M.P. Springer

Antimicrobial treatment in acute maxillary sinusitis: A meta-analysis

OBJECTIVE The aims of this study were to assess which antibiotic is most effective in the treatment of acute maxillary sinusitis in otherwise healthy adults and adolescents, and which has the fewest side effects. DESIGN To assess the short-term effects of antimicrobial treatments, a meta-analysis was performed using Mantel-Haenszel procedures on 16 comparative, randomized studies with a total number of 3358 patients. No placebo-controlled studies were available. Antimicrobial treatments were categorized according to type, spectrum, beta-lactamase inhibition, and bactericidal effect. Outcomes were clinical cure, clinical success, and adverse events. RESULTS When studies were analyzed separately, we found significant differences between cefpodoxim and cefaclor in relation to clinical cure, and between loracarbef and doxycycline in relation to clinical success. When data was pooled, sulphonamides were significantly more effective than penicillins in relation to clinical cure, and macrolids were more effective than penicillins in relation to clinical success, whereas cephalosporins caused significantly less adverse events than penicillins. When studies were stratified (standard classic meta-analysis), antibiotics with beta-lactamase inhibition offered significantly more clinical cures than antibiotics without beta-lactamase inhibition. However, this significant effect was only due to one study from Southern Europe, published before 1991. CONCLUSION Differences in outcome between antimicrobial treatments of acute sinusitis in otherwise healthy adults and adolescents appear to be small. Therefore, the cheapest antimicrobial treatment can be selected.

Identifying asthma and chronic obstructive pulmonary disease in patients with persistent cough presenting to general practitioners: descriptive study

Abstract Objective: To determine the prevalence of asthma and chronic obstructive pulmonary disease in patients not known to have these disorders, who present in general practice with persistent cough, and to ascertain criteria to help general practitioners in diagnosis. Design: Descriptive study. Setting: Primary healthcare centre in the Netherlands. Subjects: 192 patients aged 18-75 years, not known to have asthma or chronic obstructive pulmonary disease, attending their general practitioner with cough persisting for at least 2 weeks. Methods: A diagnosis of asthma or chronic obstructive pulmonary disease was based on the recurrence of airway symptoms in the past year accompanied by spirometric measurements (including bronchodilator testing) and methacholine provocation tests. A scoring formula to estimate the probability of asthma or chronic obstructive pulmonary disease, based on history and physical examination, was generated by means of logistic regression. Results: 74 patients (39%) were classified as having asthma, 14 (7%) as having chronic obstructive pulmonary disease. The best formula for predicting asthma or chronic obstructive pulmonary disease used scores for three symptoms: (reported) wheeze,(reported) dyspnoea, and allergen induced symptoms, together with prolonged expiration, pack years of smoking, and female sex. Variables were scored 1 when present and 0 when absent, except for allergen induced symptoms (1.5) and number of pack years of smoking (n/25). With a cut off value of 3 on the scoring formula, 76% of the patients could be classified correctly. Conclusions: About half of patients with persistent cough who present to a general practitioner have asthma or chronic obstructive pulmonary disease. With a simple formula based on three symptoms and prolonged expiration, pack years of smoking, and female sex, most patients may be identified correctly in general practice. Key messages Nearly half the patients attending a general practitioner with persistent cough show features of asthma or chronic obstructive pulmonary disease (significant bronchodilator response, airway obstruction, or hyperresponsiveness) Most cases can be identified through history taking and physical examination only The key variables to predict which patients are likely to have asthma or chronic obstructive pulmonary disease are: current wheeze and dyspnoea, symptoms elicited by allergens, prolonged expiration, cumulative smoking, and female sex The scoring formula composed of the key variables may help to determine when it is necessary to perform pulmonary function testing to confirm or reject a diagnosis of asthma or chronic obstructive pulmonary disease

Can peak expiratory flow measurements reliably identify the presence of airway obstruction and bronchodilator response as assessed by FEV1 in primary care patients presenting with a persistent cough

BACKGROUND In general practice airway obstruction and the bronchodilator response are usually assessed using peak expiratory flow (PEF) measurements. A study was carried out in patients presenting with persistent cough to investigate to what extent PEF measurements are reliable when compared with tests using forced expiratory volume in one second (FEV1) as the measure of response. METHODS Data (questionnaire, physical examination, spirometry, PEF) were collected from 240 patients aged 18–75 years, not previously diagnosed with asthma or chronic obstructive pulmonary disease (COPD), who consulted their general practitioner with cough of at least two weeks duration. The relationship between low PEF (PEF < PEFpred − 1.64RSD) and low FEV1 (FEV1 < FEV1pred − 1.64RSD) was tested. A positive bronchodilator response after inhaling 400 μg salbutamol was defined as an increase in FEV1 of ⩾9% predicted and was compared with an absolute increase in PEF with cut off values of 40, 60, and 80 l/min and ΔPEF % baseline with cut off values of 10%, 15%, and 20%. RESULTS Forty eight patients (20%) had low FEV1, 86 (35.8%) had low PEF, and 32 (13.3%) had a positive bronchodilator response. Low PEF had a positive predictive value (PPV) for low FEV1 of 46.5% and a negative predictive value (NPV) of 95%. ΔPEF of ⩾10%, ⩾15%, or ⩾20% baseline had PPVs of 36%, 52%, and 67%, respectively, and ΔPEF of ⩾40, ⩾60, and ⩾80 l/min in absolute terms had PPVs of 39%, 45%, and 57%, respectively, for ΔFEV1 ⩾9% predicted; NPVs were high (88–93%). CONCLUSIONS Although PEF measurements can reliably exclude airway obstruction and bronchodilator response, they are not suitable for use in the assessment of the bronchodilator response in the diagnostic work up of primary care patients with persistent cough. The clinical value of PEF measurements in the diagnosis of reversible obstructive airway disease should therefore be re-evaluated.

Sensitivity and specificity of diagnostic tests in acute maxillary sinusitis determined by maximum likelihood in the absence of an external standard.

This study shows how to obtain maximum likelihood estimates of test sensitivities and specificities in case of lack of an external standard, using the Expectation Maximisation (EM) algorithm. This method is used to compare four diagnostic tests in patients suspected of acute maxillary sinusitis. Data were analyzed from published studies. Antral aspiration is the test with the highest diagnostic value. The diagnostic value of a positive clinical examination (according to explicit criteria) and of a positive radiograph or ultrasound are comparable. A negative radiograph is of more diagnostic value than a negative clinical examination or ultrasound. The width of the confidence intervals may be too small, due to model deviations which may give incorrect standard errors. However, the estimated likelihood ratios adequately reflect the relative value of the diagnostic tests considered, even when the assumption of independence is dropped.

Value of measuring diurnal peak flow variability in the recognition of asthma: a study in general practice

In this study we analysed the value of measuring diurnal peak flow variability (DPV) in general practice for diagnosing asthma or chronic obstructive pulmonary disease (COPD). One hundred and eighty-two subjects, aged 18-75 yrs, with undiagnosed asthma or COPD, presenting with a persistent cough recorded a peak flow diary twice daily for 2 weeks. A diagnosis of asthma or COPD was based on the recurrence of airway symptoms in the past year accompanied by spirometric measurements and a provocative dose of methacholine causing a 20% fall in forced expiratory volume in one second. DPV was expressed as amplitude percentage highest of the day. Cut-off values of 15% and 20% (DPV15%, DPV20%) were employed and the number of days that these values were reached, was assessed. The influence of age, sex and pack-years smoking on DPV was analysed by logistic regression. The a priori probability to have asthma (n=69) or COPD (n=12) was 45% (81/182) and increased to >70% with a DPV20% for at least 3, and a DPV15% for at least 4 days. Scoring formulas for asthma (DPV15% (number of days present) + 4 (if female sex)) and for asthma and COPD combined (8x DPV15% (number of days present) + 24 (if female sex) + pack-years smoking) predicted which subjects were at risk for having asthma (or COPD). Simple formulas based on the number of days with diurnal peak flow variability at 15%, female sex and pack-years can predict which patients with persistent cough are likely to have asthma or chronic obstructive pulmonary disease.

Screening for hearing and visual loss among elderly with questionnaires and tests: which method is the most convincing for action?

Objective - To examine the extent to which self-report and performance-based measures identify the same people, and also whether one of these methods any more than the other induces the general practitioner (GP) to offer a patient help? Design - Comparison of tests and questionnaire in a screening programme for hearing and visual loss. Setting - Twelve general practices in the western part of The Netherlands. Patients - 1121 people 75 years of age and older. Main outcome measures - Hearing loss according to the whispered voice test and two questions (Q1, Q2) and visual loss according to the Snellen and low vision charts and two questions (Q3, Q4). The extent to which test and questions influence the GPs judgment regarding intervention is calculated using logistic regression. Results ? For hearing loss, the concordance of the whispered voice test with Q1 was 67%, and with Q2, 71%. For visual loss, the concordance of the Snellen chart with Q3 was 79% and of the Low Vision Chart with Q4, 69%. For hearing loss, the results of the test were noticeably more significant for the GP in offering help than the answers to the questions, and for visual loss the results of the Snellen chart slightly more convincing than the answers to the questions. Conclusion ? When in a screening programme with simple instruments for visual and hearing loss the choice has to be made between questionnaire and tests, the tests will be the best choice.

A postmarketing study of flunarizine in migraine and vertigo

This prospective, open multi-centre study on flunarizine focused on the risk/benefit ratio of the use of flunarizine in the prophylaxis of migraine and in the treatment of vertigo, due to disorder of the vestibular system. The assessment of risks focused on the incidence of new events of depression and/or extrapyramidal syndrome during flunarizine treatment. For migraine, flunarizine was compared to propranolol in 686 patients; for vertigo, flunarizine was compared to betahistine in 198 patients. The incidence of depression during follow-up in this study was significantly higher in the flunarizine group than in the propranolol group in the condition of migraine. There were no observations of an extrapyramidal syndrome. There was a suggestion that flunarizine has more benefits than propranolol in the condition of migraine, and that betahistine has more benefit than flunarizine in the condition of vertigo. Differences in dosages could possibly explain these differences.

Asthma in adult patients presenting with symptoms of acute bronchitis in general practice

Objectives - To investigate the association between asthma and acute bronchitis in adults and to ascertain criteria to help general practitioners (GPs) differentiate between acute bronchitis and asthma. Design - Descriptive study. Setting - Primary health care centre in The Netherlands. Patients - 192 patients, aged 18-75 years, not known to have asthma or other pulmonary diseases, attending their GP with cough persisting for at least 2 weeks. Methods - Patients were considered to have asthma or chronic obstructive pulmonary disease on the basis of a questionnaire on respiratory symptoms, spirometry and methacholine challenge testing. They were classified as having acute bronchitis if, according to international guidelines, coughing was more frequent than normal for at least 2 weeks, but no more than 4 weeks. Furthermore, either expectoration of purulent sputum for a maximum of 2 weeks and/or rhonchi as assessed by auscultation had to be present. By means of logistic regression symptoms, signs and peak expiratory flow measurements were sought to predict which patients with acute bronchitis actually had asthma. Results - Of the 80 (41.7%) subjects with symptoms of acute bronchitis, 29 (36.9%) were patients with asthma. Within the acute bronchitis group, female sex and symptoms of current reported wheeze, reported episodes of attacks of dyspnoea over the last year and symptoms elicited by allergens were of help in identifying patients who actually had asthma. Conclusions - A considerable proportion of the patients presenting with acute bronchitis are actually patients with asthma. The absence or presence of a few symptoms and female sex may help to differentiate between these disorders.OBJECTIVES To investigate the association between asthma and acute bronchitis in adults and to ascertain criteria to help general practitioners (GPs) differentiate between acute bronchitis and asthma. DESIGN Descriptive study. SETTING Primary health care centre in The Netherlands. PATIENTS 192 patients, aged 18-75 years, not known to have asthma or other pulmonary diseases, attending their GP with cough persisting for at least 2 weeks. METHODS Patients were considered to have asthma or chronic obstructive pulmonary disease on the basis of a questionnaire on respiratory symptoms, spirometry and methacholine challenge testing. They were classified as having acute bronchitis if, according to international guidelines, coughing was more frequent than normal for at least 2 weeks, but no more than 4 weeks. Furthermore, either expectoration of purulent sputum for a maximum of 2 weeks and/or rhonchi as assessed by auscultation had to be present. By means of logistic regression symptoms, signs and peak expiratory flow measurements were sought to predict which patients with acute bronchitis actually had asthma. RESULTS Of the 80 (41.7%) subjects with symptoms of acute bronchitis, 29 (36.9%) were patients with asthma. Within the acute bronchitis group, female sex and symptoms of current reported wheeze, reported episodes of attacks of dyspnoea over the last year and symptoms elicited by allergens were of help in identifying patients who actually had asthma. CONCLUSIONS A considerable proportion of the patients presenting with acute bronchitis are actually patients with asthma. The absence or presence of a few symptoms and female sex may help to differentiate between these disorders.

Hoe up-to-date is het medisch dossier?

SamenvattingInleiding In het elektronisch medisch dossier van huisartsen wordt in toenemende mate gebruik gemaakt van episodegewijze registratie. Wanneer de titel van een zorgepisode in de loop van de tijd verandert, dient deze ‘transitie’ te worden geregistreerd in de episodelijst. Wij onderzochten hoe up-to-date de episodelijsten van de huisartsen van het Registratie Netwerk Universitaire Huisartspraktijken Leiden en Omstreken in dit opzicht zijn.Methode Uit het databestand van het RNUH-LEO werd een selectie gemaakt van verwijzingen naar interne geneeskunde in de periode januari 1998 t/m juni 1999 (n=505). In de gevallen waarbij sprake was van een transitie van werkdiagnose naar definitieve diagnose, werd nagegaan of deze diagnose adequaat in het medisch dossier was geregistreerd (n=218).Resultaten Bij bijna een derde van de onderzochte verwijzingen was de titel van de zorgepisode niet veranderd, hoewel de internist wel een definitieve diagnose had gesteld. In 71% van de gevallen was de definitieve diagnose als episodetitel geregistreerd. In 57% van de gevallen was dit adequaat gebeurd: de episodetitel was veranderd van werkdiagnose naar definitieve diagnose. In 14% van de gevallen was een nieuwe episode in de episodelijst aangemaakt.Conclusie In de praktijk blijkt dat het adequaat bijhouden van de episodelijst te wensen overlaat. Eén blik op de episodelijst is voor (collega-)huisartsen soms nog niet voldoende om op de hoogte te zijn van de actuele situatie van de patiënt.