Henrik Schmidt

Predicting acute maxillary sinusitis in a general practice population

Abstract Objective: To evaluate the diagnostic value of symptoms, signs, erythrocyte sedimentation rate, and C reactive protein for acute maxillary sinusitis. Design: Prospective cohort study. Setting: Danish general practice in cooperation with the otorhinolaryngology and neuroradiology department at Aalborg County Hospital. Subjects: 174 patients aged 18-65 years who were suspected by the general practitioner of having acute maxillary sinusitis. >Main outcome measure: The independent association of symptoms, signs, erythrocyte sedimentation rate, and concentration of C reactive protein in patients with acute maxillary sinusitis defined as purulent or mucopurulent antral aspirate. Results: Only raised erythrocyte sedimentation rate (P=0.01) and raised C reactive protein (P=0.007) were found to be independently associated with a diagnosis of acute maxillary sinusitis. The combination of the two variables had a sensitivity of 0.82 and a specificity of 0.57. Conclusion: Erythrocyte sedimentation rate and C reactive protein are useful diagnostic criteria for acute maxillary sinusitis.

Randomised, double blind, placebo controlled trial of penicillin V in the treatment of acute maxillary sinusitis in adults in general practice

Objective - To compare the effectiveness of penicillin V with placebo in the treatment of adult patients with acute maxillary sinusitis in general practice. Design - Randomised, double blind, placebo controlled trial. Setting - 26 Danish general practices. Patients - 133 adult patients with a clinical diagnosis of acute maxillary sinusitis based on maxillary pain and raised values of either C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR). Main outcome measures - Pain score and illness score as well as measurement of CRP and ESR values after initiation of treatment. Results - Penicillin V led to a better recovery than did placebo. The difference was statistically significant 3 days after the initiation of treatment with regard to pain reduction, whereas no significant difference was found with regard to the reduction in the sense of illness. At the end of the study, significantly more patients in the penicillin group were completely free of pain compared to the placebo group. This difference was only found in patients with an initial pain score of more than three. The cure rate was 71% in the penicillin group and 37% in the placebo group. Significantly more patients achieved normal CRP values when treated with penicillin (88%) as opposed to placebo (75%). Conclusion - Penicillin V is more effective than placebo in the treatment of acute maxillary sinusitis in adults in general practice, but only in patients with pronounced pain.OBJECTIVE To compare the effectiveness of penicillin V with placebo in the treatment of adult patients with acute maxillary sinusitis in general practice. DESIGN Randomised, double blind, placebo controlled trial. SETTING 26 Danish general practices. PATIENTS 133 adult patients with a clinical diagnosis of acute maxillary sinusitis based on maxillary pain and raised values of either C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR). MAIN OUTCOME MEASURES Pain score and illness score as well as measurement of CRP and ESR values after initiation of treatment. RESULTS Penicillin V led to a better recovery than did placebo. The difference was statistically significant 3 days after the initiation of treatment with regard to pain reduction, whereas no significant difference was found with regard to the reduction in the sense of illness. At the end of the study, significantly more patients in the penicillin group were completely free of pain compared to the placebo group. This difference was only found in patients with an initial pain score of more than three. The cure rate was 71% in the penicillin group and 37% in the placebo group. Significantly more patients achieved normal CRP values when treated with penicillin (88%) as opposed to placebo (75%). CONCLUSION Penicillin V is more effective than placebo in the treatment of acute maxillary sinusitis in adults in general practice, but only in patients with pronounced pain.

A wet smear criterion for bacterial vaginosis

OBJECTIVE To evaluate a simpler criterion for bacterial vaginosis than the recommended criterion of Amsel. DESIGN Cross-sectional study comparing diagnostic data with a recommended standard. SETTING Danish general practice. PARTICIPANTS 595 non-pregnant women aged 15-49 years who were gynaecologically examined, were divided into two groups in accordance with a complaint of vaginal discharge. MAIN OUTCOME MEASURE The associations of pH > 4.5, homogeneity, amine odour, clue cells, and wet smear assessment of predominance of lactobacilli, Gardnerella vaginalis, motile rods with the criterion of Amsel. RESULTS The four components of Amsel showed a considerable variation of association. Predominance of GV was more highly associated than several of the components. The association of a wet smear criterion composed of the presence of clue cells in combination with predominance of Gardnerella vaginalis and absence of lactobacilli was superior to other combinations. In the group without a complaint of vaginal discharge, preceding screening with use of a pH-measurement seemed advantageous. CONCLUSION The wet smear criterion seems suitable for use in general practice. But before a definitive establishment, calculation of the reproducibility of interpretation of this criterion, preferably with a more explicit setting of the components, has to be carried out.

Obstructive Ventilatory Impairment An investigation in general practice

We estimated the prevalence of obstructive ventilatory impairment and its relationship to sex, age, chronic bronchitis, asthma, and smoking in a cross-sectional epidemiological study. The population consisted of 3119 persons greater than or equal to 16 years listed as patients in our general practice. From this group, 2740 (88%) underwent dynamic spirometry (Vitalograph). The main results showed a high prevalence of obstruction. 26% had MMEF values less than 75%, 8% FEV-1 less than 75% and 5% FEV-1/FVC less than 65%. Obstruction was significantly correlated with old age, chronic bronchitis, asthma, and smoking.

Microbiology of Vaginal Discharge in General Practice

Three groups of women were examined by culture for Gardnerella vaginalis and Candida. Group I consisted of 427 women, who complained spontaneously of vaginal discharge, group II of 311 women who did not complain of vaginal discharge until questioned prior to gynaecological examination, and group III of 100 women who denied vaginal discharge. Groups I and II also had cultures made for Trichomonas vaginalis and Neisseria gonorrhoica. In group I with spontaneous complaints the one-year prevalence rate of vaginal discharge was 3.4%. Candida, Trichomonas vaginalis and Neisseria gonorrhoica were cultured in 24%, 8% and 1% respectively. Gardnerella vaginalis was cultured in half of the women in all groups. A characteristic discharge or a positive microscopic finding was related to high concentration of Gardnerella vaginalis. A characteristic discharge even without spontaneous complaints of vaginal discharge was related to a high prevalence of Gardnerella vaginalis. Women complaining from discharge had higher concentrations of Gardnerella vaginalis than non-complaining. This leads to the conclusion that clinical disease may not be present unless concentrations of Gardnerella vaginalis have risen above some minimum level. The Gardnerella vaginalis syndrome defined by positive culture, clinical finding and microscopy was found in 20% of symptomatic women.

Treatment of Bacterial Vaginosis with Metronidazole or Pivampicillin

In a double-blind randomized controlled trial from general practice, we assessed the efficacy of treatment with either metronidazole or pivampicillin in patients fulfilling the diagnostic criteria of bacterial vaginosis. 50 women were treated with metronidazole 500 mg twice daily and 54 with pivampicillin 700 mg twice daily, both for seven days. Evaluated four weeks after the start of treatment, we found a significantly higher cure rate in the metronidazole group (90%) than in the pivampicillin group (69%) (p = 0.01). Cure was defined as lack of fulfillment of the diagnostic criteria of bacterial vaginosis. Test for confounding according to parity and complaint of vaginal discharge showed no influence. Side-effects were significantly commoner in the pivampicillin group (28%) than in the metronidazole group (8%). We consider that metronidazole is a potent drug in the treatment of bacterial vaginosis, with pivampicillin as a useful alternative.

Diagnostic value of clinical examination, direct microscopy, and culture in the Gardnerella vaginalis syndrome.

In a general practice 467 women aged 15-49 years with vaginal discharge were consecutively examined in order to compare the diagnostic value in the Gardnerella vaginalis syndrome of the clinical examination, direct microscopy of the vaginal secretion, and culture. We found significant correlations between all relevant combinations of the diagnostic methods. The predictive value of a positive test for the clinical examination, the microscopy, and the clinical examination combined with microscopy, respectively, was 0.75, 0.89 and 0.90, whereas the predictive values of the negative test were 0.59, 0.72 and 0.61, respectively. Because even small numbers of Gardnerella vaginalis may yield growth on selective culture media, the clinical examination and the microscopy are often negative despite positive culture. To avoid overtreatment of a benign condition we therefore conclude that the presence of a characteristic clinical picture and positive microscopy constitute a safe basis for the diagnosis of the Gardnerella vaginalis syndrome, and that the diagnosis should be based on this combination or on the fulfilment of three of the following four criteria: 1) characteristic vaginal secretion; 2) vaginal pH greater than 4.5; 3) positive potassium hydroxide test or characteristic herring-brine smell, and 4) clue cells at microscopy. With the present methods culture for Gardnerella vaginalis should not routinely be performed, until the value of quantitated methods has been proved. Coexistence of other microorganisms rendered the diagnosis difficult. We recommend to treat the most predominant infection first.

Vaginal Discharge and Gardnerella Vaginalis Predisposing Factors

A total of 284 women in the reproductive years with vaginal discharge from which only Gardnerella vaginalis (GV) had been isolated, entered a questionnaire study on the possible causal relation between presence of GV and type of menstrual hygiene, type of contraception, number of deliveries, infertility and number of sexual partners. A control group consisted of 225 women without vaginal discharge. The study showed that patients with GV significantly more frequently used tampons for menstrual hygiene, sought medical assistance for vaginal discharge more often, and had more sexual partners. On the other hand, no difference was found between the two groups as to type of contraception, number of previous deliveries, and unsuccessful attempts of getting pregnant.

Treatment of the Gardnerella Vaginalis Syndrome: A Controlled, Double-blind Study Comparing Pivampicillin and Metronidazole

A double-blind, randomized, therapeutic study was carried out in 289 patients with vaginal discharge and growth of Gardnerella vaginalis (GV) and no growth of Neisseria gonorrhoeae, Trichomonas vaginalis or Candida. Treatment consisted of either pivampicillin (Pondocillin), 700 mg twice daily for seven days, or metronidazole, 500 mg twice daily for seven days. The effect was evaluated on the basis of the patients statement and on the result of culture for GV immediately after end of treatment. Evaluated from the culture results metronidazole was significantly more effective than pivampicillin in eradicating GV. The efficacy of the two medications was 69% and 54%, respectively. The evaluations by the patients in the two groups, on the other hand, did not differ significantly, although there was a tendency to consider metronidazole as the most effective. Metronidazole must be considered the most potent drug today, and we recommend it as the medication of choice, provided that the diagnosis is confirmed by the clinical picture and microscopy and not only by culture.

Single Practice Research

Research in general practice is often considered as a task of many practices working together. However, it is important to retain the individual practitioner or practice as a fundamental research resource in order to make sure that problems emanating from the daily work of the general practitioner can be dealt with in a scientific way. This upholds the direct character of research questions and stimulates practitioners to identify themselves as independent researchers.