60 days, respectively. RESULTS: Groups were comparable at randomization: male, 100%; black, 53%; median age, 48 years (interquartile range, 41 to 63 years); symptom duration, 10 days (interquartile range, 6 to 17 days); bilateral maxillary disease, 51%; and radiograph score, 4 (interquartile range, 2 to 4). Outcome assessment was completed in 95% of patients at day 14 (n = 76). Medication side effects and use of nonstudy sinus medications were equal between groups. By 14 days, 77% of 3D subjects and 76% of 10D subjects rated their sinus symptoms as cured or much improved (95% confidence interval for difference, -15% to 17%). Median days to cure/much improvement were 5.0 and 4.5 for the 3D and 10D groups, respectively; distributions of time to cure were not different (P = .34). Radiograph scores improved in both groups compared with baseline (2 points; P < .001), but improvement did not differ between groups (P = .31). Eight percent of 3D subjects and 13% of 10D subjects missed work due to sinus symptoms. Of the 52 patients who were clinical successes at 14 days and completed follow-up, three (11%) of 27 3D subjects and one (4%) of 25 10D subjects relapsed symptomatically by day 30; one (4%) of 27 3D subjects and one (4%) of 25 10D subjects suffered symptomatic recurrence between days 30 and 60 (P = .45 for the relapse and recurrence rates combined). CONCLUSION: At the 2-week follow-up, clinical symptoms and radiograph scores improved equally following 3 or 10 days of TMP/SMX plus oxymetazoline nasal spray. Symptomatic relapse and recurrence were similar between groups. Three days of antibiotics were as effective as 10 days and, because of the high disease prevalence, hold the potential for substantial cost savings.

Usual care and outcomes in patients with sinus complaints and normal results of sinus roentgenography.

OBJECTIVE: To describe the usual care and outcomes of patients with sinus symptoms and normal sinus roentgenograms. DESIGN: Prospective cohort with 60-day follow-up. SETTING: Medical outpatient clinics at a university-affiliated Veterans Affairs medical center. PATIENTS: Consecutive patients (n = 126, 88% follow-up rate) with rhinorrhea (88%), facial pain (65%), or self-suspected sinusitis (24%) and normal four-view sinus roentgenography (median age, 47 years; 90% male; 56% white). MAIN OUTCOME MEASURE: Fourteen-day self-reported symptom status. RESULTS: Sixteen history and five physical examination items were recorded by clinicians who were blinded to the results of sinus roentgenography; clinical diagnoses and treatment plans were formulated by clinicians with knowledge of the results of sinus roentgenography. Clinical diagnoses included allergic rhinitis (27%), sinusitis (22%), viral respiratory tract infection (14%), and bronchitis (11%). Treatments included administration of antibiotics (40%), decongestants (32%), antihistamines (25%), and nasal steroids (9%). Forty-nine percent achieved 14-day clinical success (13.5% were cured and 36% were much improved). Improvement was more likely among patients who presented with cough (odds ratio, 3.0; 95% confidence interval, 1.3 to 6.9) but was less likely among those with itchy eyes (odds ratio, 0.18; 95% confidence interval, 0.07 to 0.43). Patients with cough and without itchy eyes had significantly shorter clinical courses (P = .003). Of patients who achieved clinical success on day 14, 30% relapsed or recurred by day 60. CONCLUSION: With usual medical care, the syndrome of sinus symptoms and normal results of sinus roentgenography persists for at least 14 days in many patients; however, patients with cough but without itchy eyes may have shorter clinical courses.

Gallstone characteristics in Mexican Americans and non-Hispanic whites.

Mexican Americans have an elevated risk of gallstones. Their increased rates may be due to genetic admixture with Native Americans, who have extremely high prevalences of cholelithiasis. Native Americans are believed to have almost exclusively cholesterol stones, whereas only 73% of non-Hispanics are reported to have such stones. Hence we hypothesized that Mexican Americans would have a higher proportion of cholesterol stones than would non-Hispanic whites. We interviewed 398 Mexican Americans and 93 non-Hispanic whites undergoing cholecystectomy and analyzed the composition of their gallstones. Mexican Americans were younger than non-Hispanic whites (P < 0.05). However, the age-sex standardized proportion of cholesterol stones was 89.7% in Mexican Americans and 87.2% in non-Hispanic whites. We conclude that Mexican Americans and non-Hispanic whites have gallstones of similar composition. The higher stone prevalence of Mexican Americans may be due to factors that predispose to both cholesterol and pigment stones.

Resident recognition of open-angle glaucoma: effects of an educational intervention.

To test an educational intervention's effect on improving detection of glaucoma by direct ophthalmoscopy, 14 medicine residents examined five patients, two with ophthalmoscopic changes of glaucoma and three with normal fundi. The residents observed a standardized slide/narrative educational intervention reviewing glaucomatous ophthalmoscopic changes and then re-examined the same patients eight to 12 weeks later. The intervention's odds of improving residents' diagnostic impression were significant (OR = 2.2; 95% CI = 1.3-3.6), with significant improvement in sensitivity (p = 0.02) and a trend toward improved specificity. These findings confirm that the diagnosis of glaucomatous ocular changes on eye examinations by medicine residents can be improved with a brief educational intervention.

The effect of sleeved arms on oscillometric blood pressure measurement.

The authors measured the blood pressures of 36 subjects who had bare and sleeved arms to determine the effect of wearing sleeves on automatic oscillometric blood pressure measurements. They found no statistically significant effect of sleeves on the measurement of either systolic or diastolic blood pressure (p > 0.15). However, based on confidence intervals of possible sleeve effects, the authors recommend repeating blood pressure measurements on bared arms when the sleeved-arm oscillometric measurements are at least 86 mm Hg diastolic or 135 mm Hg systolic.

Diagnosis of obstructive airways disease from the clinical examination.

OBJECTIVE: To determine the operating characteristics of history and physical examination items for pulmonary airflow obstruction. DESIGN: Prospective observational study. SETTING: Medical Preoperative Evaluation Clinic at the Durham Veterans Affairs Medical Center. PATIENTS/PARTICIPANTS: Consecutive patients referred for outpatient medical preoperative risk assessment. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Number of years the patient had smoked cigarettes, patient-reported wheezing [LR+ (likelihood ratio for finding present) = 3.1; LR- (likelihood ratio for finding absent) = 0.58], and auscultated wheezing (LR+ = 12; LR- = 0.87) were independent predictors of obstructive airways disease from the history and physical examination. Forced expiratory time and peak expiratory flow rate, both measured by the clinician at the bedside, were additional independent predictors of airflow obstruction. A nomogram using patient-reported wheezing, number of years the patient had smoked, and auscultated wheezing was developed and validated (area under receiver operating characteristic curve = 0.78; p = 0.0001) for the bedside prediction of obstructive airways disease. Peak expiratory flow rate can be substituted for auscultated wheezing with similar predictive ability. CONCLUSIONS: The results of bedside clinical examinations predict the presence of obstructive airways disease. A nomogram based on a combination of four bedside findings predicts airflow obstruction as well as clinicians' overall clinical impressions.