Constance D. Baldwin

Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment.

Objective. The widespread use of antibiotics for treatment of acute otitis media (AOM) has resulted in the emergence of multidrug-resistant pathogens that are difficult to treat. However, it has been shown that most children with nonsevere AOM recover without ABX. The objective of this study was to evaluate the safety, efficacy, acceptability, and costs of a non-ABX intervention for children with nonsevere AOM. Methodology. Children 6 months to 12 years old with AOM were screened by using a novel AOM-severity screening index. Parents of children with nonsevere AOM received an educational intervention, and their children were randomized to receive either immediate antibiotics (ABX; amoxicillin plus symptom medication) or watchful waiting (WW; symptom medication only). The investigators, but not the parents, were blinded to enrollment status. Primary outcomes included parent satisfaction with AOM care, resolution of symptoms, AOM failure/recurrence, and nasopharyngeal carriage of Streptococcus pneumoniae strains resistant to ABX. Secondary outcomes included medication-related adverse events, serious adverse events, unanticipated AOM-related office and emergency department visits and telephone calls, the childs absence from day care or school resulting from AOM, the parents absence from school or work because of their childs AOM, and costs of treatment. Subjects were defined as failing (days 0–12) or recurring (days 13–30) if they experienced a higher AOM-severity score on reexamination. Results. A total of 223 subjects were recruited: 73% were nonwhite, 57% were <2 years old, 47% attended day care, 82% had experienced prior AOM, and 83% had not been fully immunized with heptavalent pneumococcal vaccine. One hundred twelve were randomized to ABX, and 111 were randomized to WW. Ninety-four percent of the subjects were followed to the 30-day end point. Parent satisfaction with AOM care was not different between the 2 treatment groups at either day 12 or 30. Compared with WW, symptom scores on days 1 to 10 resolved faster in subjects treated with immediate ABX. At day 12, among the immediate-ABX group, 69% of tympanic membranes and 25% of tympanograms were normal, compared with 51% of normal tympanic membranes and 10% of normal tympanograms in the WW group. Parents of children in the ABX group gave their children fewer doses of pain medication than did parents of children in the WW group. Subjects in the ABX group experienced 16% fewer failures than subjects in the WW group. Of the children in the WW group, 66% completed the study without needing ABX. Immediate ABX resulted in eradication of S pneumoniae carriage in the majority of children, but S pneumoniae strains cultured from children in the ABX group at day 12 were more likely to be multidrug-resistant than strains from children in the WW group. More ABX-related adverse events were noted in the ABX group, compared with the WW group. No serious AOM-related adverse events were observed in either group. Office and emergency department visits, phone calls, and days of work/school missed were not different between groups. Prescriptions for ABX were reduced by 73% in the WW group compared with the ABX group. Costs of ABX averaged

Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life

47.41 per subject in the ABX group and

Integrating Web-based computer cases into a required clerkship: development and evaluation.

11.43 in the WW group. Conclusions. Sixty-six percent of subjects in the WW group completed the study without ABX. Parent satisfaction was the same between groups regardless of treatment. Compared with WW, immediate ABX treatment was associated with decreased numbers of treatment failures and improved symptom control but increased ABX-related adverse events and a higher percent carriage of multidrug-resistant S pneumoniae strains in the nasopharynx at the day-12 visit. Key factors in implementing a WW strategy were (a) a method to classify AOM severity; (b) parent education; (c) management of AOM symptoms; (d) access to follow-up care; and (e) use of an effective ABX regimen, when needed. When these caveats are observed, WW may be an acceptable alternative to immediate ABX for some children with nonsevere AOM.

Identification of social‐emotional problems among young children in foster care

The relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion (OME) was evaluated in a cohort of 698 healthy infants prospectively monitored by tympanometry in the home every 2 to 4 weeks until 2 years of age. Except for an experimental group of children who were offered early tube placement, the study children received conventional care from their personal physician or clinic. We used LISREL, a structural equation modeling procedure (computer software), to explore associations between environmental variables and OME onset and duration while controlling for interrelations among the variables. Supine feeding position and early initiation of group child care were associated with earlier onset of OME. Shorter duration of breast-feeding, increased packs of cigarettes smoked per day in the home, and increased hours per week in group child care were associated with an increase in the amount of time with OME during one or more of the age blocks studied (birth to 6, 6 to 12, 12 to 18, and 12 to 24 months). For a decrease in the amount of time with OME during the first 2 years of life, prolonged breast-feeding and upright feeding position should be encouraged, and cigarette smoke exposure should be minimized. Limiting early child care in large groups might also be advisable.

Role of the virology laboratory in diagnosis and management of patients with central nervous system disease.

Purpose To evaluate a five-year experience (1995–2000) developing and integrating computer cases into a required clerkship. Method In Study 1, 54 volunteer students were randomly assigned to study articles, a paper case, or a computer case on low back pain/kidney stones. Students were given an exam immediately after the exercise and one week later. In Study 2, 325 clerkship students were asked to select and complete two computer cases or to prepare assignments on unrelated topics. Among the cases offered were two test cases on low back pain/kidney stones and pneumonia. Questions specific to the computer test cases (CC) and other noncomputer cases (NCC) were in the final exam. Exam scores related to CC questions and NCC questions were compared between the groups of students who did and did not complete the computer cases. Students also rated the computer cases on a questionnaire. Results In Study 1, reading articles required the most time and received the most negative comments. The students who completed the computer case scored the best on the exam one week later. In Study 2, the students who completed the two computer cases scored significantly higher on the CC questions than did students who studied only one or none of the computer cases (p < .001). There was no difference among groups for the NCC scores (p = .76). Students rated the computer cases with a mean of 6 on a seven-point scale (7 = strongly agree). Conclusion Computer cases are effective learning tools, are well-received by students, and can be successfully integrated into existing clerkships.

Breast Feeding and Children's Intelligence

BACKGROUND Little is known about how best to implement behavioral screening recommendations in practice, especially for children in foster care, who are at risk for having social-emotional problems. Two validated screening tools are recommended for use with young children: the Ages and Stages Questionnaire: Social Emotional (ASQ-SE) identifies emotional problems, and the Ages and Stages Questionnaire (ASQ) identifies general developmental delays in five domains, including personal-social problems. The current study examined: (1) whether systematic use of a social-emotional screening tool improves the detection rate of social-emotional problems, compared to reliance on clinical judgment; (2) the relative effectiveness of two validated instruments to screen for social-emotional problems; and (3) the patterns of social-emotional problems among children in foster care. METHODS We used retrospective chart review of children in foster care ages 6 months to 5.5 years: 192 children before and 159 after screening implementation, to measure detection rates for social-emotional problems among children. The ASQ-SE and the ASQ were used in multivariable logistic regression analyses to examine associations between children with social-emotional problems. RESULTS Use of the screening tool identified 24% of the children as having a social-emotional problem, while provider surveillance detected 4%. We identified significantly more children with social-emotional problems using the ASQ-SE than using the ASQ, and agreement between the instruments ranged from 56% to 75%, when data were stratified by age group. Multivariable modeling showed that preschool children were more likely to have a social-emotional problem than toddlers and infants (aOR = 3.4, 95% CI = 1.1-10.8). CONCLUSIONS Systematic screening using the ASQ-SE increased the detection rate for social-emotional problems among young children in foster care, compared to provider surveillance and the ASQ. A specific social-emotional screening tool appears to detect children with psychosocial concerns who would not be detected with a broader developmental screening tool.

Approach to communicating with patients about the use of nutritional supplements in cancer care.

A number of viruses cause acute central nervous system disease. The two major clinical presentations are aseptic meningitis and the less common meningoencephalitis. Clinical virology laboratories are now more widely available than a decade ago; they can be operated on a modest scale and can be tailored to the needs of the patients they serve. Most laboratories can provide diagnostic information on diseases caused by enteroviruses, herpesviruses, and human immunodeficiency virus. Antiviral therapy for herpes simplex virus is now available. By providing a rapid diagnostic test or isolation of the virus or both, the virology laboratory plays a direct role in guiding antiviral therapy for patients with herpes simplex encephalitis. Although there is no specific drug available for enteroviruses, attention needs to be paid to these viruses since they are the most common cause of nonbacterial meningitis and the most common pathogens causing hospitalization for suspected sepsis in young infants in the United States during the warm months of the year. When the virology laboratory maximizes the speed of viral detection or isolation, it can make a significant impact on management of these patients. Early viral diagnosis benefits patients with enteroviral meningitis, most of whom are hospitalized and treated for bacterial sepsis or meningitis or both; these patients have the advantage of early withdrawal of antibiotics and intravenous therapy, early hospital discharge, and avoidance of the risks and costs of unnecessary tests and treatment. Enteroviral infection in young infants also is a risk factor for possible long-term sequelae. For compromised patients, the diagnostic information helps in selecting specific immunoglobulin therapy. Good communication between the physician and the laboratory will result in the most benefit to patients with central nervous system viral infection.

A randomized, placebo-controlled trial of the effect of antihistamine or corticosteroid treatment in acute otitis media

Breast feeding was reported in 1992 by Lucas, et al. to provide advantages for the development of intelligence in children of low birth weight, possibly through nutrients or other biological factors found in human breast milk but not cows milk. Research on breast feeding and intelligence in children of normal birth weight has yielded mixed results, probably because measurement of environmental influences has not been thorough and the range of intelligence components measured has been limited. Our research with 204 3-year-old children of normal birth weight included control measures for the environment and maternal intelligence (Hollings-head socioeconomic status, Home Observation for the Measured Environment, Shipley) and two measures of childhood intelligence (Stanford-Binet Fourth Edition and Peabody Picture Vocabulary Test-Revised). Controlling for environmental variables and maternal intelligence, initiation of breast feeding predicted scores on intelligence tests at age three. Breast feeding was associated with 4.6-point higher mean in childrens intelligence.

Development of a practical tool for assessing the severity of acute otitis media

In recent years, complementary and alternative medicine has become popular among the general population in the Western world. Cancer patients have joined this global trend, often seeking supplements to conventional oncologic care, usually without their physicians’ knowledge. Among the most common forms of complementary and alternative medicine used by cancer patients are natural products such as herbs and megavitamins. The extensive use of nutritional supplements by cancer patients raises multiple questions and challenges for the physician. Since there are limited scientific data on the efficacy and safety of many nutritional supplements, advising patients about when to use them during the course of illness is difficult. This is true for each stage of cancer care: prevention, acute active care (radiation, chemotherapy, surgery), and post-acute care (follow-up visits and prevention of recurrence). The authors describe a patient-centered approach to the use of nutritional supplements in cancer care.

Guidelines for Evaluating the Educational Performance of Medical School Faculty: Priming a National Conversation

OBJECTIVES To determine whether the adjunctive drugs antihistamine and corticosteroid improve immediate and long-term outcomes of acute otitis media (AOM). STUDY DESIGN Children with AOM (3 mos-6 y) were enrolled in a randomized, double-blind, placebo-controlled trial. All 179 children received one dose of intramuscular ceftriaxone and were assigned to receive either chlorpheniramine maleate (0.35 mg/kg/d) and/or prednisolone (2 mg/kg/day) or placebo for 5 days. Main outcome measures were rate of treatment failure during the first 2 weeks, duration of middle ear effusion, and rate of recurrences of AOM to 6 months. RESULTS Clinical outcomes and recurrence rates did not differ significantly with treatment. Children who received antihistamine alone had significantly longer duration of middle ear effusion (median, 73 days) than subjects in other treatment groups (median, 23 to 36 days, P=.04). Temporary normalization of tympanometric findings on day 5 occurred more frequently in the corticosteroid-treated group (P=.04). CONCLUSIONS Five-day treatment with antihistamine or corticosteroid, in addition to antibiotic, did not improve AOM outcomes. Antihistamine use during an acute episode of OM should be avoided, since the drug may prolong the duration of middle ear effusion. The efficacy of 7- to 10-day treatment of AOM with corticosteroid, in addition to antibiotic, deserves further investigation.