Sinusitis Treatment Guideline Adherence in the E-Visit Setting: A Performance Improvement Project.

Acute exacerbations of chronic rhinosinusitis occur in a distinct seasonal pattern

Acute bacterial sinusitis is among the most frequent outpatient infections in children and adolescents and is well suited to study in large healthcare utilization databases, but the validity of International Classification of Diseases, 10th Revision (ICD-10) codes together with antibiotic prescriptions to identify cases of acute bacterial sinusitis has not been established. We aimed to evaluate the validity of ICD-10 codes combined with antibiotic prescriptions to identify new diagnoses of acute bacterial sinusitis among pediatric patients evaluated in the outpatient setting. Children and adolescents aged 17 years and younger with an outpatient diagnosis of acute sinusitis along with an antibiotic prescription from an ambulatory facility affiliated with the Mass General Brigham health system were identified via a clinical data warehouse. Patients were stratified by age (0-5 years, 6-11 years, and 12-17 years), and 50 cases per age group were randomly sampled. Medical records were independently reviewed by two pediatric infectious diseases physicians to assess for the documentation of a clinician-defined diagnosis of acute bacterial sinusitis. Positive predictive values (PPVs) and 95% confidence intervals (CIs) were calculated. A total of 150 patients were included in the final cohort. Frontal, maxillary, and "unspecified" sinuses accounted for 88% of the diagnoses. The positive predictive value of the algorithm to identify clinician-defined diagnoses of acute bacterial sinusitis was 92% (95% CI 87%, 95%). The PPVs were consistent across age strata. ICD-10 codes for acute sinusitis, when paired with a same-day antibiotic prescription, have a high positive predictive value among a cohort of pediatric patients, suggesting that they can be used to study new acute bacterial sinusitis diagnoses with claims.

Pan‐American Clinical Guideline on Rhinosinusitis

BackgroundDiabetic Retinopathy (DR) is an important public health issue in Nepal. Despite the availability of retinal services, people may not access them because of the lack of knowledge about DR and poor referral systems. DR screening uptake was low at Reiyukai Eiko Masunaga Eye Hospital(REMEH) since retina services were started. Scheer Memorial Hospital is a multispeciality hospital near to REMEH. It has no eye department but has been running a regular diabetic clinic. This was a site for referring diabetic patients for DR screening. Improving DR awareness among general physicians has the potential to address these challenges.MethodsThe aim of our study was to investigate the effectiveness of providing health education to selected health personnel and establish a referral pathway on the attendance of diabetic patients for retinal screening at REMEH. This was a non-randomized, pre-post intervention study design. Total of three health education sessions were provided to the health care professionals of Scheer on diabetic retinopathy using Power Point presentations, posters, pamphlets and videos. The study period was 16 months (2020 June –2021 September) and divided into 8 months pre-intervention(baseline data collection) and 8 months post intervention period. The proportional increase in number of diabetes attendance pre and post intervention was calculated by Z test. The change in knowledge of health care personnels pre and post intervention was scored and evaluated through a questionnaire and calculated by paired- t test. Data was analyzed using Excel and Epi Info 7.The Protocol was published on August 21, 2021, in JMIR Publications.ResultsThe proportional increase in number of referrals of diabetes attendance post intervention increased from 50 to 95% and was statistically significant (p < 0.001, 95% CI: 0.214–0.688). The mean score of knowledge gained by physicians on DR awareness was more at post intervention (8.8 ± 1.32) than pre intervention (6.4 ± 1.51). It was statistically significant (p < 0.001).ConclusionThis study shows that a well-planned health education intervention changes the knowledge in physicians about DR. There is an increase in the number of referrals and attendance of patients for DR screening with the change in knowledge and referral mechanism.Trial RegistrationClinical Trials.gov NCT04829084; https://clinicaltrials.gov/ct2/show/NCT04829084:02/04/2021.

Aims: To audit eye screening attendance rates in children pre and post implementation of a screening service offered on the same day as their diabetes clinic appointment and to identify characteristics of non‐attenders.Methods: Data were extracted from the diabetic eye screening software ‘OptoMize’ between 1 April 2018 and 31 March 2019 (pre intervention) and between 1 April 2019 and 31 March 2020 (post intervention). Attendance rates of 72 eligible participants were gained and their diabetes characteristics (age, duration of diabetes and HbA1c) were examined pre and post intervention with application of the Mood's median test in order to determine statistical significance.Results: Same day screening with routine diabetes appointments improved the eye screening attendance rate by 22%. Those with a higher HbA1c were significantly less likely to attend (p&lt;0.05) pre intervention, while post intervention, the median HbA1c of those who did not attend was lower than those who did. There was no significant difference between the age of participants for those who attended and those who did not pre and post intervention (p=0.705/0.235). Those who did not attend despite the intervention had a longer duration of diabetes than those who did, yet significance was not gained.Conclusion: This study has addressed a gap within existing knowledge and provided quantitative analysis within the field of paediatric diabetic eye screening. Findings have identified the positive impact of a ‘same day screening service’ integrated with routine diabetes care on attendance, and have also identified a clear improvement in attendance rates of those with the higher risk factors of developing sight‐threatening retinopathy. Copyright © 2023 John Wiley &amp; Sons.

In a prospective study of rhinosinusitis treatment efficacy in 163 subjects at 30 medical facilities between 2008 and 2009, we studied isolation of three major pathogenic bacteria-Streptococcus pneumoniae, Haemophillus influenzae, and Moraxella catarrhalis. We also examined clinical garenoxacin (GRNX) efficacy in 106 acute rhinosinusitis cases and 57 acute chronic rhinosinusitis exacerbation cases using Japan Acute Rhinosinusitis Clinical Guideline 2010 clinical scoring. Isolation of S. pneumoniae was 50.0% (22/44), H. influenzae 43.2% (19/44), and M. catarrhalis 6.8% (3/44) in 106 acute rhinosinusitis subjects. Drug-resistant strains accounted for over 50% in S. pneumoniae and H. influenzae. Isolation of the three bacterial pathogens in 57 acute chronic rhinosinusitis exacerbation subjects was 50.0% (9/18) in S. pneumoniae, 27.8% (5/18) in H. influenzae, and 22.2% (4/18) in M. catarrhalis. Drug resistance exceeded 40% in S. pneumoniae and H. influenzae. In efficacy studies of 97 subjects, GRNX at 400 mg/day in 54 with acute rhinosinusitis was 100%—marked improvement in 51.9% (28/54) and moderate in 48.1% (26/54). Efficacy in 43 acute chronic rhinosinusitis exacerbation subjects was 95.3%—marked improvement in 79.1% (34/43) and moderate in 16.3% (7/43). These results show the usefulness of clinical scoring in diagnosing diseases severity and in studying the efficacy of antimicrobial agents. Data clearly indicated the high clinical and bacterial efficacy of garenoxacin in treating adult rhinosinusitis.

Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic Brain Injury

Background. According to Russian clinical guidelines, amoxicillin/clavulanic acid is an antibiotic of the 1st choice in treatment of adult outpatients with acute sinusitis with suspected or confirmed bacterial etiology. The growth of bacterial resistance causes reasonable concern of otorhinolaryngologists about the efficacy of commonly used antibiotics in the routine clinical practice. Objective. The objective of this study was to evaluate the clinical success rate and tolerability of acute sinusitis treatment with Flemoclav Solutab® as initial antibiotic treatment in adult outpatients with acute sinusitis in routine clinical practice. Methods. A prospective multi-center study. The study covered adult outpatients with acute sinusitis with suspected or confirmed bacterial etiology treated with Flemoclav Solutab® and included the assessment of effectiveness and tolerability of Flemoclav Solutab® in the patients with acute sinusitis. Besides, the clinical effectiveness of treatment with this antibiotic in the subgroups of patients aged 65 years or older, smokers and non-smokers was assessed. Clinical success was determined as the complete resolution of all the symptoms and clinical signs of acute bacterial sinusitis that did not require supplementary of alternative antimicrobial therapy. In period of October 2015 to February 2016 eighty otorhinolaryngologists from various regions of Russia examined 893 adult outpatients (346 men and 547 women) with acute sinusitis treated with the antibiotic Flemoclav Solutab®. Clinical recovery confirmed by the data of all the examinations was achieved in 97.2% [(868/893), 95% CI 96.1 – 98.3%]. In the subgroup of patients aged 65 years or older the clinical success rate was 98.5% [(128/130), 95% CI 96.3 – 100%], in the subgroup of non-smokers clinical success was 97.3% [(690/709), 95% CI 96.1 – 98.5], in the subgroup of smokers clinical success was 96.7% [(178/186), 95% CI 94.2–99.3%]. Twenty five cases of adverse drug reactions (ADR) were recorded in 20 (2.2%) patients, of them 22 non-serious ADRs were in 17 (1.9%) patients and 3 serious ADRs were in 3 (0.3%) patients. Conclusion. The study proved high clinical success of acute sinusitis treatment with Flemoclav Solutab® in adult outpatients, including the patients aged 65 years or older, smokers and non-smokers. Antimicrobial treatment with Flemoclav Solutab® was well tolerated.

Background: The goal of the present study was to estimate the prevalence of patient and physician related variables associated with antibiotic prescriptions in patients diagnosed with acute lower and upper respiratory tract infections (ALURTI), treated in general practices (GP) and pediatric practices, in Germany. Methods: The analysis included 1,140,095 adult individuals in 1237 general practices and 309,059 children and adolescents in 236 pediatric practices, from the Disease Analyzer database (IQVIA), who had received at least one diagnosis of an ALURTI between 1 January 2015 and 31 March 2019. We estimated the association between 35 predefined variables and antibiotic prescription using multivariate logistic regression models, separately for general and pediatric practices. The variables included the proportion (as a percentage) of antibiotics or phytopharmaceuticals on all prescriptions per practice, as an indicator of physician prescription preference. Results: The prevalence of antibiotic prescription was higher in patients treated in GP (31.2%) than in pediatric practices (9.1%). In GP, the strongest association with antibiotic prescription was seen in the practice preference for antibiotic use, followed by specific diagnoses (acute bronchitis, sinusitis, pharyngitis, laryngitis, and tracheitis), and higher patient age. In pediatric practices, acute sinusitis and bronchitis were the variables with the strongest association, followed by practice preference for antibiotic prescription. The strongest association with the non-prescription of antibiotics was practice preference for phytopharmaceuticals and the specific diagnosis of a viral infection. Conclusion: This study shows a high prevalence of antibiotic prescribing for patients with ALURTI in a primary care setting, especially in adult patients; physician related factors play an important role that should be addressed in interventions to reduce potentially inappropriate antibiotic prescribing.

Clinical Decision Support Tools

Chronic rhinosinusitis (CRS) and allergic rhinitis (AR) are two highly prevalent airway diseases in the United States. While the coexistence of CRS and asthma is well recognized, less is known about the development of new-onset asthma in CRS, particularly in the context of comorbid AR. This study assessed the impact of CRS and AR on incident asthma using a large electronic health record (EHR) database. We conducted a retrospective cohort study using the TriNetX US Collaborative Network, a federated EHR platform encompassing over 100 million patients. Adults ≥ 18 years between January 2009 and December 2019 with CRS were compared to controls without CRS. A second analysis compared patients with CRS and concurrent AR to those with CRS alone. Supplemental analyses substituted chronic rhinosinusitis with nasal polyps (CRSwNP) for CRS. Propensity score matching balanced cohorts on demographics and comorbidities. Primary outcomes were new-onset asthma and asthma exacerbations, assessed at 1, 2, and 5 years. After matching, pre-existing CRS was associated with higher risk of new-onset asthma (adjusted relative risk [aRR] = 1.42, 95% CI 1.36-1.48) and exacerbations (aRR = 1.87, 95% CI 1.75-2.00) at 1 year versus CRS controls, with similar trends at 2 and 5 years. Coexisting AR further amplified risk: patients with CRS + AR had increased asthma incidence relative to CRS alone at 1 year (aRR = 1.69, 95% CI 1.65-1.73), 2 years (aRR = 1.65, 95% CI 1.62-1.68), and 5 years (aRR = 1.58, 95% CI 1.56-1.60), with more than doubled exacerbation risk across all time points. Directionally similar findings were observed in CRSwNP analyses. CRS is associated with increased risk of incident asthma and subsequent exacerbations, and coexisting AR identifies a higher-risk phenotype within CRS. These findings highlight the need for phenotype-informed studies to determine whether targeted upper-airway management can mitigate downstream asthma burden.

Background Many studies conducted in healthcare settings with limited resources reported healthcare associated infections (HAIs) rates higher than in developed countries. Hand hygiene is considered as the most effective procedure for reducing infection in a wide variety of settings. The aim of this study was to assess the effectiveness of an intervention program to improve knowledge and perception of hand hygiene among healthcare workers (HCWs). Methods We conducted a prospective before-and-after study design in university hospital Sahloul, Sousse, Tunisia, from January 2015 to December 2016. The same questionnaire, constructed by the WHO was distributed and collected at HCWs’ workplace. Results A total of 149 and 146 HCWs were enrolled, respectively at pre and post intervention. The majority was nursed women aged between 20 and 35 in pre intervention, whereas in post intervention the majority where physicians. Globally, our results showed tendencies toward improvement, but only two items were significant: the HW is the appropriate technique after injury (73.5% vs 86.8%; p = 0.006) and the hands of HCWs are the lead vehicle of HAIs (65.1% vs 83.6%; p = 0.01). On the other hand, judging by the HCWs’ responses, the probably most effective intervention to enhance hand hygiene compliance was that an alcohol-based hand-rub is available at each point of patient care. In contrast, empowering patients to remind HCWs to perform hand hygiene was mostly rated to be the least effective intervention both in pre and post intervention. Conclusions Our intervention to positively influence hand hygiene knowledge was unfortunately less effective than we had hoped it would be, which suggests a HCWs’ reluctance to attend the training program. Key messages Hand hygiene is considered as the most effective procedure for reducing nosocomial infection. the intervention to positively influence hand hygiene knowledge was effective.

Introduction Mechanical thrombectomy (MT) represents a paradigm shift of treatment in modern medicine. However, a significant awareness gap persists amongst medical students and neurology trainees regarding MT and neurointervention, both domestically and globally. This study aimed to evaluate the impact of a targeted educational workshop combining didactic lectures and hands on neuroendovascular simulation to enhance awareness of this subspeciality and as well as global stroke disparities. Materials/Methods We conducted a pre and post intervention study involving 43 medical trainees spanning in training from first year of medical school to residents (24% M1, 24% M2, 12% M3, 5% M4, 12% resident) recruited through the Student Interest Group in Neurology (SIGN) at our hospitals’ affiliated medical schools. The intervention comprised of didactic sessions discussing neuroendovascular training pathways, global stroke care disparities and women in Neuro‐IR, followed by a hands on neuroendovascular workshop simulating MT and clot science. Participants completed pre and post intervention surveys assessing knowledge and interest in neuroendovascular procedures. Survey completion rates were 100% pre intervention and 77% post intervention. Results Pre‐intervention data revealed limited exposure to neuroendovascular procedures, with only 26% reporting prior exposure during medical training. 62% of participants self‐reported as “not at all knowledgeable” or “not very knowledgeable” about neurointerventional radiology. Only 59% were familiar with mechanical thrombectomy, and 40% were aware of its utilization rate for large vessel occlusions in the USA. Post‐intervention, 100% of participants reported increased awareness of specialties involved in neurointervention and conditions amenable to neuroendovascular treatment. 97% expressed confidence in explaining mechanical thrombectomy to peers. All participants reported enhanced understanding of local and global neurointerventional service needs. Interest in pursuing further training in neurointervention increased by 64%, with 96% indicating likelihood to explore a career in the field. 70% expressed inspiration to consider working in underserved areas. Participants suggested earlier exposure in training, expanding these workshops throughout medical schools, and structuring a medical student elective would impact their understanding and interest within neurointervention. Conclusion This study demonstrates the significant impact of a targeted educational intervention on medical trainees’ awareness and interest in neurointerventional radiology. The findings emphasize the importance of early exposure to this subspecialty, particularly given the variability in training center resources. Implementation of similar workshops could address the current knowledge gap and potentially influence career trajectories in this critical field.

BackgroundUpper respiratory infections, acute sinus infections, and sore throats are common symptoms that cause patients to seek medical care. Despite well-established treatment guidelines, studies indicate that antibiotics are prescribed far more frequently than appropriate, raising a multitude of clinical issues.MethodsThe primary goal of this study was to increase guideline adherence rates for acute sinusitis, pharyngitis, and upper respiratory tract infections (URIs). This study was the first Plan-Do-Study-Act (PDSA) cycle in a quality improvement program at an internal medicine resident faculty practice at a university-affiliated community hospital internal medicine residency program. To improve guideline adherence for respiratory infections, a package of small-scale interventions was implemented aimed at improving patient and provider education regarding viral and bacterial infections and the necessity for antibiotics. The data from this study was compared with a previously published study in this practice, which evaluated the adherence rates for the treatment guidelines before the changes, to determine effectiveness of the modifications. After the first PDSA cycle, providers were surveyed to determine barriers to adherence to antibiotic prescribing guidelines.ResultsAfter the interventions, antibiotic guideline adherence for URI improved from a rate of 79.28 to 88.58% with a p-value of 0.004. The increase of adherence rates for sinusitis and pharyngitis were 41.7–57.58% (p=0.086) and 24.0–25.0% (p=0.918), respectively. The overall change in guideline adherence for the three conditions increased from 57.2 to 78.6% with the implementations (p<0.001). In planning for future PDSA cycles, a fishbone diagram was constructed in order to identify all perceived facets of the problem of non-adherence to the treatment guidelines for URIs, sinusitis, and pharyngitis. From the fishbone diagram and the provider survey, several potential directions for future work are discussed.ConclusionsPassive interventions can result in small changes in antibiotic guideline adherence, but further PDSA cycles using more active methodologies are needed.

Australia has relatively high rates of antibiotic prescribing in the community. The aim of this study was to identify clinical insights regarding antibiotic prescribing choices for the management of common upper respiratory tract infections through analysis of anonymised primary care electronic medical records (EMRs). EMR data relating to 1926 antimicrobial prescriptions for tonsillitis, pharyngitis and acute rhinosinusitis in adults and acute otitis media (AOM) in children were extracted from 11 general practices in Victoria and analysed for consistency with Australian Therapeutic Guidelines recommendations. The analysis suggests that underdosing of amoxicillin for AOM in children, prescription of phenoxymethylpenicillin at doses not consistent with Therapeutic Guidelines recommendations for tonsillitis and pharyngitis in adults,and potential overprescription of antibiotics for patients with acute rhinosinusitis are not infrequent ingeneral practice. Anonymised EMR data provide an opportunity to analyse antibiotic prescribing practices at scale and provide insights relevant to clinical practice.