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.

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.

A quasi-randomised controlled trial of water as a quick softening agent of persistent earwax in general practice.

BACKGROUND: Earwax is a common problem in general practice. The incidence of complaints owing to earwax in general practice in the Netherlands is 39.3 per 1000 patients. AIM: To determine the feasibility of a strategy using water as a quick dispersant for persistent earwax, compared with the usual strategy using oil as a dispersant for three days in a general practice setting. DESIGN OF STUDY: Practice based, prospective controlled intervention study. SETTING: Forty-two patients (59 ears) in four general practices in the Netherlands. METHOD: Patients with persistent earwax were randomised into an intervention group and a control group. For patients in the intervention group, water drops at body temperature were dropped into the impacted ear and the auditory meatus was blocked with a wet wad of cotton. After the patient had waited for 15 minutes in the waiting room a series of attempts at syringing was completed. Patients in the control group received the usual strategy and were instructed to soften the earwax with oil each night before sleeping and to block the auditory meatus with a wad of cotton, for three days. They were asked to come back after three days for the second attempt of syringing. For both strategies the mean number of syringing attempts (and 95% confidence interval) was calculated and compared by testing the difference between the means using a t-test for independent samples. All ears in which the wax was still persistent after another five syringing attempts were given the value of 6 in the calculations. RESULTS: The mean number of syringing attempts needed per patient in the intervention group was 3.0 (95% CI = 2.4 to 3.6) and for the control group, the mean was 2.4 (95% CI = 1.7 to 3.1). The difference between means (0.6, 95% CI = 0.3 to 1.5) was not statistically significant (P = 0.18). CONCLUSION: A patient with persistent earwax can stay in the waiting room following the initial series of five attempts at syringing, with water instilled in the ear canal. After 15 minutes, the earwax is removed as easily as in the usual strategy using oil instilled for three days. The strategy using water as a dispersant for persistent earwax is quick and more convenient for the patient.

Clinical risk factors as predictors of postmenopausal osteoporosis in general practice.

BACKGROUND: Case-finding strategies to identify women with high risk for osteoporotic fractures have recently been proposed, but little information about such an approach in general practice is known. AIM: To study the validity of the proposed case-finding strategy for osteoporosis. DESIGN OF STUDY: Survey using case-finding strategy. SETTING: Seven hundred and twelve women aged between 55 and 84 years, randomly selected from a general practice in The Netherlands. METHOD: Of the 712 randomly selected women, 449 women participated. Information was obtained from a questionnaire, direct questioning, and computerised patients files. Bone mineral density of the femoral neck was measured by dual energy X-ray absorptiometry and vertebral morphometry was performed on lateral X-rays of the spine. Osteoporosis was defined by a bone mineral density T-score of less than 2.5 and/or the presence of severe vertebral deformities. Sensitivity, specificity, and predictive values were calculated for the whole set of risk factors; those significantly associated with osteoporosis and in logistic models. RESULTS: Clinical risk factors were present in 55% of the women and identified 68% of the women with osteoporosis. Three risk factors--a low body mass index, fragility fractures, and severe kyphosis and/or loss of height--were associated significantly with osteoporosis; they were present in 33% of the women and identified 60% of those with osteoporosis. A logistic model based on age and fragility fractures selected 32% of the women and identified 76%. CONCLUSION: No single risk factor could assist in identifying women with osteoporosis. A simplified case-finding strategy using only three risk factors, that is suitable for primary care, reduces the number of women to be evaluated by two-thirds; however, this is at the cost of missing the diagnosis in 40% of the women with osteoporosis. Addition of spine radiographs to the case-finding approach helped to obtain a better risk profile of the women and had also practical consequences for the management of some. We propose that radiographs should be included in any case-finding strategy.

The whispered voice: the best test for screening for hearing impairment in general practice?

Hearing loss is an important health problem in the elderly which sometimes leads to social isolation. In a study with 62 patients, the diagnostic value of four simple tests for screening for hearing loss in general practice was examined. When paying attention to the loudness of the whispering, the whispered voice test can be a valuable test for assessment of hearing loss in general practice.

Accelerated chilling of carcasses to improve pork quality.

Our objectives were to determine the optimal accelerated chill time immediately postmortem necessary to improve the quality of pork muscle and to decrease the incidence of pale, soft, and exudative pork. Carcasses from 81 market hogs were cooled either by conventional chill (CC) at 2 degrees C or by accelerated chill (AC) at -32 degrees C for 60, 90, 120, or 150 min, and then placed into a 2 degrees C cooler for the remainder of the 24-h chill period. Loin muscle pH was higher (P < 0.05) for the carcasses that were accelerated chilled longer than 60 min. Although loin visual color, texture, and firmness scores increased (P < 0.05) with AC time, no improvements were noted beyond 60 min. Color, pH, texture, firmness, and CIE L*a*b* values of fresh ham muscles were not (P > 0.05) affected by AC. In addition, AC did not (P > 0.05) affect purge, drip, or thaw loss of fresh products, sensory scores of loins or processed hams (except initial juiciness; P < 0.05), water-holding capacity of processed hams, or processing characteristics of hams. Cooking loss and Warner-Bratzler shear values for hams and loins were not (P > 0.05) affected by AC. Accelerated chilling caused loins to be darker (lower L* value; P < 0.05) and to have lower (P < 0.05) b* values (less yellow) than CC loins. Accelerated chilling increased water-holding capacity in fresh hams, bound water being the greatest (P < 0.05) in the 120- and 150-min AC groups. These results demonstrate that improvements in pork loin quality can be made using freezer-accelerated chilling for carcasses.

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

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. : 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.

[The Dutch College of General Practitioners' practice guidelines, "Examination of the neonate": response from the perspective of general practice medicine]. / De standaard 'Onderzoek van de pasgeborene' van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

With the publication of the Dutch College of General Practitioners' practice guideline 'Examination of the neonate', a discussion which has lasted several decades has been brought to an end. Up to now a second neonatal examination by the general practitioner on the third, fourth or fifth day after a midwife-assisted birth was recommended. The arguments in support of this recommendation were based on the following: (a) the limited expertise of midwives in the past, (b) the experience that general practitioners had in examining children, although this experience was not specifically related to the defects for which neonates should be checked, and (c) the government bodies' wish to restrict the number of hospital deliveries by giving greater structure to the organisation of midwife care, which in practice, did not lead to large changes. Based on three studies, the practice guideline recommends that a second examination is of no added value.

[Strong relationship between the course of the first pregnancy, delivery and puerperium and that of the following]. / Sterk verband tussen het verloop van de eerste zwangerschap-baring-kraambedepisode en dat van de daaropvolgende.

OBJECTIVE: To evaluate the significance of the course of a first pregnancy, delivery and puerperium (episode) for the course of a second episode. DESIGN: Retrospective cohort analysis. METHOD: Data from 3591 pregnancies, deliveries (3624 children) and puerperium of women from the Dutch town of Urk in the period 1986-1995 were analysed. RESULTS: The study group consisted of 910 nulliparous women. Of these, 387 (group 1) had experienced an uncomplicated first pregnancy-delivery-puerperium episode and 523 (group 2) a complicated one. In the study period, 77.3% of the women in group 1 and 59.8% of the women in group 2 gave birth for a second time. The course of the second episode was uncomplicated in 74.6% of group 1 and 46.3% of group 2. This difference was significant (p < 0.0001). The percentage of home deliveries in groups 1 and 2 was 80.3% and 50.5% respectively (p < 0.0001). The percentage of operative deliveries (vaginal and abdominal) was 1.3% and 8.6% respectively (p = 0.0008). No significant differences in perinatal outcome and postpartum referrals were found. Sixty-two of the 313 women with a complicated first episode had a primary indication for hospital delivery for a second partus, based on the outcome of the first episode. Even when these women were excluded, the differences in outcome as described were significant. CONCLUSION: An uncomplicated versus complicated first pregnancy-delivery-puerperium episode was an important prognostic factor with respect to an uncomplicated or complicated secondary episode respectively.

[Potential role for family physicians in pushing back age-related impairment: hearing and vision disorders, incontinence and arthrosis]. / Mogelijke rol voor de huisarts bij het terugdringen van de beperkingen door verouderingsaandoeningen: gehoor- en visusstoornissen, incontinentie en artrose.

OBJECTIVE: To determine which age-related disorders lend themselves for screening followed by intervention in general practice. SETTING: Department of General Practice Medicine, University of Leiden. DESIGN: Descriptive. METHODS: This study concerned eight frequent age-related disorders: auditory and visual disorders, cognitive limitations, vertigo, incontinence, prostate symptoms, osteoarthritis and depressive symptoms. Four criteria (diagnostic possibilities, therapeutic possibilities, suitability of general practice for screening and intervention, the benefit of the programme to the elderly) were applied to selected literature (from Medicine and the electronic article files of the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine) and of Huisarts en Wetenschap (GP and Science) to find out whether screening followed by intervention appeared useful. RESULTS: With regard to three disorders (auditory and visual disorders and incontinence) it appeared possible to reduce the impairments caused by them, while in osteoarthritis, screening and intervention might lead to better mobility. CONCLUSION: With reference to recent literature, it appears theoretically possible to reduce the impairments caused by auditory and visual disorders, incontinence and osteoarthritis.

[Prescription of antidepressants in family practice]. / Voorschrijven van antidepressiva in de huisartspraktijk.

OBJECTIVE: To evaluate the prescription of antidepressants in general practice. DESIGN: Retrospective observational study. SETTING: Three health centres and one practice with two partners in the Western part of the Netherlands (near Leiden). METHOD: Medication data and daily medical records of general practitioners (GPs) were analysed in the anonymous data set of Registratie network universitaire huisartspraktijken Leiden en Omstreken (RNUH-LEO, with a total of about 23,000 patients) of patients 18 years of age and over, whom the GP issued a first prescription for an antidepressant in the period May 1994-April 1995. For indication 'depression' we also evaluated whether the prescription was repeated and a minimal effective dosage was reached. RESULTS: In one year 218 patients received a first prescription of an antidepressant (9/1,000/year), mostly a classical antidepressant. In 61% the indication 'depression' was found in the medical records. Sixty-three per cent had a repeat prescription after one month. Serotonin reuptake inhibitors were repeated more frequently than classical antidepressants, especially for patients under the age of 65. The minimally effective dosage was reached in 61% of the patients with depression for the classical antidepressants, and for 98% of patients with serotonin reuptake inhibitors. CONCLUSION: Serotonin reuptake inhibitors were not prescribed more frequently than classical antidepressants. The percentage of patients with repeat prescriptions showed that the GPs should pay continued attention to compliance with therapy when prescribing antidepressants. The effective dosage appeared to be reached most often with serotonin reuptake inhibitors.

[Prevalence of chronic fatigue syndrome in 4 family practices in Leiden]. / Prevalentie van chronische-vermoeidheidsyndroom in 4 huisartspraktijken in de regio Leiden.

OBJECTIVE: To determine the prevalence of chronic fatigue syndrome (CFS) in general practice. DESIGN: Descriptive. SETTING: General practice and primary health care centres in Leyden region, the Netherlands. METHOD: RNUH-LEO is a computerized database which contains the anonymous patient information of one general practice (with two practitioners) and four primary health care centres. The fourteen participating general practitioners were asked what International Classification of Primary Care (ICPC) code they used to indicate a patient with chronic fatigue or with CFS. With these codes and with the code for depression patients were selected from the database. It then was determined whether these patients met the criteria of CFS by Holmes et al. RESULTS: The general practitioners used 10 codes. Including the code for depression a total of 601 patients were preselected from a total of 23,000 patients in the database. Based on the information from the patients' records in the database, 42 of the preselected patients were selected who might fulfill the Holmes' criteria of CFS. According to the patients' own general practitioner, 25 of the 42 patients would fulfil the Holmes' criteria. The men:women ratio was 1:5. The prevalence of CFS in the population surveyed was estimated to be at least 1.1 per 1,000 patients.

[Incidental high blood pressure in family practice: due to hypertension and/or left ventricular hypertrophy in more than half of the patients]. / Incidenteel verhoogde bloeddruk in de huisartspraktijk: bij meer dan de helft van de patiënten hypertensie en (of) linkerventrikelhypertrofie.

OBJECTIVE: To determine if patients with incidentally high blood pressure actually have hypertension and if these patients have an increased left ventricular mass. DESIGN: Cross-sectional study. SETTING: Two family practices with 8 general practitioners in Leiden and Noordwijk, the Netherlands. METHODS: From the Family Practice Network in the Leiden area 133 (67%) out of 200 patients with incidental high blood pressure, who did not receive antihypertensive medication, participated in the study. Their blood pressure was measured 6 times with a mercury manometer, an automatic, non-invasive ambulatory blood pressure monitoring during 24 hours was performed once and their left ventricular mass was measured by means of echocardiography. RESULTS: Of the 133 selected patients 46% had a mean diastolic blood pressure > 95 mmHg measured with the mercury manometer and 64% had a mean 24-hr diastolic blood pressure > 90 mmHg measured with the ambulatory blood pressure monitor. The correlation between both blood pressure measurements was moderate (correlation coefficient 0.73). Left ventricular hypertrophy was found in 53% of the patients, irrespective of their blood pressures. CONCLUSION: In this investigation 45-65% of patients with an incidentally high blood pressure had a mean diastolic pressure > 95 mmHg as measured with a mercury manometer and (or) a mean 24-hr diastolic blood pressure > 90 mmHg as measured with the ambulatory blood pressure monitor; 53% had left ventricular hypertrophy.

[The Depression Recognition Scale: and aid in the diagnosis of depression in family practice]. / De 'Depressieherkenningsschaal': een hulpmiddel bij het diagnosticeren van depressie in de huisartspraktijk.

OBJECTIVE: To assess the reliability, positive predictive value and concurrent validity of a brief and simple interview to diagnose major depression in general practice, the Depression recognition scale (DRS). DESIGN: Descriptive. SETTING: University of Leiden, the Netherlands. METHODS: The DRS was compared with a semi-structured psychiatric interview to assess major depression and with the depression items of the Symptom checklist-90 (SCL-90), a self-rating scale for perceived symptoms. RESULTS: The study consisted of 233 subsequent patients of II general practices who were screened for an interview; 95 patients were actually interviewed, 15 of these patients had a major depression (15/233; 6%). The DRS was also compared with the SCL-90 among 428 other patients. The validity was 0.73 and 0.66 and the internal consistency (Cronbach's alpha) was 0.63 and 0.75, respectively. If the DRS were used only for patients the general practitioner considers mildly depressed (43/233 = 18%), few cases of major depression would be missed (2/15). CONCLUSION: The DRS appears a practical, reliable and valid diagnostic tool.

[Influenza vaccine in 85-and-over aged: motivation of elderly and family physicians to vaccinate or not]. / Influenzavaccinatie bij 85-plussers: de motieven van ouderen en huisartsen om wel of niet te vaccineren.

OBJECTIVE: To determine on what grounds persons over 85 years are or are not vaccinated against influenza. DESIGN: Descriptive. SETTING: Gerontological Research Centre and Department of General Practice Medicine, University of Leiden, the Netherlands. METHOD: A random sample (n = 331) of the general population of Leiden aged 85 years or older and not institutionalized were interviewed. Early in October 1993, 163 interviews were suitable for analysis (response rate 54%). An analysis of non-responders revealed no significant difference as regards gender and housing, but persons aged 90 and older were under-represented. The general practitioners (n = 41) of the 163 elderly persons were interviewed about these persons (response: n = 127; 78%) and about influenza vaccination in general (response: n = 33; 82%). RESULTS: The vaccination coverage rates were 51% according to the elderly and 56% according to the GPs; those of elderly people with an indication (48% according to themselves and 64% according to the GP) 52% and 67%, respectively. Reasons for elderly people not to accept vaccination were that they considered vaccination unnecessary, that they felt well and wanted to avoid possible adverse effects. A doctor's recommendation to have vaccination done was a positive influence. GPs' motives not to vaccinate were absence of an indication and the elderly person's wish. CONCLUSION: Only two-thirds of those over 85 not living in a nursing home with an indication for influenza vaccination were indeed vaccinated. Information about the possible damage done by influenza and about the pros and cons of vaccination, together with a doctor's advice to be vaccinated appeared to have a positive effect on the vaccination coverage.

[Prevalence of osteoporosis in postmenopausal women in family practice]. / Prevalentie van osteoporose bij postmenopauzale vrouwen in een huisartspraktijk.

OBJECTIVE: To assess the prevalence of osteopenia, osteoporosis and severe vertebral deformities in general practice. DESIGN: Cross-sectional study. METHODS: Of a randomly selected group of 712 women aged 55 to 84 years in a general practice in Noordwijk, the Netherlands, 449 (63%) participated in a study in 1996, in which Dual Energy X-ray Absorptiometry (DXA) of the femoral neck was performed: in 428 women vertebral morphometry of lateral radiographs of the spine was also done. The World Health Organization definitions of osteopenia and osteoporosis were used. RESULTS: The mean bone mineral density (BMD) was 0.866 g/cm2 (SD: 0.135). With increasing age the BMD decreased statistically significantly by 0.0073 g/cm2/year. There were 189 women with osteopenia (42%). 33 (7%) with osteoporosis and 44 (10%) with one or more severe vertebral deformities. A significantly lower mean BMD was found in those with severe vertebral deformities than in those without.

The prognosis of depressive disorder in elderly primary care patients. An exploratory observational study: course at 6 and 12 months.

OBJECTIVE: To assess the course of depression or borderline depression and its determinants in elderly primary care patients. DESIGN: An observational cohort study with three measurements, at inclusion and after 6 and 12 months. SETTING: 14 general practitioners (GPs) in the western region of the Netherlands. PATIENTS: From a baseline random sample of 582 consecutive elderly patients 65+ years of age, a total of 39 patients with depression and 60 with borderline depression were available for this cohort study. MAIN OUTCOME MEASURES: Diagnostic assessment was carried out in the patients' homes by trained interviewers according to the Diagnostic Interview. Schedule (plus additional questions to assess minor depression). RESULTS: Of the 39 patients with depression at baseline, 20 had depression after 6 months, and 18 after 12 months. Of the 60 patients with borderline depression at baseline, 53 had no evidence of depression after 6 months, and 54 had no evidence after 12 months. However, 7 patients had depression at 6 months and 6 patients at 12 months. Two determinants were related to a depressed state at 6 or 12 months among the patients with borderline depression: recognition by the GP and living with a partner. CONCLUSION: The results suggest that once elderly patients suffer from depression, this condition remains present for a long time. The prognosis for borderline depression was better, although 20% became depressed at 6 and/or 12 months. Future studies should aim to identify this group of patients.