Adele K. Evans

Detection of group A Streptococcus in tonsils from pediatric patients reveals high rate of asymptomatic streptococcal carriage

BackgroundGroup A Streptococcus (GAS) causes acute tonsillopharyngitis in children, and approximately 20% of this population are chronic carriers of GAS. Antibacterial therapy has previously been shown to be insufficient at clearing GAS carriage. Bacterial biofilms are a surface-attached bacterial community that is encased in a matrix of extracellular polymeric substances. Biofilms have been shown to provide a protective niche against the immune response and antibiotic treatments, and are often associated with recurrent or chronic bacterial infections. The objective of this study was to test the hypothesis that GAS is present within tonsil tissue at the time of tonsillectomy.MethodsBlinded immunofluorescent and histological methods were employed to evaluate palatine tonsils from children undergoing routine tonsillectomy for adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis.ResultsImmunofluorescence analysis using anti-GAS antibody was positive in 11/30 (37%) children who had tonsillectomy for adenotonsillar hypertrophy and in 10/30 (33%) children who had tonsillectomy for recurrent GAS pharyngitis. Fluorescent microscopy with anti-GAS and anti-cytokeratin 8 & 18 antibodies revealed GAS was localized to the tonsillar reticulated crypts. Scanning electron microscopy identified 3-dimensional communities of cocci similar in size and morphology to GAS. The characteristics of these communities are similar to GAS biofilms from in vivo animal models.ConclusionOur study revealed the presence of GAS within the tonsillar reticulated crypts of approximately one-third of children who underwent tonsillectomy for either adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis at the Wake Forest School of Medicine.Trial RegistrationThe tissue collected was normally discarded tissue and no patient identifiers were collected. Thus, no subjects were formally enrolled.

A review of unilateral hearing loss and academic performance: is it time to reassess traditional dogmata?

OBJECTIVE The aim of this paper was to review traditional approaches to habilitation of unilateral hearing losses as well as new research concerning management of unilateral hearing loss. DATA SOURCES Literature review/systematic review. REVIEW METHODS A PubMed search was performed for articles pertaining to unilateral hearing loss and academic loss and academic performance. Articles ranged in date from 1986 to 2012. Five resources were reviewed for content to determine the pertinence of the materials to the understanding of the history of diagnosis of unilateral hearing loss, the traditional treatment methods and their advantages and disadvantages, and more recent publications concerning academic outcomes for patients with unilateral hearing loss with and without treatment. RESULTS Unilateral hearing loss scan be detrimental to the academic success of children. Effects encompass not only auditory effects such as difficulty hearing in noise, but also self esteem and exhaustion. Although assistive devices were traditionally not offered as options, more recent literature suggests that devices such as BAHA, hearing aids, or FM systems may provide aids in the classroom and that early intervention may provide more favorable outcomes. CONCLUSION Since the 1980s, the approach to management of unilateral hearing losses has evolved. In order to maximize academic potential, treatment options should be discussed and implemented.

One third of middle ear effusions from children undergoing tympanostomy tube placement had multiple bacterial pathogens

BackgroundBecause previous studies have indicated that otitis media may be a polymicrobial disease, we prospectively analyzed middle ear effusions of children undergoing tympanostomy tube placement with multiplex polymerase chain reaction for four otopathogens.MethodsMiddle ear effusions from 207 children undergoing routine tympanostomy tube placement were collected and were classified by the surgeon as acute otitis media (AOM) for purulent effusions and as otitis media with effusion (OME) for non-purulent effusions. DNA was isolated from these samples and analyzed with multiplex polymerase chain reaction for Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis, and Moraxella catarrhalis.Results119 (57%) of 207 patients were PCR positive for at least one of these four organisms. 36 (30%) of the positive samples indicated the presence of more than one bacterial species. Patient samples were further separated into 2 groups based on clinical presentation at the time of surgery. Samples were categorized as acute otitis media (AOM) if pus was observed behind the tympanic membrane. If no pus was present, samples were categorized as otitis media with effusion (OME). Bacteria were identified in most of the children with AOM (87%) and half the children with OME (51%, p < 0.001). A single bacterial organism was detected in middle ear effusions from children with AOM more often than those with OME (74% versus 33%, p < 0.001). Haemophilus influenzae was the predominant single organism and caused 58% of all AOM in this study. Alloiococcus otitidis and Moraxella catarrhalis were more frequently identified in middle ear effusions than Streptococcus pneumoniae.ConclusionsHaemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis, and Moraxella catarrhalis were identified in the middle ear effusions of some patients with otitis media. Overall, we found AOM is predominantly a single organism infection and most commonly from Haemophilus influenzae. In contrast, OME infections had a more equal distribution of single organisms, polymicrobial entities, and non-bacterial agents.

Simulation model for tracheotomy education for primary health-care providers.

Objectives: We performed this study to evaluate the competency of health-care providers managing patients with tracheotomies, and assess the need for, and efficacy of, a multidisciplinary educational program incorporating patient simulation. Methods: The prospective observational study included 87 subjects who manage patients with tracheotomies within a tertiary-care hospital. The subjects completed self-assessment questionnaires and objective multiple-choice tests before and after attending a comprehensive educational course using patient simulation. The outcome measurements included pre-course and post-course questionnaire and test scores, as well as observational data collected during recorded patient simulation sessions. Results: Before the education and simulation, the subjects reported an average comfort level of 3.3 on a 5-point Likert scale across 10 categories in the questionnaire, which improved to 4.4 after the training (p < 0.0001). The subjects’ mean scores improved from 56% on the pre-course test to 91% on the post-course test (p < 0.0001). The specific deficiencies observed during patient simulation scenarios included unfamiliarity with different tracheotomy tube types, misunderstanding of speaking valve physiology, and delayed recognition and treatment of a plugged or dislodged tracheotomy tube. Conclusions: There is a significant need for improved tracheotomy education among primary health-care providers. Incorporating patient simulation into a comprehensive tracheotomy educational program was effective in improving provider confidence, increasing provider knowledge, and teaching the skills necessary for managing patients with a tracheotomy.

Suppurative Cervical Lymphadenitis in Infancy Microbiology and Sociology

Objective. To investigate the associations between patient age, sociological factors, and the microbiology of pediatric neck infections. Methods. Retrospective chart review of children up to 5 years old who underwent surgical management of suppurative cervical lymphadenitis. Results. A total of 76 individuals met inclusion criteria; 93% of culture-positive infections were caused by Staphylococcus aureus in infants, compared with 59% in children between 13 months and 5 years of age (P = .002). Of the S aureus isolates, 51% were methicillin-resistant S aureus (MRSA) and 49% were methicillin-sensitive S aureus. Methicillin resistance was associated with African American race (P = .004); 67% of participants received empirical antibiotics prior to admission. Of these, 73% received antibiotics in the β-lactam class, and 25% received treatment with clindamycin. Conclusions. Incidence of MRSA is high in infants with cervical lymphadenitis who fail empirical antibiotic therapy and require surgical management. Empirical coverage for cervical lymphadenitis with β-lactam antibiotics may provide inadequate coverage for early infection in this population.

Disk battery ingestion: case series with assessment of clinical and financial impact of a preventable disease.

Background Commonly, foreign objects are incidentally ingested and pass harmlessly through the gastrointestinal tract; however, disk batteries present exceptional risk. In 2009, the American Association of Poison Control Centers listed disk batteries as the number 1 cause of fatal ingestions in children younger than 5 years. Lithium batteries are the most dangerous, and they are rapidly rising in use by manufacturers. Paralleling that rise, there has been a 6.7-fold increase in major or fatal outcomes between 1985 and 2009. This study describes the variability in patient presentations, the courses of patients’ evaluations, and the clinical and financial consequences of disk battery ingestion. Methods In this retrospective study, cases from 2001 to 2011 were reviewed for details of care for disk battery ingestions including presentation and management details. Cost of care information from our patients’ records was compared with that of national averages on esophageal foreign bodies using the Healthcare Cost and Utilization Project’s Kids’ Inpatient Database. Results Six cases are presented. The patients’ age averaged 1.85 years. Presentations varied with respect to symptoms, time course, and steps in treatment. Mean length of stay was 9.0 days, and mean cost was

Otopathogens Detected in Middle Ear Fluid Obtained during Tympanostomy Tube Insertion: Contrasting Purulent and Non-Purulent Effusions.

14,994. Conclusions Emergency medicine physicians, otolaryngologists, radiologists, gastroenterologists, and pediatric surgeons may be able to mitigate, albeit not entirely prevent, potential serious complications in patients with disk battery ingestions by proper diagnosis and timely treatment. Recommendations for management are presented, which highlight the need for emergent removal of any battery that is lodged and close follow-up of these patients once they are out of the hospital.

Extracellular matrix for repair of type IV laryngotracheo-esophageal cleft.

Otitis media is a prominent disease among children. Previous literature indicates that otitis media is a polymicrobial disease, with Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis and Moraxella catarrhalis being the most commonly associated bacterial pathogens. Recent literature suggests that introduction of pneumococcal conjugate vaccines has had an effect on the etiology of otitis media. Using a multiplex PCR procedure, we sought to investigate the presence of the aforementioned bacterial pathogens in middle ear fluid collected from children undergoing routine tympanostomy tube placement at Wake Forest Baptist Medical Center during the period between January 2011 and March 2014. In purulent effusions, one or more bacterial organisms were detected in ~90% of samples. Most often the presence of H. influenzae alone was detected in purulent effusions (32%; 10 of 31). In non-purulent effusions, the most prevalent organism detected was A. otitidis (26%; 63 of 245). Half of the non-purulent effusions had none of these otopathogens detected. In purulent and non-purulent effusions, the overall presence of S. pneumoniae was lower (19%; 6 of 31, and 4%; 9 of 245, respectively) than that of the other pathogens being identified. The ratio of the percentage of each otopathogen identified in purulent vs. non-purulent effusions was >1 for the classic otopathogens but not for A. otitidis.

Compliance with Recommendations for Tympanostomy Tube Follow-up Patient Characteristics

Type IV laryngotracheo-esophageal cleft (LTEC) extending to the level of the carina presents unique challenges to operative repair, particularly with respect to soft tissue durability. This is the first report of CorMatrix(®) extra-cellular matrix (ECM) material use as an interposition graft in a four-layered LTEC repair. At day seven post-operatively, there was epithelialization along the surface of the trachea. At 3 months, she was stable for tracheotomy. At 6 months, the posterior wall resembled completely native tissue. CorMatrix(®) ECM(®) use intra-operatively and post-operative outcome were both highly satisfactory. No adverse reaction was seen in this case through 12-month follow up.

Observation of Viable Nontypeable Haemophilus Influenzae Bacteria within Neutrophil Extracellular Traps in Clinical Samples from Chronic Otitis Media

Objectives (1) To determine the percentage of otherwise healthy patients achieving “graduation,” or postoperative compliance achieving complete problem resolution and discharge from the otolaryngologist’s care, after tympanostomy tube placement. (2) To analyze follow-up behaviors and patient characteristics influencing the likelihood of graduation. Study Design Retrospective cohort study. Setting Tertiary care hospital. Subjects and Methods Analysis of details of tympanostomy tube placements performed from 2004 to 2011 by 2 pediatric otolaryngologists for children aged 0 to 18 years. Exclusion criteria were clearly defined craniofacial anomalies, cleft palates, and other ongoing postoperative care. The remaining study subjects were categorized into 3 groups. Graduation (GRAD) subjects achieved discharge from care with “follow-up pro re nata” status. LOST<2Y subjects had not attended scheduled follow-up in <2 years. LOST≥2Y subjects had no follow-up in ≥2 years. Results A total of 1454 pediatric subjects were included. GRADs constituted only 25.6% of the subject pool; 22.1% were LOST<2Y, and 52.3% were LOST≥2Y. Statistically significant factors in achieving graduation were total number of follow-up visits, total duration of follow-up, compliance with first postoperative visit, patient age, insurance type, and distance between home and practice. Conclusion Rate of graduation, or postoperative compliance achieving complete problem resolution, of otherwise healthy tympanostomy tube patients is low despite perioperative discussions of the importance of proper follow-up. Higher graduation rates are associated with increasing number of follow-up visits and duration, younger patient age, private insurance, and proximity to the practice. Compliance with attending the first postoperative visit may be an early marker for increased likelihood of graduation.