Kenneth G. Schellhase

Clinical practice guideline: Tympanostomy tubes in children

Objective Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type. Purpose The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. Action Statements The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months’ duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).

Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians.

Venous thromboembolism is a common condition affecting 7.1 persons per 10,000 person-years among community residents. Incidence rates for venous thromboembolism are higher in men, African-Americans, and increase substantially with age. It is critical to treat deep venous thrombosis at an early stage to avoid development of further complications, such as pulmonary embolism or recurrent deep venous thrombosis. The target audience for this guideline is all clinicians caring for patients who have been given a diagnosis of deep venous thrombosis or pulmonary embolism. The target patient population is patients receiving a diagnosis of pulmonary embolism or lower-extremity deep venous thrombosis.

AAFP Guideline for the Detection and Management of Post-Myocardial Infarction Depression

EVIDENCE-BASED RECOMMENDATIONS The American Academy of Family Physicians (AAFP) Commission on Science convened a panel to review the evidence on the effect of depression on persons after myocardial infarction. The evidence report on this topic was published in May 2005 by the Agency for Healthcare Research and Quality (AHRQ) and is used as the basis for this review.1 The AAFP Post–Myocardial Infarction Depression Clinical Practice Guideline Panel (Post-MI Guideline Panel) was charged with examining the evidence and developing an evidence-based clinical practice guideline for the detection and management of persons with postmyocardial infarction (post-MI) depression. The following recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they refl ect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations.

Clinical Practice Guideline Tympanostomy Tubes in Children—Executive Summary

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tympanostomy Tubes in Children. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 12 recommendations developed address patient selection, surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes.

Blood center practice and education for blood donors with anemia.

BACKGROUND: Anemia is an early indicator of many diseases, yet blood donors with low hematocrit (Hct) often receive inadequate information about its medical importance. We sought to understand the types of information that are and should be provided to these donors.

Bilirubin Screening for Normal Newborns: A Critique of the Hour-Specific Bilirubin Nomogram

Kernicterus is a devastating but rare disease with an incidence that ranges from 0.4 to 2.9 per 100000 live births.1–6 Recently, a preventive strategy of measuring predischarge bilirubin levels in all infants discharged from the newborn nursery was proposed and included as an option in the American Academy of Pediatrics guidelines.7 The percentile location of these levels on an hour-specific “nomogram” of total serum bilirubin (TSB) levels first described by Bhutani et al8 is thought to predict the risk of severe hyperbilirubinemia. In this commentary we highlight the methodologic flaws in the development of the nomogram, the lack of evidence for efficacy of screening, and the potential undesirable consequences of such an approach. Multiple flaws in the methods used to create the nomogram8 and assess its accuracy generate serious questions about its validity. Some of these issues were emphasized previously by experts on hyperbilirubinemia who stated that “the study biases and interlaboratory variability in TSB measurements preclude general extrapolation of the quantitative results of this study… ”9 First, the applicability of these percentile curves to the overall US or international population is suspect, because they were developed in a retrospective study that used a small sample of infants from a single urban Philadelphia, Pennsylvania, hospital, the demographics of which (43% white, 41% black, 4% Hispanic, and 4% … Address correspondence to David L. Fay, MD, Waukesha Family Medicine Residency Program, 210 NW Barstow, Suite 201, Waukesha, WI 53188. E-mail: david.fay{at}phci.org

Community blood donors' knowledge of anemia and design of a literacy-appropriate educational intervention

BACKGROUND: The purpose of this project is to improve the health of blood donors by educating and motivating them to seek medical attention for anemia. The National Anemia Action Council, BloodCenter of Wisconsin, and the Medical College of Wisconsin formed a partnership to engage volunteer blood donors and develop an educational intervention to motivate donors with anemia to seek appropriate medical care.

Current diagnosis of venous thromboembolism in primary care

This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.