Jennifer Luz

Effect of Adenotonsillectomy in PFAPA Syndrome

OBJECTIVE To assess the benefits of adenotonsillectomy in the treatment of pediatric patients with PFAPA (periodic fever, aphthous ulcers, pharyngitis, and adenitis) syndrome. DESIGN Prospective case series. SETTING Tertiary care pediatric hospital. PATIENTS Pediatric patients meeting criteria for PFAPA syndrome. INTERVENTION Tonsillectomy with or without adenoidectomy. MAIN OUTCOME MEASURE Resolution of PFAPA symptoms. RESULTS Twenty-seven (14 female, 13 male) children with PFAPA syndrome underwent tonsillectomy with or without adenoidectomy from 2004 through 2006. The length of follow-up for all patients ranged from 8 to 41 months. A total of 26 patients experienced a complete resolution of their symptoms. The 1 child who continued to have febrile episodes had fever cycles that were not regular in duration or interval and in hindsight was not likely a patient with PFAPA syndrome. CONCLUSIONS Our findings showed complete resolution of symptoms in 26 of 27 patients with PFAPA syndrome treated surgically. Patients who meet clinical criteria for PFAPA syndrome should be considered for tonsillectomy and adenoidectomy if they do not respond to medical management.

Phosphorylcholine-coated antibiotic tympanostomy tubes: Are post-tube placement complications reduced?

OBJECTIVE To determine if a phosphorylcholine (PC) antibacterial coating on standard Armstrong beveled tympanostomy tubes (TT) reduced the incidence of post-tube placement complications. METHODS A prospective cohort aged 8-51 months received bilateral TTs for otitis media with effusion between July 2002 and February 2004 at a tertiary care pediatric hospital. Seventy children were randomized to receive a PC-coated TT in one ear and an uncoated TT in the other. Otologic examinations at prescribed intervals over two years post-operatively ascertained the status of sequelae. We analyzed the incidence of TT complications: otorrhea, premature extrusion, persistent tympanic membrane perforations, granulation tissue, and ventilation tube lumen obstruction. RESULTS There was no statistical difference in the incidence of any of these sequelae between standard and PC-coated tympanostomy tubes (p>0.05) during the 24-month-follow-up period. Results after 13 months of follow-up may have been affected by patients lost to follow-up and therefore a smaller sample size as the study continued. CONCLUSIONS This study found that there is no statistically significant difference in the incidence of complications between uncoated and PC-coated fluoroplastic Armstrong beveled TTs.

Sensorineural hearing loss in patients with cystic fibrosis

Objective: To determine the prevalence of sensorineural hearing loss (SNHL) in cystic fibrosis (CF) patients and its relationship to antibiotic use. Study Design: Case series with chart review. Setting: Tertiary care pediatric hospital. Subjects and Methods: We reviewed the medical records of CF patients seen in our childrens hospital between March 1994 and December 2007. Data collected included patient demographics, audiograms, tympanograms, genotype, and use of potentially ototoxic antibiotics. Results: Seven of 50 (14%) patients had SNHL. Three percent of patients who received ≤10 courses of intravenous aminoglycosides had SNHL versus 43 percent of those who received >10 courses (P < 0.01). No patients who received five or fewer courses of nasal irrigation with aminoglycosides had SNHL versus 23 percent of those who received more than five courses (P < 0.05). Nine percent of patients who received five or fewer courses of macrolides had SNHL versus 60 percent of those who received more than five courses (P = 0.079). Conclusion: CF patients receiving aminoglycosides are at high risk for developing SNHL.

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience

Introduction Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. Our objective was to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students. Methods This was a pilot study to introduce ultrasonography into the Harvard Medical School curriculum to first- and second-year medical students. Didactic and hands-on sessions were introduced to first-year students during gross anatomy and to second-year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam, were measured by a post-assessment survey. Results All first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum. Conclusion POCUS can effectively be integrated into the existing medical school curriculum by using didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all four years of medical school.

The Diagnostic Accuracy of Special Tests for Rotator Cuff Tear: The ROW Cohort Study.

Objective The aim was to assess diagnostic accuracy of 15 shoulder special tests for rotator cuff tears. Design From February 2011 to December 2012, 208 participants with shoulder pain were recruited in a cohort study. Results Among tests for supraspinatus tears, Jobe test had a sensitivity of 88% (95% confidence interval [CI], 80%–96%), specificity of 62% (95% CI, 53%–71%), and likelihood ratio of 2.30 (95% CI, 1.79–2.95). The full can test had a sensitivity of 70% (95% CI, 59%–82%) and a specificity of 81% (95% CI, 74%–88%). Among tests for infraspinatus tears, external rotation lag signs at 0 degrees had a specificity of 98% (95% CI, 96%–100%) and a likelihood ratio of 6.06 (95% CI, 1.30–28.33), and the Hornblower sign had a specificity of 96% (95% CI, 93%–100%) and likelihood ratio of 4.81 (95% CI, 1.60–14.49). Conclusions Jobe test and full can test had high sensitivity and specificity for supraspinatus tears, and Hornblower sign performed well for infraspinatus tears. In general, special tests described for subscapularis tears have high specificity but low sensitivity. These data can be used in clinical practice to diagnose rotator cuff tears and may reduce the reliance on expensive imaging.

Resident-Perceived Benefit of a Diagnostic and Interventional Musculoskeletal Ultrasound Curriculum: A Multifaceted Approach Using Independent Study, Peer Teaching, and Interdisciplinary Collaboration.

ABSTRACTMusculoskeletal ultrasound (MSUS) training is now a required component of physiatry residency, but formal curriculum guidelines are not yet required or established. The authors’ objective was to assess the educational value of a collaborative residency MSUS training program. The authors designed a structured MSUS training curriculum for residents based on the authors’ experience and previous literature. Twenty-five residents participated in this MSUS curriculum designed by faculty and chief residents. Resident volunteers were trained by the faculty as “table trainers” who taught their peers in small groups. Hands-on MSUS training sessions were led by a Physical Medicine and Rehabilitation faculty MSUS expert. A Likert scale–formatted questionnaire assessed resident-perceived value of the curriculum. Response rate was 96% (22 of 23). Self-reported MSUS knowledge comparing precurriculum and postcurriculum implementation resulted in significant improvement (P = 0.001). Peer teaching was highly valued, with 86% of residents rating it “very” or “extremely” beneficial (mean [SD] score, 3.9 [1.1]). Self-guided learning, by supplemental scanning and reading, was rated “beneficial” or “very beneficial” by 73% of residents (3.0 [0.7]). The authors’ successful pilot program may serve as a teaching model for other residency programs.

Point-of-care ultrasonography in the diagnosis and management of superficial peroneal nerve entrapment: case series.

Superficial peroneal nerve (SPN) entrapment at the crural fascia is a rare but perhaps underdiagnosed entity. Over the past few years, advances in ultrasound technology have allowed point-of-care ultrasound to accurately visualize peripheral nerves in the lower extremity, and may be the imaging modality of choice for peripheral nerves due to its higher resolution and ability to track the course of the nerve, even when compared to MRI. To our knowledge, there have been no reports of utilizing dynamic ultrasound imaging with realtime clinical correlation to identify SPN entrapment. We present 2 cases of SPN entrapment which were successfully diagnosed and treated by point-of-care ultrasonography. SPN entrapment was first reported by Henry in 1945. He called it “mononeuralgia in the superficial peroneal nerve.” There have been few cases reported since its discovery. Among the elusive nerve entrapment syndromes of the lower extremity, SPN entrapment is a difficult diagnosis. First, it is a rare occurrence with early studies citing only 3.5% of cases of lower leg pain due to SPN entrapment. Classically, this diagnosis has been based on the physical exam producing sensory abnormalities over the lateral leg and dorsal foot, especially after exercise provocation. Electrophysiology studies and MRI are typically ordered in an attempt to confirm the diagnosis, but these studies can often be normal despite symptoms. The diagnosis of SPN entrapment almost always comes after a workup for chronic lateral exertional compartment syndrome as these 2 entities may present with an identical clinical history and physical exam.

The Current State of Musculoskeletal Ultrasound Education in Physical Medicine and Rehabilitation Residency Programs

Exposure to musculoskeletal ultrasound (MSUS) is now a mandatory component of physical medicine and rehabilitation (PM&R) residency training. However, reports on the extent of the implementation and efficacy of MSUS education are lacking in the literature.

P161: Phosphorylcholine-Coated Ventilation Tube Study

antibiotic therapy for the treatment of CRS in pediatric patients refractory to oral antibiotic therapy. METHODS: A retrospective review of the medical records of 23 patients who received treatment looking at the following: age, presenting signs and symptoms and their duration, medical and social history, maxillary sinus culture and sensitivity results, postoperative antibiotic treatment regimen and duration, whether resolution was achieved, length of follow-up, surgical and antibiotic-related complications and compliance with follow-up and therapy. RESULTS: Of patients without a documented immunodefiency, 18/19 (95%) had complete resolution of symptoms. Overall, clinical resolution was achieved in 18 of 23 (78%) patients. Long-term resolution was maintained in 13/15 (87%) of patients who resolved. No treatment-related complications were reported, and no patients in the study required FESS. CONCLUSIONS: A stepwise protocol that includes concurrent adenoidectomy and bilateral maxillary sinus irrigation followed by long-term double oral antibiotic therapy is effective for the treatment of pediatric CRS refractory to oral antibiotic therapy. Patients with immunodeficiency may require long-term IV therapy to achieve symptom resolution.

08:18: Hearing Loss in Patients with Cystic Fibrosis

OBJECTIVES: 1. Examine the prevalence of hearing loss in cystic fibrosis (CF) patients. 2. Determine the relationship between hearing loss and ototoxic antibiotic use in CF patients. METHODS: The medical records of CF patients seen in a tertiary care children’s hospital between March 1994 and December 2006 were reviewed. Data collected included patient demographics, audiograms, and use of ototoxic antibiotics. RESULTS: Some 35/171 patients had audiograms. Although none had subjective hearing loss, 5/35 patients (14%) had highfrequency sensorineural hearing loss (90% Confidence Interval (CI) is [0.057, 0.285]), and one (3%) had normal hearing but severe bilateral tinnitus. When stratified by ototoxic drug exposure (aminoglycoside and/or azithromycin), 5/27 (19%) treated but none of the untreated (0/8) patients experienced hearing loss. The 90% CI for treated patients was (0.01, 0.35), suggesting an association between aminoglycosides/macrolides and hearing loss. However, the p value was 0.315, possibly reflecting the small sample size rather than nonsignificance. The 90% CI (0, 0.21) for the untreated group is based on only 8 patients. A trend toward a higher rate of hearing loss in the antibiotic-treated than the untreated CF patients was observed. CONCLUSIONS: Patients with CF receiving ototoxic drug treatments are at high risk for developing hearing loss. The most common pattern of hearing loss was bilateral and high frequency, suggesting an ototoxic effect. Because of the subclinical nature and high prevalence of hearing loss, the presenters propose a structured and ongoing audiometric assessment to further define the likelihood of, and risk factors for, developing hearing loss.