Tympanostomy tubes for children with acute otitis media

QuestionA 30-month-old patient in our clinic has had 4 episodes of acute otitis media (AOM) in the past 6 months. Should I refer the child and family to an ear, nose, and throat surgeon to consider tympanostomy tube placement, or should we continue medical management with antibiotics?AnswerAcute otitis media is common among children in Canada, particularly those younger than 3 years of age. Recurrent AOM (3 or more episodes of AOM in a 6-month period or 4 or more episodes of AOM in a 12-month period) is also common in this age group. Routine immunization of infants and children in Canada with pneumococcal conjugate vaccines (initially the 7-valent PCV7 and more recently the 13-valent PCV13) considerably reduced the overall incidence of AOM. Tympanostomy tube placement decreases the incidence of AOM compared with medical management. However, the procedure is no longer superior to medical management after a 2-year period. Both tympanostomy tube placement and medical management are valid options for children with recurrent AOM, and shared decision making with caregivers is recommended.     

Antibiotics for nasopharyngitis are associated with a lower risk of office-based physician visit for acute otitis media within 14 days for 3- to 6-year-old children

Objectives  This study was designed to analyse factors potentially influencing children's return visits to physicians for symptoms of acute otitis media (AOM) within 14 days after being diagnosed with nasopharyngitis (NP), and the impact of recent antibiotic use.
Design  A controlled population-based pharmaco-epidemiological trial in 3- to 6-year-old children conducted from January to May 2000.
Setting  Three different geographical regions in France.
Participants  Among 2507 eligible children, 2456 could be analysed and 505 children had 634 office-based physician visits (OBPV) for NP symptoms.
Interventions  The statistical associations between antibiotics prescribed for NP and an OBPV for AOM within 14 days in a population-based study were analysed along with risk factors of AOM.
Main outcomes measure  Clinical events and antibiotic use.
Results  During the 2 weeks following physician-diagnosed NP, antibiotic use, especially a beta-lactam, significantly decreased the risk of OBPV for AOM in children (odds ratio = 0.2; 95% confidence interval = 0.09–0.7; P  = 0.002).
Conclusion  Antibiotics prescribed to children for NP seem to protect during the following 2 weeks against the risk of OBPV for AOM. It remains to be determined whether a subgroup at high risk of developing AOM after a viral infection exists and what might be the best strategy to adopt for NP in a national programme of optimal antibiotic use.     

Burden of acute otitis media on Canadian families

Objective

To estimate the burden of acute otitis media (AOM) on Canadian families.

Design

Telephone survey using random-digit dialing.

Setting

All Canadian provinces between May and June 2008.

Participants

Caregivers of 1 or more children aged 6 months to 5 years.

Main outcome measures

Caregivers’ reports on the number of AOM episodes experienced by the child in the past 12 months, as well as disease characteristics, health services and medication use, time spent on medical consultations (including travel), and time taken off from work to care for the sick children.

Results

A total of 502 eligible caregivers were recruited, 161 (32%) of whom reported at least 1 AOM episode for their children and 42 (8%) of whom reported 3 or more episodes during the past 12 months. Most children (94%, 151 of 161) visited with health professionals during their most recent AOM episodes. The average time required for medical examination was 3.1 hours in an emergency department and 1.8 hours in an outpatient clinic. Overall, 93% of episodes resulted in antibiotics use. A substantial proportion of caregivers (38%) missed work during this time; the average time taken off work was 15.9 hours.

Conclusion

In Canada, episodes of AOM are still associated with substantial use of health services and indirect costs to the caregivers.     

Update on acute otitis media in children younger than 2 years of age

Question As concern about antimicrobial resistance grows, I am aware of the need to reduce unnecessary antibiotic treatment; however, in my practice I see many children with acute otitis media (AOM) and this is the most common reason I prescribe antibiotics. Most of these children are young and otherwise healthy, and I am uncertain about when to prescribe antibiotics and when to endorse “watchful waiting.” Which children will benefit from antibiotic treatment?Answer Current Canadian guidelines recommend all children younger than 2 years of age with otalgia due to AOM and fever greater than 39°C be considered for treatment with amoxicillin. Watchful waiting is indicated only for children older than 6 months with mild-to-moderate AOM. Recent evidence suggests young children with a definitive diagnosis of AOM will benefit from antibiotics and experience fewer treatment failures compared with placebo, regardless of the severity of otitis. These studies do not challenge watchful waiting directly, and determining which children will improve spontaneously remains an enigma.     

Comparative study of once-weekly azithromycin and once-daily amoxicillin treatments in prevention of recurrent acute otitis media in children.

Continuous chemoprophylaxis is effective in the prevention of new episodes of acute otitis media (AOM) in otitis-prone children, but compliance can be a problem and thus efficacy can be decreased. Intermittent chemoprophylaxis has so far shown conflicting results. Azithromycin, which has a peculiar pharmacokinetics, resulting, even after a single dose, in persistently elevated concentrations in respiratory tissues, could permit a periodic administration with higher compliance. We compared a 6-month course of once-weekly azithromycin (5 or 10 mg/kg of body weight) with that of once-daily amoxicillin (20 mg/kg) in a single-blind, randomized study of prophylaxis for recurrent AOM in 159 children aged 6 months to 5 years with at least three episodes of AOM in the preceding 6 months. In the amoxicillin group, 23 (31.1%) of 74 children developed 29 episodes of AOM, while in the 10-mg/kg azithromycin group, 11 (14.9%) of 74 children experienced 15 episodes. The 5-mg/kg/week azithromycin trial was prematurely interrupted after nine cases, due to the high occurrence rate of AOM (55.5%). During the 6-month prophylaxis period, the proportion of children with middle ear effusion declined similarly in both groups. No substantial modification of the nasopharyngeal flora was noted at the end of prophylaxis in both antimicrobial groups. In the 6-month-postprophylaxis follow-up period, about 40% of children in both groups again developed AOM. Azithromycin at 10 mg/kg once weekly can be regarded as a valid alternative to once-daily low-dose amoxicillin for the prophylaxis of AOM. Although in the present study no microbiological drawback was noted, accurate selection of children eligible for prophylaxis is mandatory to avoid the risk of emergence of resistant strains.     

How Do Parents of Preverbal Children With Acute Otitis Media Determine How Much Ear Pain Their Child Is Having?

The objective of this study was to determine how parents of preverbal children determine whether their child is having otalgia. We constructed 8 cases describing a 1-year-old child with acute otitis media (AOM) using various combinations of the following 6 observable symptoms: fussiness, ear tugging, eating less, fever, sleeping difficulty, and playing less. Parents of children with a history of AOM presenting for well or sick appointments to an ambulatory clinic were asked to assign a pain level to each case on a visual analog scale. Sixty-nine parents participated in the study. Each of the 6 behaviors was associated with increased pain levels (P < .0001). Ear tugging and fussiness had the highest impact on the assigned pain levels. Higher level of parental education and private insurance were associated with higher reported pain levels (P = .007 and P = .001, respectively). Because interpretation of symptoms appears to be influenced by socioeconomic status, we question the utility of using an overall pain score from a 1-item parent scale as an outcome measure in clinical trials that include preverbal children.     

High-dose versus standard-dose amoxicillin for acute otitis media

BACKGROUND: Emergence of drug-resistant bacteria has led to a recommendation to use high-dose (HD) amoxicillin (80-90 mg/kg/d) rather than standard-dose (SD) amoxicillin (40-45 mg/kg/d) to treat children with acute otitis media (AOM). OBJECTIVE: To compare the efficacy and tolerability of HD versus SD amoxicillin among children with AOM who were considered at low risk for infection with antibiotic-resistant bacteria. METHODS: A double-blind, randomized, 3-year clinical trial was conducted using participants who met the following criteria: age >3 mo, weight 相似文献   

Medical and non-medical direct costs of chronic low back pain in patients consulting primary care physicians in France

A retrospective, observational, cohort study in primary care. To determine the total direct medical and non-medical cost of chronic low back pain (LBP) in France and its associated factors. Chronic LBP affects 5–10% of the population its burden in France is unknown. Ninety-eight randomly selected general practitioners included 796 adult patients with chronic LBP between October 2001 and December 2002. Direct costs due to physician visits, investigations, medications, hospitalizations, and other medical and non-medical resource use were collected for the 6 months prior to study visit. Costs both reimbursed and not by the French health insurance system were considered. Quality of life (QoL) and disease severity were measured using Short Form (SF)-8 and Roland-Morris disability questionnaire (RMDQ), respectively. Costs were updated to represent 2007 prices. Men represented 50.6% of the 796 patients, mean age was 53 ± 11.3 years, and the duration of LBP was more than 1 year in 80.9% of patients. The total mean cost per patient over six months was 715.6€ (95% CI: 644.2–797.8). Of these costs, 22.9% related to care provided by physiotherapists and allied specialists, 19.5% to medications, 17.4% to hospitalizations, 9.6% to investigations, and 12.5% to physician fees. In multivariate analysis, the factors associated with the cost of chronic LBP were disease severity (RMDQ score) and age of the patients. LBP is a disease that is both common and costly.     

The laws of acute otitis media

One key to successfully navigating the quagmire of otitis media is to understand otitis media and share that understanding with parents. The Laws of Otitis Media can be useful in this endeavor. Another key to success is to help parents understand that they and their child's physician are partners in the goal of preventing AOM as much as possible, and treating episodes as precisely as possible when they occur. Parents need to know that AOM usually occurs at < 3 years of age and most normal children experience some AOM. The number of AOM episodes depends on a combination of inherited factors that are compounded by immature immunity and anatomy plus the degree of exposure to provoking respiratory pathogens. A firm understanding of the difference between AOM and OME makes it simpler to withhold antibiotics for OME; and understanding that infrequent AOM usually gets well without antibiotics also may reduce some of parents' anxieties. Parents of patients with frequent AOM deserve more guidance about the need for more potent antibiotics and the reduced expectations for cure despite use of appropriate antibiotics. Clinicians need to share with parents the fact that most information about antibiotics and AOM comes from studies sponsored by pharmaceutical companies, with the goal of optimizing the chance that the company's drug would appear to be a good choice. Therefore, only by understanding critical study-design characteristics that ensure fair and proper comparison, will the clinician (or parent using the Internet) be able to decide which drugs are best. Because there are so few well-designed studies, pharmacodynamics has become an alternative method to decide which drugs are best. Practitioners may need to rely on an expert to help interpret the application of pharmacodynamics to local AOM pathogens. While shorter courses of antibiotics are attractive from the compliance and perhaps even the reduction of resistance perspective, failure rates will be higher in young children with tough-to-treat AOM. Further, some of the better tasting or more convenient drugs turn out to be less effective in these same hard-to-treat patients. To further minimize parental anxiety, clinicians should share the fact that it is very rare to see severe complications or lifelong hearing problems due to AOM that is reasonably managed. This is important because the available tools to prevent AOM are limited in number and efficacy. The Laws of AOM can be a basis for busy practitioners to establish a structure for constructively sharing information and responsibility with parents concerning AOM.     

Previous ear, nose and throat surgery in children presenting with allergic perennial rhinitis

Children with allergic perennial rhinitis had a four-fold greater likelihood of having had an ear, nose and throat (ENT) operation than children with orthopaedic problems. Whilst the patients who had ENT operations had significantly lower serum IgA and IgE levels than the non-operated patients, there was no difference in clinical features of atopy or allergy skin-test responses between the two groups of rhinitic patients. Forty per cent of the perennial rhinitics had an improvement in symptoms following ENT operations, whereas 90% improved on medical therapy. Thus, patients with perennial rhinitis should have allergy investigations and the benefit of medical treatment prior to consideration for surgery.     

Infrared Tympanic Thermometry in the Evaluation of Pediatric Acute Otitis Media

Objective : The reliability of infrared tympanic thermometry (ITT) in children and the effect of acute otitis media (AOM) on ITT are unsettled. This study assessed the effect of AOM on ITT and the utility of ITT in the diagnosis of AOM.
Methods : 520 consecutive children, aged 6 months to 6 years, presenting to the ED of an urban teaching hospital were eligible for this prospective observational study. Nurses recorded oral or rectal reference temperatures (RefTs) and bilateral ITT temperatures upon presentation. Emergency physicians were blinded to the ITT temperatures. AOM was diagnosed according to published clinical criteria.
Results : Among 520 patients, 108 had unilateral AOM and 78 had bilateral AOM. In patients with unilateral AOM, the infected ears were warmer (I = 100.4 ± 1.8°F) than the uninfected ears (U = 100.3 ± 1.8°F, p = 0.035). However, the disparity in TM temperatures in infected and uninfected ears with unilateral AOM (I - U = 0.2 ± 0.9°F) was similar to the difference between right and left ears in those without AOM (R - L = 0.1 ± 0.8°F, p = 0.60). Compared with patients without AOM, patients with AOM demonstrated no significant elevation of ITT temperatures over RefTs (I - RefT = -0.8 ± 1.2°F in AOM; ITT -RefT = -0.8 ± 1.2°F in non-AOM; p = 0.94). This study had >99% power to detect a 1.0°F difference for all groups compared.
Conclusions : Infrared tympanic temperatures are not helpful in diagnosing AOM in children. AOM has little direct effect on ITT temperatures.     

Renunciation of routine coagulation diagnostics before ENT operations in children. Results of a survey into the implementation of this recommendation in Dresden

In Germany a recommendation was introduced by experts from several medical associations concerning the renunciation of preoperative coagulation diagnostics in ENT interventions in children with inconspicuous bleeding history and published in July 2006. In August 2007 a survey concerning the implementation of this recommendation was sent to all pediatricians and ENT doctors working in medical offices in Dresden. RESULT: The survey was answered by 23 (49%) paediatricians out of 47 who were contacted and 8 (33%) out of 24 ENT doctors. Fifteen pediatricians (65%) and 3 ENT doctors (38%) have implemented the recommendation consequently and 6 respectively 3 occasionally. Only 2 pediatricians and 2 ENT doctors did not accept the recommendation. Four paediatricians and 4 ENT doctors expressed their concerns with the implementation of recommendation. Since the implementation of this recommendation 3 children suffered from bleeding complications in ambulant ENT operations but in no case a coagulation disorder was present. CONCLUSION: The implementation of the recommendation at the regional level is practicable. Its acceptance is obviously higher in paediatricians than in ENT doctors.     

Public perceptions of cardiovascular risk in five European countries: the react survey

Little is known of the attitudes and behaviours of the general public with regard to their general and personal risk factors for coronary heart disease (CHD), particularly in relation to cholesterol. This study attempted to determine patient perceptions of general population and personal risks regarding cardiovascular disease. Face-to-face interviews were conducted with 5104 members of the public in five countries (France, Germany, Italy, Sweden and the UK). Main results showed only 45% of the public correctly identified CHD as the leading cause of death in their country, and only 51% were aware that high cholesterol increases CHD risk. The presence of cardiovascular disease or risk factors in respondents did not appear to alter perceptions of risk compared with the public who had no existing disease. Of the different nationalities interviewed, the Swedes and the Germans appeared to be most aware of CHD risk factors. Awareness and knowledge of LDL-C and HDL-C were very poor in all countries except Italy Half of the general public (50%) reported they had never discussed their cholesterol levels with a physician and only 33% knew what their target level was. Despite this, the most common source of information on CHD and cholesterol was the physician (60%). Only 9% of the total sample reported that they were currently taking medication for high cholesterol, compared with 20% for hypertension. In summary the general public in several European countries has major lack of awareness of the risks of CHD. This gap in knowledge is particularly marked over the risks of high cholesterol. Significant public health education is required.     

Implications of the Facing Dementia Survey for health care professionals across Europe

Approximately 600 general practitioners, primary care physicians and specialists in six European nations (France, Germany, Italy, Poland, Spain and UK) who treat patients with Alzheimer's disease (AD) were interviewed during the Facing Dementia Survey. Compared with generalists, specialists displayed the most optimism regarding the effects of age, believing that health and memory do not inevitably deteriorate as one grows older. Most physician respondents agreed that the diagnosis of AD is too often delayed. A primary reason cited for this delay was the difficulty experienced by both physicians and the general public in identifying early signs of AD. Many physicians believed treatments are available that can slow the disease course. The vast majority surveyed in each nation believed that early treatment of AD can delay disease progression [mean, 87%; range, 68% (United Kingdom) to 96% (Poland)]. More than half of physicians who initiate treatment in France (66%), Germany (59%), Italy (82%), Poland (82%) and Spain (69%) said they institute treatment for AD immediately after diagnosis. The exception was the United Kingdom, where 48% initiated treatment immediately, whereas more than half waited at least a month to start therapy. To a large extent, physicians saw the governments of their countries as a hindrance rather than a help in caring for persons with AD.