Implementation of indication-based antibiotic order sentences improves antibiotic use in emergency departments

INTRODUCTION

Prior data have suggested that suboptimal antibiotic prescribing in the emergency department (ED) is common for uncomplicated lower respiratory tract infections (LRTI), urinary tract infections (UTI), and acute bacterial skin and skin structure infections (ABSSSI). The objective of this study was to measure the effect of indication-based antibiotic order sentences (AOS) on optimal antibiotic prescribing in the ED.

METHODS

This was an IRB-approved quasi-experiment of adults prescribed antibiotics in EDs for uncomplicated LRTI, UTI, or ABSSSI from January to June 2019 (pre-implementation) and September to December 2021 (post-implementation). AOS implementation occurred in July 2021. AOS are lean process, electronic discharge prescriptions retrievable by name or indication within the discharge order field. The primary outcome was optimal prescribing, defined as correct antibiotic selection, dose, and duration per local and national guidelines. Descriptive and bivariate statistics were performed; multivariable logistic regression was used to determine variables associated with optimal prescribing.

RESULTS

A total of 294 patients were included: 147 pre-group and 147 post-group. Overall optimal prescribing improved from 12 (8%) to 34 (23%) (P < 0.001). Individual components of optimal prescribing were optimal selection at 90 (61%) vs 117 (80%) (P < 0.001), optimal dose at 99 (67%) vs 115 (78%) (P = 0.036), and optimal duration at 38 (26%) vs 50 (34%) (P = 0.13) for pre- and post-group, respectively. AOS was independently associated with optimal prescribing after multivariable logistic regression analysis (adjOR, 3.6; 95%CI,1.7-7.2). A post-hoc analysis showed low uptake of AOS by ED prescribers.

CONCLUSIONS

AOS are an efficient and promising strategy to enhance antimicrobial stewardship in the ED.

910. Impact of Indication-based Antibiotic Order Sentences on Optimal Prescribing in the Emergency Department: A Quasi-experiment

Background

A prior study demonstrated suboptimal antibiotic prescribing in the emergency department (ED) at 77.4% for uncomplicated lower respiratory tract infections (LRTI), urinary tract infections (UTI), and acute bacterial skin and skin structure infections (ABSSSI). This study measured the effect of indication-based antibiotic order sentences (AOS) on prescribing.

Methods

IRB-approved quasi-experiment of adults prescribed antibiotics in ED for uncomplicated LRTI, UTI, or ABSSSI from January - June 2019 (pre-group) or September - December 2021 (post-group). Exclusion: hospital admission, immunocompromised, active cancer, or prophylactic antibiotics. AOS are lean process, electronic discharge prescriptions retrievable by name or indication; AOS implementation occurred July 2021. Optimal prescribing was defined as the correct antibiotic selection, dose, and duration per local and national guidelines. Seven-day endpoints: antibiotic escalation, ED or hospital readmission, any outpatient contact, and reported adverse drug event (ADE). Descriptive and bivariate statistics performed. Variables considered for multivariable logistic regression had p< 0.2 or plausible association with optimal prescribing.

Results

294 patients included: 147-pre and 147-post. Patient characteristics are in Table 1. Overall optimal prescribing improved from 12 (8.2%) to 34 (23.1%) (p< 0.001). Breakdown of optimal prescribing in pre- and post-groups: selection 90 (61.2%) vs 117 (79.6%) (p< 0.001), dose 99 (67.3%) vs 115 (78.2%) (p=0.036), duration 38 (25.9%) vs 50 (34%) (p=0.126). After adjustment, AOS were independently associated with optimal prescribing (Table 2). Secondary endpoints: antibiotic escalation 10 (6.8%) vs 7 (4.8%) (p=0.662), hospital or ED readmission 12 (8.2%) vs 10 (6.8%) (p=0.658), outpatient contact 31 (21.1%) vs 28 (19%) (p=0.662), and ADE 2 (1.4%) vs 4 (2.7%) (p=0.684). Post-hoc analysis showed suboptimal uptake of AOS by ED prescribers. Table 1:

P-580 Cumulative live birth rate of oocyte in-vitro maturation with a pre-maturation step in women with polycystic ovary syndrome or high antral follicle count

Study question

What is the cumulative live birth rate (CLBR) at 24 months of women undergoing oocyte in vitro maturation (IVM) a with pre-maturation step (CAPA-IVM)?

Summary answer

The CLBR at 24 months with CAPA-IVM was 38.2%.

What is known already

IVM with a pre-maturation step, known as capacitation IVM (CAPA-IVM) improves the competence of oocytes matured in-vitro by sustaining meiotic arrest to allow the synchronization of cytoplasmic and genetic maturation of the oocytes. Results from a randomized controlled trial showed that CAPA-IVM resulted in a live birth rate after the first transfer of 35.2% which was non-inferior to IVF. There is a lack of data on cumulative live birth following CAPA-IVM.

Study design, size, duration

A multi-center, retrospective study, performed at IVFMD, My Duc Hospital and IVFMD Phu Nhuan, My Duc Phu Nhuan Hospital from 1 January 2017 to 31 December 2019.

Participants/materials, setting, methods

All women with polycystic ovary syndrome (PCOS) or high antral follicle count (AFC) treated with a CAPA-IVM cycle were recruited to the study. All embryos were frozen at day 3. Cumulative live birth was difined as at least one live birth resulting from initiated CAPA-IVM cycle. If the women did not return for embryo transfer, outcomes were followed up until 24 months from aspiration day. Logistic regression was performed to assess which factors predicted CLBR.

Main results and the role of chance

Between 1 January 2019 and 31 December 2019, there were 374 eligible women included in the study, among them, 368 patients had embryos for transfer (98.4%) and six patients had no embryo for transfer (1.6%). A total of 496 frozen embryo transfer (FET) cycles from 368 patients were performed. Mean age and body max index (BMI) were 29.5±3.21 years and 22.3±3.09, respectively. The maturation rate was 63.2%. The median number of embryos was 4.0 [2.00; 6.00]. The cumulative clinical pregnancy rate was 60.4%, cumulative ongoing pregnancy rate was 51.6%. At 24 months after starting the treatment, the CLBR of CAPA-IVM was 38.2%. Multivariate analysis showed that patient age and number of metaphase II oocytes were the predictive factors for cumulative live birth after CAPA-IVM.

Limitations, reasons for caution

The study limitation derives from its retrospective nature. The generalizability of the study may be limited due to the single ethnicity group.

Wider implications of the findings

In patients with PCOS or high AFC, CAPA-IVM was viable and resulted in acceptable CLBR. CAPA-IVM may be the first-line treatment for women with PCOS or high AFC requiring assisted reproduction.

Trial registration number

not applicable

O-223 Latest development of IVM in assisted reproduction

Latest development of IVM in assisted reproduction

In vitro maturation (IVM) is an assisted reproductive technology involving collection of immature cumulus-oocyte complexes at the prophase I stage, which are then matured to the metaphase II stage in vitro. IVM has several advantages over IVF, including negligible risk of ovarian hyperstimulation syndrome, lower medication costs, and patient convenience.

Given that IVM can be done within a relatively short time frame without the need for ovarian stimulation, it is particularly useful for fertility preservation in patients with cancer who are unable to delay chemotherapy, or in women with breast cancer for whom exposure to elevated estradiol concentrations may accelerate their disease. The European Society of Human Reproduction and Embryology (ESHRE) Guideline on Female Fertility Preservation published in 2020 suggested IVM as a fertility preservation technique.

The Practice Committees of ASRM in 2021 published the document that presented an overview of published evidence supporting the conclusion that IVM should no longer be considered an experimental technique. The potential for wider clinical application of IVM was suggested. Patient populations particularly suited to the use of IVM include women with polycystic ovaries, have higher risk of ovarian hyperstimulation syndrome, and those requiring fertility preservation.

During the last two decades, IVM has been utilized for patients with PCOS to reduce the health risks associated with ovarian hyperstimulation syndrome, for fertility preservation, or just as an alternative, more user-friendly approach to ART.

The effectiveness of IVM relies on successful synchronization of meiotic and cytoplasmic maturation of oocytes. Efforts to improve the efficacy of IVM have included the use of new IVM culture systems, aimed at enhancing the competence of IVM oocytes. Recently, the use of oocyte prematuration (or pre-IVM) culture systems to prevent spontaneous in vitro maturation processes and maintain cumulus-oocyte gap junctional communication have been described in humans.

Over the last five years, a new biphasic IVM culture system has been developed to improve the efficacy of IVM. Recent promising data from this new IVM culture system, called capacitation (CAPA) IVM, showed promising results. CAPA-IVM involves successfully maturing oocytes from small 2–8 mm follicles with no hCG injected prior to oocyte retrieval. Recently, a large RCT compared the efficacy of CAPA IVM and conventional IVF/ICSI in women with PCO showed that CAPA (biphasic) IVM was non-inferior to IVF in term of live birth rate after the first embryo transfer.

One of the concerns regarding IVM is the health of babies after utilization of this procedure. Based on currently available data, IVM appears to be safe from a neonatal health and childhood development perspective.

There is still room for further development of more efficient IVM protocols (89). Recent knowledge about oocyte physiology and development can be translated into clinical practice to improve the efficacy of these protocols.

There are several reasons why all major modern ART centers should have IVM facilities and protocols available. These include the likelihood of wider application of IVM in the future, the requirement to manage indications where IVM is the only option (e.g. fertility preservation, GROS), the increasing need for more patient-friendly ART treatment, and the fact that IVM protocols are improving thanks to advances in knowledge on human follicular and oocyte development.

147. Antibiotic Prescribing: Shorter is Also Better in the Emergency Department

Background

Published information suggests room for improvement in antibiotics prescribed on discharge from the emergency department (ED). The objective of this study was to evaluate antibiotic prescribing in the ED for uncomplicated infections of the lower respiratory tract (LRTI), urinary tract (UTI), and skin and skin structure (SSTI).

Methods

IRB-approved retrospective cross-sectional study of patients discharged from the ED from January to June 2019 at 6 locations. Inclusion: ≥ 18 years old and uncomplicated LRTI, UTI, or SSTI. Exclusion: hospital admission. Appropriate prescribing was defined having all three of the following correct per local and national guidelines: antibiotic selection, dose, and duration. Correct duration: 5 days for LRTI and SSTI; 3 days for trimethoprim-sulfamethoxazole (TMP-SMX), 5 days for nitrofurantoin (NFT), and 7 days for beta-lactams for UTIs. Endpoints within 7 days: antibiotic escalation, readmission to ED or hospital, any outpatient contact, and report of adverse drug event (ADE). Endpoints within 90 days: Clostridioides difficile infection (CDI). Descriptive and bivariable statistics were performed.

Results

Inappropriate prescribing: 77% (304) vs. appropriate 23% (89). Infection type: 47.8% SSTI, 30% UTI, and 22.1% LRTI. SSTI was associated with the greatest proportion of inappropriate prescribing at 89.4% (Figure 1). Comparisons for inappropriate vs. appropriate groups: 15.8% vs. 22.5% for beta-lactam allergy and 23.4% vs. 19.1% for cultures drawn in ED. Most common antibiotics for inappropriate vs. appropriate: first generation cephalosporin at 70.1% vs. 7.3% (p< 0.05), TMP-SMX at 14.3% vs. 12.2% (p=0.75), and NFT at 7.8% vs. 65.9% (p< 0.05). Prescriptions considered inappropriate were primarily driven by excess duration (Figure 2). Endpoints for inappropriate vs. appropriate groups: antibiotic escalation at 6.6% (2.8% were due to cultures drawn in the ED) vs. 1.1% (p=0.06), readmission at 8.6% vs. 9.0% (p=0.9), any outpatient contact at 18.4% vs. 19.1% (p=0.89), and report of ADE at 1.3% vs. 1.1%. No CDI in either group.

Figure 1. Appropriateness of Discharge Prescriptions by Infection Type, N = 393

Figure 2. Subset Analysis: Reasons for Inappropriate Prescribing, n = 304

Conclusion

The main reason for inappropriate prescribing in the ED was excess duration of therapy, making this an area of opportunity for future antibiotic stewardship improvement.

Disclosures

Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Susan L. Davis, PharmD, Nothing to disclose

56. High Frequencies of Adverse Drug Events with Intravenous vs Oral High-Dose Trimethoprim-Sulfamethoxazole: An Opportunity for Antibiotic Stewardship

Background

Trimethoprim-sulfamethoxazole (TMP-SMX) is a high-bioavailability antibiotic associated with potentially serious adverse drug events (ADE). The objective of this study was to evaluate the safety of intravenous (IV) and oral (PO) high-dose TMP-SMX.

Methods

IRB-approved retrospective cohort of hospitalized patients from January 2016 to November 2020. Inclusion: ≥ 18 years old and > 72 hours of renally adjusted high-dose TMP-SMX defined as ≥ 5 mg/kg/day of TMP. Exclusion: prophylaxis. Endpoints during treatment: hyponatremia with sodium < 135 mmol/L, hyperkalemia with potassium > 5 mmol/L, serum creatinine increase of ≥ 0.3 mg/dL or 1.5-1.9 times from baseline, and fluid overload on physical exam. Descriptive and bivariate statistics were performed.

Results

Each group included 50 patients (Table 1). Intensive care unit patients comprised 82% IV TMP-SMX compared to 32% PO. Most common infection: respiratory tract 86% IV and 68.1% PO. Most common organisms were Stenotrophomonas maltophilia (52% IV and 18% PO) and Pneumocystis jiroveci (16.3% IV and 62% PO). Median (IQR) days of inpatient therapy: 6 (5-7.5) PO vs. 7.5 (6-11.3) IV. Median (IQR) days of total duration: 9 (6-21.5) PO vs. 12 (7.8-14) IV (p=0.93). IV group: 88% of patients received >1 liter of D5W daily. Median (IQR) liters of D5W daily was 1 (1-1.5). 56% had a diuretic added, and 38% had a diuretic dose increase. Majority of patients (78%) on IV were taking other oral medications. 100% patients experienced any adverse event with IV vs. 70% with PO (unAdjOR 2.43; 95% CI 1.89-3.13). Most common ADE in both groups: hyponatremia, hyperkalemia, and elevated creatinine. Hyponatremia: 92% with IV and 32% with PO (unAdjOR 24.44; 95% CI 7.50-79.68). Edema on physical exam, an ADE specific to IV TMP-SMX, was the third most common side effect in the IV group. Relative changes from baseline in sodium, potassium, and creatinine from those who experienced hyponatremia, hyperkalemia and elevated creatinine were listed in Table 2.

Table 1. Baseline and Clinical Characteristics

Table 2. Adverse Effects

Conclusion

Patients on IV TMP-SMX therapy were more likely to experience an ADE compared to PO, likely driven by the high volume of free water. Most patients on IV TMP-SMX were on other PO medications, suggesting a missed stewardship opportunity for IV to PO conversion to reduce patient harm.

Disclosures

Susan L. Davis, PharmD, Nothing to disclose Michael P. Veve, Pharm.D., Cumberland (Grant/Research Support)Paratek Pharmaceuticals (Research Grant or Support) Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

O-233 Micronized progesterone plus dydrogesterone versus micronized progesterone alone for luteal phase support in frozen-thawed cycles: a prospective cohort study

Study question

Does the addition of oral dydrogesterone to vaginal progesterone as luteal phase support improve pregnancy outcomes during frozen embryo transfer (FET) cycles compared with vaginal progesterone alone?

Summary answer

Luteal phase support with oral dydrogesterone added to vaginal progesterone improves live birth rates and reduces miscarriage rates compared with vaginal progesterone alone.

What is known already

Progesterone is an important hormone that triggers secretory transformation of the endometrium to allow implantation of the embryo. During in vitro fertilization (IVF), exogenous progesterone is administered for luteal phase support. However, there is wide inter-individual variation in absorption of progesterone via the vaginal wall. Oral dydrogesterone is effective and well tolerated when used to provide luteal phase support after fresh embryo transfer. However, there are currently no data on the effectiveness of luteal phase support with the combination of dydrogesterone with vaginal micronized progesterone compared with vaginal micronized progesterone after FET.

Study design, size, duration

Prospective cohort study conducted at an academic infertility center in Vietnam from 26 June 2019 to 30 March 2020.

Participants/materials, setting, methods

We studied 1364 women undergoing IVF with FET. The luteal support regimen was either vaginal micronized progesterone 400 mg twice daily plus oral dydrogesterone 10 mg twice daily (second part of the study) or vaginal micronized progesterone 400 mg twice daily (first 4 months of the study). The primary endpoint was live birth after the first FET of the started cycle, with miscarriage &lt;12 weeks as one of the secondary endpoints.

Main results and the role of chance

The vaginal progesterone + dydrogesterone group and vaginal progesterone groups included 732 and 632 participants, respectively. Live birth rates were 46.3% versus 41.3%, respectively (rate ratio [RR] 1.12, 95% confidence interval [CI] 0.99–1.27, p = 0.06; multivariate analysis RR 1.30 (95% CI 1.01–1.68), p = 0.042), with a statistically significant lower rate of miscarriage at &lt; 12 weeks (3.4% vs 6.6%; RR 0.51, 95% CI 0.32–0.83; p = 0.009). Birth weight of both singletons (2971.0 ± 628.4 vs. 3118.8 ± 559.2 g; p = 0.004) and twins (2175.5 ± 494.8 vs. 2494.2 ± 584.7; p = 0.002) was significantly lower in the progesterone plus dydrogesterone versus progesterone group.

Limitations, reasons for caution

The study were the open-label design and the non-randomized nature of the sequential administration of study treatments. However, our systematic comparison of the two strategies was able to be performed much more rapidly than a conventional randomized controlled trial. In addition, the single ethnicity population limits external generalizability.

Wider implications of the findings

Oral dydrogesterone in addition to vaginal progesterone as luteal phase support in FET cycles can reduce the miscarriage rate and improve the live birth rate. Carefully planned prospective cohort studies with limited bias could be used as an alternative to randomized controlled clinical trials to inform clinical practice.

Trial registration number

NCT03998761

2685. Oral Third-Generation Cephalosporins vs. Levofloxacin for Antibacterial Prophylaxis in Neutropenic Patients with Hematologic Malignancies

Background

Fluoroquinolone (FQ) prophylaxis for high-risk neutropenic patients has been shown to reduce rates of febrile neutropenia and is standard at many centers. For patients who cannot receive a FQ, oral third-generation cephalosporins (OTGCs) are often used as an alternative; however, this strategy is not well studied. We sought to compare clinically-relevant outcomes in patients receiving FQ vs. OTGC prophylaxis.

Methods

This was a retrospective cohort study of adults who were admitted to the Malignant Hematology service at the University of California, San Francisco between December 2012 and June 2018 and received >48 hours of an OTGC (cefdinir or cefpodoxime) or an FQ (levofloxacin) for neutropenic prophylaxis. For each OTGC patient, an FQ patient was randomly selected from the same admission year. Exclusion criteria were fever on admission, receipt of systemic antibiotics prior to or during the prophylaxis period, diagnosis of acute promyelocytic leukemia, and crossover. A multivariable logistic regression analysis adjusting for age, QTc, Charlson Comorbidity Index, underlying diagnosis, receipt of stem cell transplant (SCT), and duration of neutropenia was used to compare the groups with respect to a primary composite outcome of 30-day in-hospital mortality, intensive care unit (ICU) admission, and bacteremia.

Results

Of 520 patients screened, 173 (33.3%) were included in the study; 76 of these received an OTGC and 97 received an FQ. Hematologic diagnoses included multiple myeloma (38.2%), acute myeloid leukemia (29.5%), acute lymphoblastic leukemia (8.7%), B-cell lymphoma (12.7%), aplastic anemia (2.9%), and others (3.5%). During admission, 9.2% underwent allogeneic SCT and 28.3% underwent autologous SCT. Outcomes are shown in Table 1.

Conclusion

Prophylaxis with an OTGC rather than a FQ was not associated with worse outcomes in this pragmatic evaluation of a heterogeneous group of patients with hematologic malignancies. In this multivariable model, neutropenia lasting more than 7 days was the only consistent predictor of failure across outcomes, suggesting that degree of immunosuppression is a much more significant driver of poor outcomes in this population than is prophylaxis choice. Further evaluation of the role of prophylaxis is needed.

Disclosures

All authors: No reported disclosures.

Sharing and community curation of mass spectrometry data with Global Natural Products Social Molecular Networking

The potential of the diverse chemistries present in natural products (NP) for biotechnology and medicine remains untapped because NP databases are not searchable with raw data and the NP community has no way to share data other than in published papers. Although mass spectrometry (MS) techniques are well-suited to high-throughput characterization of NP, there is a pressing need for an infrastructure to enable sharing and curation of data. We present Global Natural Products Social Molecular Networking (GNPS; http://gnps.ucsd.edu), an open-access knowledge base for community-wide organization and sharing of raw, processed or identified tandem mass (MS/MS) spectrometry data. In GNPS, crowdsourced curation of freely available community-wide reference MS libraries will underpin improved annotations. Data-driven social-networking should facilitate identification of spectra and foster collaborations. We also introduce the concept of 'living data' through continuous reanalysis of deposited data.

Sharing and community curation of mass spectrometry data with Global Natural Products Social Molecular Networking

The potential of the diverse chemistries present in natural products (NP) for biotechnology and medicine remains untapped because NP databases are not searchable with raw data and the NP community has no way to share data other than in published papers. Although mass spectrometry (MS) techniques are well-suited to high-throughput characterization of NP, there is a pressing need for an infrastructure to enable sharing and curation of data. We present Global Natural Products Social Molecular Networking (GNPS; http://gnps.ucsd.edu), an open-access knowledge base for community-wide organization and sharing of raw, processed or identified tandem mass (MS/MS) spectrometry data. In GNPS, crowdsourced curation of freely available community-wide reference MS libraries will underpin improved annotations. Data-driven social-networking should facilitate identification of spectra and foster collaborations. We also introduce the concept of 'living data' through continuous reanalysis of deposited data.

Phenol soluble modulin (PSM) variants of community-associated methicillin-resistant Staphylococcus aureus (MRSA) captured using mass spectrometry-based molecular networking

Molecular genetic analysis indicates that the problematic human bacterial pathogen methicillin-resistant Staphylococcus aureus possesses more than 2000 open reading frames in its genome. This number of potential gene products, coupled with intrinsic mechanisms of posttranslational modification, endows methicillin-resistant Staphylococcus aureus with a highly complex biochemical repertoire. Recent proteomic and metabolomic advances have provided methodologies to better understand and characterize the biosynthetic factors released by microbial organisms. Here, the emerging tool of mass spectrometry-based molecular networking was used to visualize and map the repertoire of biosynthetic factors produced by a community-associated methicillin-resistant Staphylococcus aureus strain representative of the epidemic USA300 clone. In particular, the study focused on elucidating the complexity of the recently discovered phenol soluble modulin family of peptides when placed under various antibiotic treatment stresses. Novel PSM truncated variant peptides were captured, and the type of variants that were clustered by the molecular networks platform changed in response to the different antibiotic treatment conditions. After discovery, a group of the peptides were selected for functional analysis in vitro. The peptides displayed bioactive properties including the ability to induce proinflammatory responses in human THP-1 monocytes. Additionally, the tested peptides did not display antimicrobial activity as previously reported for other phenol soluble modulin truncated variants. Our findings reveal that the PSM family of peptides are quite structurally diverse, and suggest a single phenol soluble modulin parent peptide can functionally spawn differential bioactivities in response to various external stimuli.

Chronic pain and head injury following motor vehicle collisions: a double whammy or different sides of a coin

Chronic pain and head injury are common and burdensome sequelae of motor vehicle collisions. The aim of this study was to compare differences in physical injury and functional impairment, psychological distress and pain coping in head injured and non-head injured chronic pain persons subsequent to motor vehicle collisions. Two groups of 54 participants matched in terms of age, gender, and years of formal education underwent a psychological-legal assessment. As part of the assessment, participants completed the Multidimensional Pain Inventory, Sickness Impact Profile, Minnesota Multiphasic Personality Inventory-2, and Coping Strategies Questionnaires. Select scales from questionnaires were combined and underwent multivariate analyses of covariance to test the effects of pain sites at the time of psychological-legal assessment (low, high) and head injury status (head injured and non-head injured chronic pain). Overall, some differences between the two groups were noted but the results did not strongly support the hypothesis that head injured chronic pain participants have a greater physical or psychological burden than non-head injured chronic pain participants. The results suggest the import of assessing and managing pain sites and pain severity in persons injured in motor vehicle collisions.

[Contribution of panoramic tomography in exploration of maxillary sinuses (author's transl)]

Panoramic tomography (orthopantomography) is useful in exploration of maxillary sinuses, specially of its floor and its connection with teeth alveoles. Interest of this examination in the diagnosis of sinusian cyst of polypus, apical teeth cyst growing in the sinus, fistula from mouth to sinus, repeating sinusitis by dental infectious focus, sinusian stranger corps and finally, in the schedule or surveillance of the extension of sinus maxillary cancer to the posterior wall, particularly to the pterygomaxillary fossae.