Primary-care-based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis

BACKGROUND: The value of antibiotics in acute rhinosinusitis is uncertain. Although maxillary sinusitis is commonly diagnosed and treated in general practice, no effectiveness studies have been done on unselected primary-care patients. We used a randomised, placebo-controlled design to test the hypothesis that there would be an improvement associated with amoxycillin treatment for acute maxillary sinusitis patients presenting to general practice. METHODS: Adult patients with suspected acute maxillary sinusitis were referred by general practitioners for radiographs of the maxillary sinus. Those with radiographic abnormalities (n = 214) were randomly assigned treatment with amoxycillin (750 mg three times daily for 7 days; n = 108) or placebo (n = 106). Clinical course was assessed after 1 week and 2 weeks, and reported relapses and complications were recorded during the following year. FINDINGS: After 2 weeks, symptoms had improved substantially or disappeared in 83% of patients in the study group and 77% of patients taking placebo. Amoxycillin did not influence the clinical course of maxillary sinusitis nor the frequency of relapses during the 1-year follow-up. Radiographs had no prognostic value, nor were they an effect modifier. Side-effects were recorded in 28% of patients given amoxycillin and in 9% of those taking placebo (p < 0.01). The occurrence of relapses was similar in both groups (21 vs 17%) during the follow-up year. INTERPRETATION: Antibiotic treatment did not improve the clinical course of acute maxillary sinusitis presenting to general practice. For these patients, an initial radiographic examination is not necessary and initial management can be limited to symptomatic treatment. Whether antibiotics are necessary in more severe cases warrants further study.     

Adjunct effect of loratadine in the treatment of acute sinusitis in patients with allergic rhinitis

Recently, it has been recognized that cell-bound heparan sulfate (HS) proteoglycans (HSPG) are able to bind and subsequently initiate degradation of lipoproteins. Two mediators of lipoprotein catabolism, both with HS binding capacity, lipoprotein lipase (LPL) and apolipoprotein E (apoE), are involved in this process. This mechanism is known as the secretion-capture process of apoE. Lipoprotein(a) [Lp(a)] was shown to have a strong binding capacity to cell-associated HSPG. This binding capacity was increased by LPL addition. We investigated the effects of recombinant apoE (r-apoE) enrichment of Lp(a) on the binding to HS. Lp(a), isolated by ultracentrifugation and gel filtration, was incubated with r-apoE and reisolated by ultracentrifugation, resulting in r-apoE-enriched Lp(a). ApoE-enriched Lp(a) and control Lp(a) were coated to microtiter plates. The capacity to bind biotin-conjugated HS (b-HS) in the presence or absence of inactivated bovine LPL was studied. R-apoE-enriched Lp(a) showed increased b-HS binding capacity versus control Lp(a). Addition of LPL resulted in an increased b-HS binding capacity of both control and r-apoE-enriched Lp(a). To investigate whether binding of Lp(a) to endothelial cell HSPG occurred in vivo, 39 volunteers were injected with heparin (50 U/kg) and plasma lipid and Lp(a) levels were determined before and 20 minutes after heparin injection. No significant increase in plasma Lp(a) concentrations was found. The results showed that Lp(a) can be enriched with apoE and that this resulted in increased LPL-enhanced binding to HSPG. From the in vitro studies, it can be concluded that the secretion-capture process of apoE is a possible catabolic route for Lp(a). However, whether this also occurs in vivo remains to be confirmed.     

Controlled study of brodimoprim and cephalexin in the treatment of patients with acute sinusitis in general practice

Brodimoprim, a new dehydrofolate reductase inhibitor, was compared with cephalexin in the treatment of patients with acute sinusitis. A total of 49 patients were randomly assigned to receive either brodimoprim 200-mg tablets once a day (400 mg on the first day as a loading dose) or cephalexin 500-mg tablets three times a day for 8 to 12 days. Nearly all patients treated were judged clinically cured/improved; in fact, only one failure (in the cephalexin group) was noted. In the 45 assessable patients, the time until disappearance of the symptoms and the duration of treatment did not differ significantly between the two groups. A bacteriologic examination was performed in all patients at baseline as well as at the end of therapy. Bacteriologic eradication was obtained in 88% of the patients treated with brodimoprim and in 76% of those receiving cephalexin. Both compounds were generally well tolerated (one patient in the brodimoprim group complained of skin reactions). These results suggest that once-daily treatment with brodimoprim represents safe and effective therapy for adults with acute bacterial sinusitis.     

Cefuroxime axetil in the treatment of acute sinusitis in childhood

A study of the efficacy of cefuroxime axetil was conducted for the treatment of acute sinusitis in childhood. Thirty-nine patients aged 5-14 years were given cefuroxime axetil 20 mg/kg/day divided into two doses for seven days. The diagnosis of acute sinusitis was based on history, physical examination, and radiological findings. The results of throat cultures before treatment were 17 patients with group A beta-haemolytic streptococci, seven patients with pneumococci, and two patients with Staphylococcus aureus; in the remainder of the patients only normal throat flora were isolated. In 36 patients (92%) a satisfactory improvement was reported at the end of the treatment. It was found that cefuroxime axetil was efficaceous for the treatment of sinusitis in childhood.     

Gallium-67 scanning in the differentiation of maxillary sinus carcinoma from chronic maxillary sinusitis

Gallium-67 scans of 25 patients in whom the clinical symptoms and radiographic findings were suggestive of either maxillary sinus carcinoma or chronic sinusitis proved to be valuable in the differentiation between the two disease processes. Those patients with carcinoma had positive scans, while those with sinusitis had either negative or only weakly positive scans.     

Azithromycin versus amoxicillin/clavulanate in the treatment of acute sinusitis

One possible mechanism that accounts for the alterations observed in varicose veins is the activation of endothelial cells by ischemia occurring in the leg veins during blood stasis and the cascade of reactions that follows. Because in vitro data suggest that endothelium alteration is a key event in the development of the pathology, it was important to confirm this hypothesis in patients. We used the number of circulating endothelial cells detached from the vascular wall as a criterion of the endothelium injury. We first compared the number of circulating endothelial cells (CECs) in patients with chronic venous insufficiency (CVI) with those of a control population. A twofold increase in the CEC count (1,001+/-127 CEC/ml of plasma compared with 514+/-82 CECs/ml) was observed in CVI patients, which indeed suggests an alteration of the endothelium in this disease. Second, the protective effect of a venotropic drug, Ginkgo biloba extract, troxerutine, and heptaminol (Ginkor Fort), was tested by a randomized double-blind, placebo-controlled clinical trial. In the active-treatment group, the mean values of the CEC count decreased by 14.5% after a 4-week treatment, whereas in the placebo group, the decrease was less (8.4%). The decrease from week 0 to the end of treatment was significantly higher in the active-treatment group than in the placebo group. These results confirm the important role of the endothelium alterations in the development of varicose veins and suggest a potential beneficial action of a venotropic drug on the venous wall.     

The antibiotic treatment of acute otitis media and sinusitis in children

The development of resistance among the bacterial pathogens causing acute otitis media and sinusitis in children is causing considerable concern. Although normally a mild infection, acute otitis media can produce serious complications with sequelae that can have long-lasting effects. High levels of resistance are now being seen in the three principal pathogens. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Most clinical trials comparing the efficacy of different antibiotics have failed to show differences in clinical efficacy. To overcome this problem, alternative methods of assessing antibiotics have been developed including the "in-vivo sensitivity test" proposed by Howie and retrospective analyses of treatment failures. The treatment of sinusitis is complicated by the difficulty in establishing a clear differential diagnosis. To date, no definitive trials of bacteriologic efficacy in children have been published.     

An open-label, noncomparative study to evaluate the efficacy, safety, and tolerability of azithromycin in the treatment of patients with acute sinusitis

The efficacy, safety, and tolerability of a 5-day, once-daily course of azithromycin were assessed in patients with acute sinusitis. Patients received two 250-mg capsules of azithromycin on day 1 and one 250-mg capsule on days 2 through 5. Of 102 clinically assessable patients, 27 (26.5%) were cured and 69 (67.6%) were improved on days 5 to 7. At days 12 to 16, 88 (86.3%) had a favorable clinical response. A total of 64 patients experienced adverse events; in all but two patients, adverse events were of mild or moderate severity. Thus azithromycin given once daily for 5 days was an effective treatment for patients with acute sinusitis.     

Comparative effectiveness and safety of cefdinir and amoxicillin-clavulanate in treatment of acute community-acquired bacterial sinusitis. Cefdinir Sinusitis Study Group

Cefdinir is an extended-spectrum oral cephalosporin that is active against pathogens commonly seen in acute community-acquired bacterial sinusitis (ACABS), including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Two randomized, investigator-blind, multicenter trials (one in the United States and one in Europe) compared two dosage regimens of cefdinir (600 mg once a day for 10 days and 300 mg twice a day for 10 days) to amoxicillin-clavulanate (A-C) (500 mg three times a day for 10 days) for adult and adolescent patients with ACABS. Twelve hundred twenty-nine patients entered the U.S. study, 698 with antral puncture; 569 patients entered the European study, all with antral puncture. Clinical response (cure or improvement) was determined 7 to 14 days and 3 to 5 weeks posttherapy. Microbiologic eradication rates were determined 10 to 30 days posttherapy in a subset of patients who underwent pre- and posttherapy sinus aspirate culture. Rates of adverse events and treatment discontinuations due to adverse events were examined. Cefdinir, given once or twice daily, was as effective clinically (approximately 90% cure rate) as amoxicillin-clavulanate given three times daily in the treatment of ACABS. Microbiologic eradication rates were also similar in the three groups. The major side effect was mild diarrhea, occurring in approximately 20% of each group. Cefdinir caused fewer adverse events requiring treatment discontinuation.     

Analysis of the surgical treatment results in patients with acute pancreatitis

The results of treatment of 248 patients with an acute pancreatitis (AP) are analyzed. Conservative therapy was effective in 178 of them. Mortality was 0.3%. Surgical intervention was done in 64 patients, including 25 with AP, of them 2 (8%) have died; 27--with destructive AP, after cholecystectomy, drainage of bursa omentalis and abdominal cavity 15 (55.5%) died. Pancreatic resection, necrotomy, programmed relaparotomy with permanent necrotomy of pancreas and retroperitoneal cellular tissue were conducted in 17 patients, 3 (17.6%) died.     

Evaluation and treatment of allergic fungal sinusitis. I. Demographics and diagnosis

BACKGROUND: Few cases of allergic fungal sinusitis have been systematically evaluated to conclusively confirm working clinical, histopathologic, and serologic diagnostic criteria. OBJECTIVES: The objective of this study was to describe 67 consecutive cases of allergic fungal sinusitis, the largest number of cases yet published. METHODS: Cases from 1 practice over 8 years were evaluated with a consistent protocol, including skin testing, serum chemistries and serologies, and surgical specimen analysis. RESULTS: All patients were atopic (100 %) and had nasal polyposis (100%). They tended to be young (33.3+/-13.1 years, mean +/-SEM), immunocompetent (92 %; remaining 8 % with low quantitative immunoglobulin but normal function), have slight female preponderance (58%), have a history of hypertrophic rhinosinusitis (100%), report nasal cast production (75%), and have developed their disease in the southwestern United States. Bipolaris spicifera was the most prevalent fungus involved (67%). Total serum IgE (mean 668 IU/mL) and fungal-specific IgG were generally elevated, whereas fungal-specific precipitins and specific IgE were generally negative despite positive fungal-specific immediate hypersensitivity skin tests. CONCLUSIONS: Patients with allergic fungal sinusitis tend to have elevated total serum IgE and fungal-specific IgG at diagnosis but not fungal-specific IgE or precipitins. Histopathologic criteria for allergic fungal sinusitis diagnosis are discussed. The southwestern United States appears to be a "hot spot" for the disease, particularly caused by B spicifera.     

Comparative study of the prevalence of maxillary sinusitis in later Medieval urban and rural populations in northern England

Six hundred sixty-three Medieval individuals from Wharram Percy, a rural settlement in the Yorkshire Wolds, and 1,042 individuals from St. Helen-on-the-Walls, a poor parish in the Medieval city of York, were examined in order to test the hypothesis that maxillary sinusitis would be more prevalent in an urban population due to social and environmental conditions characteristic of an industrialized settlement. The results showed that the individuals from St. Helen-on-the-Walls, living in the urban environment, had a greater prevalence of maxillary sinusitis than the rural population; 39% (106) of the individuals from Wharram Percy had evidence of sinusitis compared to 55% (134) of the individuals from St. Helen-on-the-Walls. It is suggested that this pattern may be attributed to occupation and industrial air pollution in the Medieval city of York.     

A multicenter, investigator-blinded, randomized comparison of oral levofloxacin and oral clarithromycin in the treatment of acute bacterial sinusitis

The effects of Vitamin E administration on antioxidant enzyme activities and nitrite-nitrate levels of the reperfused rat kidney tissues were investigated by performing a 60 min ischemia followed by 24 and 72 hours of reperfusion. Vitamin E administration or the placebo (SF) was applied as 100 mg/kg BW. As expected, catalase (CAT) (p<0.05) and superoxide dismutase (SOD) (p<0.05) activities of ischemia/reperfused (I/R) kidney tissue were lower and malondialdehyde (MDA) levels were higher than control kidneys in both SF and vitamin E treated groups following 24 h reperfusion. During reperfusion of long term (72 h), vitamin E triggered a decrease in the MDA levels in the ischemic tissue, while it did not provoke a significant effect on SOD and catalase activities. Total nitrite levels of ischemic tissues in both of the groups were higher than matched control kidneys and this elevation was more clear in the vitamin E treated group. Our results showed that vitamin E has a protective effect on I/R injury, by a direct chain breaking effect on lipid peroxidation (LPO) and hence preventing the nitric oxide (NO) reservoir of ischemic tissue. Alfa-tocopherol may be a promising agent for the prevention of tissue injury caused by free oxygen radicals.     

Infectious sinusitis in HIV infection. Clinical and therapeutic data on 20 patients

To assess the clinical presentation and outcome of infectious sinusitis in HIV-infected patients, we analyzed in a retrospective study, the records of HIV-infected patients hospitalized from June 1986 to November 1989. Twenty-eight episodes of infectious sinusitis, defined by radiological signs, were recorded in 20 HIV-infected patients. Clinical presentation suggestive of acute sinusitis was inconstant and in 6 episodes a persistent fever was the only symptom. Concomitant pneumonia was detected in 8 episodes. Bacteria were isolated in 8 episodes, and in 4 of them, Haemophilus influenzae was identified. Clinical relapses occurred in 8/20 patients, requiring a surgical drainage in 3 cases. The frequency of relapses and the possibility of chronicity justify a more prolonged and aggressive therapy in infectious sinusitis occurring in HIV-infected patients.     

Use of trans-tube treatment program in patients with acute intestinal obstruction and peritonitis

In 92 patients with enteral insufficiency syndrome, an acute ileus (AI) and diffuse peritonitis (DP) the prolonged small intestine decompression, the small intestine lavage with solution analogous to the chyme by electrolyte composition, medicinal decontamination, enterosorption and intraluminal electrophoresis of medicinal preparations was conducted. The pH magnitude and the degree of microbial contamination were determined; the toxicity in the probe contents according to paramecium test coefficient value was estimated. The advantage of transtube treatment over passive decompression of small bowel was proved, the hospitalization period reduced in AI on average by 7.5 days, for DP--by 11 days, mortality--by 13.2% and 22.5% accordingly.     

Immunological studies of patients with asbestosis. I. Studies of cell-mediated immunity

A variety of cancers have been documented in patients exposed to asbestos dust. Since a deranged immune system may play a r?le in cancer development, the general level of immunocompetence was studied in a group of twenty-six patients with radiographically defined asbestosis, who might be at risk of developing asbestos-related neoplasms. Statistical comparisons were made with a comparable control group. A disproportionate number of the patients displayed cutaneous energy to certain recall antigens and to 2,4-dinitrochlorobenzene. In vitro studies of cellular immunity, as evaluated by phytohaemagglutinin-induced proliferative and cytotoxicity assays, showed significantly lower values amongst the patient group. Serum inhibitors of mitogen-induced lymphocyte transformation were also detected in several of the patients. The possible significance of these findings is discussed.