Maxillary sinusitis in adults: an evaluation of placebo-controlled double-blind trials

BACKGROUND: In general practice, acute sinusitis is frequently diagnosed and treated with antibiotics. OBJECTIVE: This study aimed to determine the evidence for the effectiveness of antibiotic treatment in acute maxillary sinusitis in adults by assessing the methodological quality of placebo-controlled double-blind randomized trials. METHOD: An evaluation by four raters through a 35-item scoring-scale for internal and external validity of all placebo-controlled double-blind randomized trials on acute sinusitis found between January 1966 and July 1996. RESULTS: Eighty-five trials were excluded because they were not placebo-controlled, double-blind, randomized, or were carried out in patients with chronic sinusitis or in children. The three remaining trials were performed in different populations (one in general practice) between 1973 and 1978. Only one study claimed superiority of antibiotic treatment. Different inclusion criteria and major outcome measures were used by the authors. The reliability of major outcome events was reported poorly or not at all and in two studies outcome measures were clinically inappropriate. The studies scored 30-62% of the maximum attainable score for internal validity and 10-20% for external validity. CONCLUSION: The effectiveness of antibiotic treatment in acute maxillary sinusitis in a general practice population is not based sufficiently on evidence.      

Spontaneous reports of most distressing concerns in patients with inoperable lung cancer: at present,in retrospect and in comparison with EORTC-QLQ-C30+LC13

Patients with lung cancer experience considerable distress. Therefore, accurate methods for assessing distress and quality of life over time may play a key role for managing and evaluating palliative care. Alternatives to commonly used standardized questionnaires are individual measures. This study prospectively and retrospectively explored the concerns that 46 patients with inoperable lung cancer spontaneously reported as causing most distress close to diagnosis and 6 months later. Changes in content individually generated through a structured inductive freelisting were compared with EORTC-QLQ-C30+LC13 ratings. The results showed that patients perceived a wide variety of concerns as most distressing and that their concerns changed over time. Between 56 and 62% of these concerns were assessed by items included in the EORTC-QLQ-C30+LC13 questionnaires. Furthermore, patients’ reports of most distress from fatigue, pain and dyspnea were not always reflected in intensity ratings of comparable EORTC-QLQ-C30+LC13 items. These results indicate that items included in standardized measures are not always adequate to assess patients’ concerns, priorities and changes over time. In addition to standardized questionnaires, individualized measures may be useful in the clinical palliative setting for providing detailed information about the individual’s problems and prioritizations.     

Lethal Congenital Muscular Dystrophy with Arthrogryposis Multiplex Congenita: Three New Cases and Review of the Literature

Congenital muscular dystrophy (CMD) comprises a heterogeneous group of muscle disorders. We report on two stillborn sibs with early lethal CMD and a prematurely born boy who died within minutes after birth. The pregnancies were complicated by polyhydramnios. All presented with arthrogryposis multiplex congenita, severe muscle wasting, lung hypoplasia, and hydrops. The muscle biopsies showed fibrosis, variation in fiber size, and extensive fat replacement compatible with muscular dystrophy. Fatal CMD seems to be distinct from CMD with survival after birth and is probably autosomal recessively inherited.     

K. Ulsenheimer, Arztstrafrecht in der Praxis

Ohne Zusammenfassung     

Longitudinal changes in nutritional habits of teenagers: differences in intake between schooldays and weekend days

Longitudinal changes in nutritional habits were studied in Dutch adolescents from 12 to 17 years of age (131 girls and 102 boys). The dietary differences on schooldays and weekend days are reported. In girls only small changes in nutritional habits were seen as they grew older. In boys there was a gradual increase in food intake with age. Overall, higher nutrient intakes could be seen on weekend days. The energy intake on weekend days was consistently higher for girls and boys in all age-groups. The proportional intakes of fat and sugar were rather high, especially on weekend days. The alcohol consumption increased with age for girls as well as boys, and was for some individuals extremely high (boys) on weekend days. The observed levels of intake compared with the recommendations showed a rather low intake of polyunsaturated fatty acids, polysaccharides and iron.     

Population-based prevention of influenza in Dutch general practice.

BACKGROUND: Although the effectiveness of influenza vaccination in high-risk groups has been proven, vaccine coverage continues to be less than 50% in The Netherlands. To improve vaccination rates, data on the organizational factors, which should be targeted in population-based prevention of influenza, is essential. AIM: To assess the organizational factors in Dutch general practice, which were associated with the influenza vaccination rate in 1994. METHOD: A retrospective questionnaire study was undertaken in 1586 of the 4758 Dutch general practices, which were randomly selected. A total of 1251 (79%) practices returned a questionnaire. The items verified were practice profile, urbanization, delegation index, use of computer-based patient records, influenza vaccination characteristics and influenza vaccination rate. RESULTS: No differences were found with regard to the percentage of single-handed practices (65%), practices situated in urban area (38%), practices with a pharmacy (12%), patients insured by the National Health Service (59%) and use of computer-based patient records (57%) when compared with national statistics. The mean overall influenza vaccination rate was 9.0% (SD 4.0%). Using a logistic regression analysis, a high vaccination rate (> or = 9%) was associated with the use of personal reminders (odds ratio (OR) 1.7, 1.3-2.2), monitoring patient compliance (OR 1.8, 1.3-2.4), marking risk patients in computer-based patient records (OR 1.3, 1.0-1.6), a small number of patients per full-time practice assistant (OR 1.5, 1.1-1.9), urban areas (OR 1.6, 1.3-2.1) and single-handed practices (OR 1.5, 1.1-1.9). CONCLUSION: Improvement of vaccination rates in high-risk patients may be achievable by promoting the use of personal reminders and computer-based patient records, as well as monitoring patient compliance. In addition, the role of practice assistants with regard to preventive activities should be developed further. Practices situated in rural areas and group practices may need more support with a population-based approach for the prevention of influenza.     

Isochromosome 18q in a girl with holoprosencephaly,DiGeorge anomaly,and streak ovaries

We report on the clinical and pathologic findings in a girl with isochromosome 18q (46, XX,i(18q)) who had combined manifestations of monosomy 18p and trisomy 18q. Major congenital anomalies included premaxillary agenesis, alobar holoprosenphaly, double Outlet right ventricle, DiGeorge anomaly and streak ovaries. The clinical spectrum in i(18q) is very broad. © 1993 Wiley-Liss, Inc.     

Differential loss of neuromuscular connections according to activity level and spinal position of neonatal rabbit soleus motor neurons

We have tested whether the ability of synapses to compete for occupancy of endplates during neuromuscular synapse elimination is affected by differences in the spinal position or in the activity level of the parent motor neuron. To test the role of spinal position, the relative sizes of motor units for motor neurons from middle and extreme (rostral/caudal) positions in the rabbit soleus motor pool were determined at 3 postnatal ages: 4-5 d ("early" ages, when the soleus is heavily polyinnervated), 8-9 d ("intermediate"), and 11-15 d ("late," when the soleus has just reached singly innervated state). Average motor unit sizes from extreme ventral roots were similar to those from middle ventral roots in early-aged soleus muscles but were significantly smaller (by 18-27%) for both intermediate and late muscles. Thus, motor neurons from extreme positions evidently compete less effectively for retention of synapses than those from middle positions. To test the role of differential activity, inactive and active synapses were pitted directly against one another by implanting Silastic plugs laden with tetrodotoxin (TTX) into one of the spinal nerves containing a minority of the soleus motor axons. Differential activity was maintained during a period of extensive synapse loss, from the time of the implant at day 4 or 5 until the intermediate age (day 8-9). Motor unit twitch tensions were subsequently measured to determine the relative number of synapses retained by individual active and inactive motor neurons. The inactivated motor units were on average significantly larger (by more than 50%) than the corresponding group from normal and control-implanted animals. The abnormally large size of inactivated motor units persisted in animals allowed to recover from the TTX block and examined after multiple innervation had disappeared. Hence, the effect of the TTX block cannot be attributed to a simple slowing of synapse elimination specifically among the inactive motor neurons. We conclude that complete presynaptic inactivity improves the chances of survival relative to that for normal activity during synapse elimination in the neonatal rabbit soleus muscle. This difference in competitive ability may contribute to the development of an important characteristic of adult muscles, the correlation between motor unit size and recruitment threshold.     

The contribution of membrane hyperpolarization to adaptation and conduction block in sensory neurones of the leech

The factors underlying sensory adaptation and conduction block have been studied in cutaneous mechanoreceptor neurones of the leech. A touch-sensitive cell was activated by applying mechanical or electrical stimuli to its receptive field on the skin. Impulses were recorded extracellularly from its axons and intracellularly from its cell body, which is situated within the C.N.S.1. Activation of the touch cell by mechanical stimuli revealed two distinct types of adaptation with characteristically different time courses. Sustained pressure on the skin caused a brief burst of impulses at the onset of the stimulus. This rapid adaptation to pressure was restricted to the part of the receptive field that had been stimulated mechanically. A second type of adaptation developed more slowly during the course of repetitive mechanical stimulation. It persisted for many seconds after the end of a train of impulses and appeared as an increase in the threshold to mechanical stimuli not only in the region of skin that had been rubbed but throughout the receptive field of the cell.2. Impulses initiated in the cell body propagated antidromically towards the skin and also raised the threshold to touch, indicating that after-effects of impulse activity were responsible for the long-lasting threshold increase.3. Repetitive mechanical stimulation could also produce a reversible conduction block in branches of the touch cell. The block occurred in discrete regions of low safety factor such as axonal branch points both within the ganglion and in the periphery. In some experiments impulses intermittently failed to reach one axonal branch yet continued to invade a separate branch of the same cell.4. Several lines of evidence indicate that both conduction block and the slow component of adaptation are linked to a prolonged hyperpolarization that follows repetitive stimulation of the touch cell. Strophanthidin, which blocks the after-hyperpolarization in touch cells, reduced the adaptation following trains of impulses and also relieved a conduction block previously established by repetitive stimulation. Furthermore, a comparison of the effects of hyperpolarizations produced by current injection and by repetitive firing showed that most of the threshold increase in the cell body after a train of impulses could be attributed directly to the membrane hyperpolarization.5. These experiments suggest several ways in which repetitive activity can have pronounced and long-lasting effects on the performance of a highly branched sensory cell. Thus a relatively small number of impulses in a touch cell can markedly decrease its sensitivity to touch. The functional role of the conduction block observed during vigorous stimulation is not as clear because activity for many seconds or minutes is usually needed to establish a block in the larger branches of the cell.