Audiovestibular and vaccination complications of COVID-19

Objectives: Since its first appearance in Wuhan December 2019, SARS-CoV2 virus received great attention due to its severe symptoms and high spread causing COVID-19 disease which spread all over the world like a pandemic. The causative virus is capable of human-to-human transmission via droplet and direct contact suggesting that upper respiratory tract is the main site to virus manifestations. There is a great diversity in its clinical picture, although the severe respiratory and neurological symptoms are commonly present;however, other symptoms are present. Although otological manifestations are reported in many COVID-19 patients even in asymptomatic cases, they did not receive much attention compared with other critical manifestations. In this article, we paid our attention specifically to the otological manifestations of COVID-19 and their relevance either to the virus infection, treatment, or vaccination through literature review. Conclusion(s): COVID-19 disease has a deleterious effect on the inner ear. This effect is not only due to SARS-Cov-2 infection, but it could be also due to the ototoxic drugs used for treatment. The COVID-19 vaccinations are found to be implicated in the otological symptoms in some cases.Copyright © 2022, The Author(s).

Top 20 Research Studies of 2021 for Primary Care Physicians

This article summarizes the top 20 research studies of 2021 identified as POEMs (patient-oriented evidence that matters) that did not address the COVID-19 pandemic. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists prevent adverse cardiovascular and renal outcomes in patients with type 2 diabetes mellitus and also reduce all-cause and cardiovascular mortality. Most older adults (mean age, 75 years) with prediabetes do not progress to diabetes. Among patients in this age group with type 2 diabetes treated with medication, an A1C level of less than 7% is associated with increased risk of hospitalization for hypoglycemia, especially when using a sulfonylurea or insulin. For patients with chronic low back pain, exercise, nonsteroidal anti-inflammatory drugs, duloxetine, and opioids were shown to be more effective than control in achieving a 30% reduction in pain, but self-discontinuation of duloxetine and opioids was common. There is no clinically important difference between muscle relaxants and placebo in the treatment of nonspecific low back pain. In patients with chronic pain, low- to moderate-quality evidence supports exercise, yoga, massage, and mindfulness-based stress reduction. For acute musculoskeletal pain, acetaminophen, 1,000 mg, plus ibuprofen, 400 mg, without an opioid is a good option. Regarding screening for colorectal cancer, trial evidence supports performing fecal immunochemical testing every other year. For chronic constipation, evidence supports polyethylene glycol, senna, fiber supplements, magnesium-based products, and fruit-based products. The following abdominal symptoms carry a greater than 3% risk of cancer or inflammatory bowel disease: dysphagia or change in bowel habits in men;rectal bleeding in women;and abdominal pain, change in bowel habits, or dyspepsia in men and women older than 60 years. For secondary prevention in those with established arteriosclerotic cardiovascular disease, 81 mg of aspirin daily appears to be effective. The Framingham Risk Score and the Pooled Cohort Equations both overestimate the risk of cardiovascular events. Over 12 years, no association between egg consumption and cardiovascular events was demonstrated. Gabapentin, pregabalin, duloxetine, and venlafaxine provide clinically meaningful improvements in chronic neuropathic pain. In patients with moderate to severe depression, initial titration above the minimum starting dose of antidepressants in the first eight weeks of treatment is not more likely to increase response. In adults with iron deficiency anemia, adding vitamin C to oral iron has no effect. In children with pharyngitis, rhinosinusitis, acute bronchitis, or acute otitis media, providing education combined with a take-and-hold antibiotic prescription results in 1 in 4 of those children eventually taking an antibiotic.Copyright © 2022 American Academy of Family Physicians.

Antibiotic Use in Acute Upper Respiratory Tract Infections

Upper respiratory tract infections are responsible for millions of physician visits in the United States annually. Although viruses cause most acute upper respiratory tract infections, studies show that many infections are unnecessarily treated with antibiotics. Because inappropriate antibiotic use results in adverse events, contributes to antibiotic resistance, and adds unnecessary costs, family physicians must take an evidence-based, judicious approach to the use of antibiotics in patients with upper respiratory tract infections. Antibiotics should not be used for the common cold, influenza, COVID-19, or laryngitis. Evidence supports antibiotic use in most cases of acute otitis media, group A beta-hemolytic streptococcal pharyngitis, and epiglottitis and in a limited percentage of acute rhinosinusitis cases. Several evidence-based strategies have been identified to improve the appropriateness of antibiotic prescribing for acute upper respiratory tract infections.Copyright © 2022 American Academy of Family Physicians.

Case-control study of relationship of infection by respiratory viruses with acute otitis media in Chinese children.

Background: Acute otitis media (AOM) may occur as a complication of viral upper respiratory infection (URI) in children. Our objective was to examine children with URI + AOM or URI alone to determine the association of infection by different common respiratory viruses with AOM. Methods: Nasopharyngeal swabs were collected from March 2014 to February 2015. Quantitative PCR was then used to identify the following 10 common respiratory viruses: respiratory syncytial virus (RSV); parainfluenza viruses 1-4 (PIVs); influenza virus type A (IFVA); influenza virus type B; human rhinovirus (HRV); enterovirus; human metapneumovirus; human coronavirus OC43, 229E, NL63, and HKU1; adenovirus; and human bocavirus. Results: We examined 255 children with URIs (mean age: 32.9 ± 18.7 months), and 164 (64.1%) of them tested positive for at least one respiratory virus. The most common viruses were RSV (44, 24.3%), PIVs (28, 15.5%), and IFVA (25, 13.8%). Positivity for RSV was significantly greater in the URI + AOM group than in the URI group, but these groups did not differ in infection rates for the other 9 viruses. There were also significant seasonal differences in positivity for RSV, IFVA, HRV,HBoV, PIVs and EV. Conclusion: Our results indicated a relationship between infection by common respiratory viruses and AOM in children from Beijing. A URI with RSV significantly increased the risk of AOM in these children.

Social distancing cut down the prevalence of acute otitis media in children.

Objectives: To evaluate the additional, unintended benefits of social distancing in cutting down the prevalence of acute otitis media (AOM) in children, especially during coronavirus disease 2019 (COVID-19) periods. Methods: The daily outpatient attendance of AOM for childhood (from 6 months to 12 years) was compared in the tertiary hospital in Shanghai during pre-COVID-19 and COVID-19 year. Results: A total of 24,543 AOM cases were included from 2015 to 2020. When age was taken into account, children in kindergarten (aged 4-6) constitute 66.2% (16,236/24,543) of all case, followed by primary school students (6,441/24,543, 26.2%) and preschoolers <3 years old (1,866/24,543, 7.6%). There was an estimated 63.6% (54.32-70.36%) reduction in the daily outpatient attendance of AOM associated with the introduction of social distancing in 2020 (COVID-19 year). The epidemic trend of AOM in 2015-2019 was characterized by seasonal fluctuations, with highest incidence in December (18.8 ± 0.5%) and lower in February (4.5 ± 0.2%), June (3.7 ± 0.7%) and August (3.5 ± 0.5%). And distribution characteristics of different ages in COVID-19 period broadly in line with that in non-pandemic period. Conclusion: Seasonal fluctuation in the prevalence of AOM was observed in pre-COVID-19 period (2015-2019), with a peak in winter and a nadir in summer. The >50% drop of outpatient attendance of AOM in 2020 (COVID-19 year) suggest that social distancing, mask effects and good hand hygiene can significantly reduce the incidence of AOM, which provides a preventive and therapeutic point of view for AOM.

Evaluation of a clinical decision support system and an automated electronic health record alert on outpatient prescribing of cefdinir

Purpose of Study: Acute bacterial upper respiratory infections, such as acute otitis media, pharyngitis, and sinusitis, are common indications for antibiotics in pediatrics, and it is estimated one-third of these prescriptions may be inappropriate. Cefdinir is an oral cephalosporin commonly used in pediatrics due to taste and ease of once-a-day dosing. However, there are no evidencebased guidelines recommending it as a first-line agent. Outpatient clinician education has demonstrated some improvement in antibiotic prescribing habits but is often not sustainable long term. Clinical decision support systems in the form of pathways and order sets are more feasible in the outpatient setting and have demonstrated sustained improvements in provider prescribing habits. Best practice advisory alerts are commonly used in the inpatient setting and have shown promising results, but there are little data on their use in the outpatient setting. Methods Used: We developed an intervention in our electronic health record consisting of an order-set based on our local acute upper respiratory infection guidelines and a best practice advisory alert targeting Cefdinir use in non-penicillin allergic patients. The pre-intervention period was defined as April 2018 to December 2021. The post-intervention periodwas defined as January 2022 to December 2022. Data shown here are through September 2022. Oral antibiotic prescriptions from all general pediatric clinics within our institution with diagnosis codes pertaining to acute otitis media, pharyngitis, and sinusitis were included. Thesewere then grouped into first-line and non-first-line categories. Patient data were collected for each prescription, including diagnosis, date, sex, and race/ethnicity. The primary endpoint was the percentage of first-line prescribing. Summary of Results: A total of 45 038 prescriptions were included in our analyses with 36 578 in the pre-intervention period and 8460 in the post-intervention period. There was no difference noted between the pre- and postgroups in patient sex, however, there were notable differences in patient race/ethnicity and diagnosis. Firstline prescribing accounted for 73.5% of the pre-intervention group, and 81.9% of the post-intervention group (P = <0.001). Conclusion(s): Implementation of an outpatient order-set coupled with a best practice advisory alertwas associated with an 8.4% increase in first-line antibiotic prescribing for acute upper respiratory infections in outpatient pediatric clinics affiliated with our institution. Differences in diagnoses noted between pre- and post-intervention periods may be attributable to the COVID-19 pandemic. Copyright © 2023 Southern Society for Clinical Investigation.

Time to Presentation for Acute Otitis Media During the COVID-19 Pandemic

Background: Delays in acute care for diabetic ketoacidosis, appendicitis and malignancy resulted in more severe initial presentations for these problems during the COVID-19 pandemic. It is unknown whether the pandemic also caused delays in care for more common problems such as pediatric acute otitis media (AOM). Delays in presentation for AOM may have secondarily resulted in decreased delayed prescribing or watchful waiting (WW). We hypothesized that there was a greater time to presentation for AOM in 2020 (during the pandemic) with an increased percentage of patients presenting outside of the delayed antibiotic prescribing window compared to those who presented in 2019 (pre-pandemic). Methods: This is a retrospective secondary analysis of data collected for a national quality improvement project across 24 institutions with freestanding pediatric urgent care sites conducted in calendar years 2019 and 2020. 2020 data collection began after the pandemic was declared in the US. We included all submitted records with a diagnosis of AOM. Records were excluded if they had a codiagnosis for which an antibiotic is almost always required. The primary outcome compared the median time to presentation measured in days between 2019 and 2020 using the Wilcoxon rank-sum test. Pearson's chi-square test was used to compare categorical factors between 2019 and 2020. Results: Our analysis included 1,983 and 402 encounters diagnosed with AOM in 2019 and 2020. There was no significant difference in time to presentation for AOM between 2019 and 2020 (p=0.761). Similarly, the rate of delayed antibiotic prescriptions for eligible encounters was not different (p=0.419). Among patients without associated fever, the median time to presentation was shorter in 2019 compared to 2020, (2 days vs 3 days, p=0.02). However, when fever was present, the directionality was changed (3 days in 2019 and 2 days in 2020 p=0.04). Conclusion: Despite a growing body of evidence of delayed pediatric care during the COVID-19 pandemic, there was no difference in time to presentation, albeit many fewer diagnoses, for AOM in a national pediatric urgent care database. Both time periods had a median time to presentation of 2 days;however, children with fever had a shorter time to presentation during the pandemic. Only a small percentage of AOM encounters were eligible for delayed antibiotics due to presentation after 2 days of symptoms.

A Crick in theNeck: Lemierre Syndrome in a 4-year Old Female Presenting as Fever and Torticollis

Introduction: Described by Dr. Andre Lemierre in a 1936 case series of 20 patients, Lemierre Syndrome (LS) is defined as a septic thrombophlebitis of the internal jugular vein (IJV). LS typically begins as an oropharyngeal infection that advances to the IJV through direct extension through the fascial planes of the neck, or indirect lymphatic or hematogenous spread from the peritonsillar vessels. We present a case of LS in a 4-year-old patient who presents much younger than the typical age range of affected individuals, and who recovered well without any longterm sequelae. Case Description: A 4-year-old ex-27 week female presented with a near 3 week history of intermittent fevers and progressive right-facing torticollis. She had multiple interactions with the health care system over her illness course, and was given diagnoses ranging from general viral syndrome to gingivostomatitis and acute otitis media. Around the 2 week mark, her caretaker described her as having developed a “crick” in her neck while consistently favoring a rightward tilt. On illness day 16, she presented to her pediatrician for routine visit, and was noted to have fever, right tonsillar enlargement, and cervical lymphadenopathy, thereby prompting referral to the emergency department. Her physical exam on admission was additionally significant for a 30 degree rightward head rotation, a swollen and tender right sternocleidomastoid, and submandibular lymphadenopathy. She was resistant to active or passive neck rotation due to discomfort, but was able to traverse the midline with coaxing. Laboratory workup was notable for leukocytosis and thrombocytosis with elevated inflammatory markers, as well as mild transaminitis. Infectious serologic workup was negative for: SARS-CoV-2, Bartonella henselae, Bartonella quintana, EBV, and Mycoplasma. Blood culture showed no growth, but was drawn after antibiotics were given. A CT neck with contrast demonstrated intrinsic occlusion vs compression of the right IJV, and ultrasound and MRI confirmed IJV thrombophlebitis. Discussion: LS is typically associated with Fusobacterium necrophorum infection, a gram-negative anaerobe, with incidence estimated to be around 1 to 3.6 per million per year and mortality rate around 5 to 9%. Significant morbidity is often present, due to dissemination of septic thromboemboli, potentially affecting the CNS, bones/joints, and lungs. The typical age range for LS in pediatric patients clusters around adolescence, but infants as young as 6 months of age have been reported. As oropharyngeal infections most often precede LS, it is important to keep this rare but serious infection on any differential. Conclusion: This patient was diagnosed with Lemierre Syndrome. She was treated with an inpatient course of ampicillin/sulbactam before transitioning to oral amoxicillin/clavulanic acid to complete a total of 4 weeks of antibiotic therapy. All elevated laboratory markers normalized prior to hospital discharge, and the patient had complete resolution of symptoms at outpatient follow up.

Using Individual Clinician Feedback as Key Driver for Multiple Quality Improvement Initiatives at Large Pediatric Urgent Care Network

Purpose/Objectives: Quality improvement (QI) project implementation can be complex and effective interventions can be elusive, especially at large organizations with varied clinician practice. Our institution's large group of physicians and nurse practitioners work within a seven-site pediatric urgent care network in central Ohio. With several simultaneous QI projects we found trends showing varied compliance amongst clinicians that were present across initiatives. Prior studies have shown mixed results for individual clinician feedback as a primary intervention for quality improvement;we hypothesized that it would serve as a key driver in achieving and maintaining our project goals. Design/Methods: In September of 2020 we began emailing monthly individual physician feedback for four QI projects: acute otitis media (AOM) treatment duration, skin and soft tissue infection (SSTI) treatment duration, RSV viral testing rate and viral panel testing rate. The email contained objectives for each project, gave individual performance in relation to goal, and showed ranking compared to peers. Clinician feedback was not punitive, and clinicians' rank was not shared with the larger group. The audits were reviewed for accuracy and populated monthly by QI analyst and physician QI lead. Additionally, group compliance shown as a percentage was presented bimonthly at clinician conferences. Using statistical process control charts, we were able to track progress for all projects concurrently. Results: When scorecards began, AOM and SSTI projects had already improved from baseline while RSV and viral panel testing projects were new. After scorecard initiation, the AOM project had a second baseline shift from 67% to 85% while the SSTI project was sustained at 85% and edged towards 90% (Figure 1). For our respiratory projects, the COVID 19 pandemic had diverging effects. The RSV season abruptly ended and testing dropped precipitously at our institution. As a steady increase in the prevalence of RSV returns, with the scorecard, we have not yet seen an increase in testing and are at less than 1 test per 1000 respiratory visits compared to the pre-pandemic 16 per 1000 respiratory visits (Figure 2). Conversely, for the more comprehensive viral panel testing, we saw a significant increase above the baseline with the pandemic, from 10 per 1000 respiratory visits up to 23 per 1000 respiratory visits. After initiation of the scorecard, we achieved the pre-pandemic goal of 5 per 1000 respiratory visits (Figure 2). Conclusion/Discussion: Our scorecard approach was able to show that getting consistent, reliable, and relevant clinician direct feedback can meaningfully improve clinical practice across varied QI initiatives at different stages of development and with different objectives.

Updated principles of prevention, diagnosis and treatment of COVID-19 in children in Poland - recommendations for paediatricians and family medicine doctors

Since late 2021, we have observed a significant increase in the proportion of children infected with SARS-CoV-2. The course of the disease in children is usually sparsely symptomatic or asymptomatic. However, the predominance of new virus variants makes children more likely to become symptomatically ill and require hospitalisation. This paper aims to update recommendations for managing a child with COVID-19 in out- and inpatient settings. Current options for prevention and antiviral treatment are discussed, noting the limited availability of therapy for children. In most children with COVID-19, the basis for treatment remains symptomatic and supportive therapy and measures to reduce SARS-CoV-2 infection spread.

eHealthResp: educational intervention to improve antibiotic use in primary care - a protocol for a pilot study

Introduction: Antibiotic resistances are among themost threatening public health issues worldwide, being highly associated with inadequate antibiotic use. To tackle this challenge, it is crucial to educate health professionals to appropriately prescribe and dispense antibiotics. Thus, out team developed eHealthResp, an educational intervention composed by two online courses and a clinical decision support system in the form of a mobile app directed to primary care physicians and community pharmacists, aiming to improve antibiotic prescribing and dispensing in respiratory tract infections. Objectives: The main goal of this pilot study is to validate the eHealthResp online courses and the clinical decision support system (mobile app), involving a small group of health professionals. Methods: Aproximately 15 physicians and 15 pharmacists will be recruited to participate in the study. Participants will have complete autonomy to explore and evaluate the eHealthResp mobile app and online courses, composed by six modules on respiratory tract infections for physicians (i) acute otitis media, ii) acute rhinosinusitis, iii) acute pharyngotonsilitis, iv) acute tracheobronchitis, v) community-acquired pneumonia, and vi) COVID-19), and three modules for pharmacists (i) common cold and flu, ii) acute rhinosinusitis, acute pharyngotonsilitis, and acute tracheobronchitis, and iii) acting protocol). Each online course is also composed by four clinical cases and the most recommended pharmacological therapy. Additionally, for the the global validation of the online course and the mobile app, participants will be invited to complete a questionnaire including three sections of questions. The first part, consisting of five brief questions, will allow the collection of sociodemographic data. The second part contains four groups of closed questions, and the third part consists of four open-answer questions, both aiming to evaluate the online course and mobile app elements. Results: After the assessment made by the physicians and pharmacists who agreed to participate in the pilot study, the data obtained will be duly analyzed and integrated by the research team. The appropriate changes will be incorporated into the e-Health platforms to improve the quality of both the online courses and the eHealthResp mobile app. Conclusions: The findings of this pilot study will provide important information for the next stage of the project, ensuring the feasibility of the educational interventions in a group of primary care physicians and community pharmacists from the Centre region of Portugal, using a randomized controlled trial designed by clusters.

Features of the treatment of acute otitis media in the COVID-19 pandemic

In the pandemic new coronavirus infection (COVID-19), different clinical symptoms are observed depending on its dominant strain. The Omicron strain affects the nasal mucosa, causing the possibility of complications such as tubootitis and acute otitis media. Untimely or incomplete treatment of otitis media can contribute to the development of chronic forms of the course. Inflammatory process in the middle ear always proceeds with impaired hearing function due to the development of adhesions in the tympanic cavity. In patients with a reduced immune status, weakened course of the coronavirus infection itself, recovery comes later with a long recovery of hearing acuity, so it is very important to start treatment at the first manifestations of pain in the ear. In addition, the danger of otitis media against the background of SARS-CoV-2, if not treated in time, is the development of serious complications – mastoiditis, meningeal syndrome. Local analgesic therapy in the form of analgesic ear drops is recommended to reduce inflammation of the eardrum tissues. The combination of phenazone and lidocaine allows you to quickly stop the pain, block the development of phases of inflammation in the middle ear. Using a combination of phenazone and lidocaine reduces the time of onset of the analgesic effect, while increasing the intensity and duration of action, which is very important, especially in children. These components are not resorbed and have no systemic effect on the patient’s body. The combination of phenazone and lidocaine can be used in the treatment of children of all age groups, adults, pregnant women and nursing mothers. © 2022, Remedium Group Ltd. All rights reserved.

SARS-CoV-2 and Acute Otitis Media in Children: A Case Series

Background. Reports in adults with COVID-19 and acute otitis media (AOM) show that severe symptoms and hearing loss may be more common than with the clinical presentation of typical AOM. However, the association of SARS-CoV-2 with AOM in children is poorly understood. Methods. Cases were identified as a subpopulation enrolled in the NOTEARS prospective AOM study in Denver, CO from March-December 2020. Children enrolled were 6-35 months of age with uncomplicated AOM and prescribed amoxicillin. Children diagnosed with AOM and SARS-CoV-2, detected by polymerase chain reaction assay, were included in the case series. Data was obtained from electronic medical records and research case report forms. Patients completed surveys at enrollment and 5, 14 and 30 days after enrollment that included the Acute Otitis Media Severity of Symptoms (AOM-SOS©) scale. All patients had nasopharyngeal otopathogen testing completed. Results. A total of 108 patients had been enrolled through December 2020 (all of whom were subsequently tested for SARS CoV-2). During the study period for this case series, 16 patients were enrolled, and 7 (43.6%) were identified with AOM/SARS-CoV-2 co-infection. Among these 7 patients, fever was present in 3 children (29%). Four children (57%) attended daycare. Only 2 children (29%) had testing for SARS CoV-2 as part of their clinical workup. Mean AOM-SOS © scores were similar among the SARS CoV-2 positive and negative patients with no statistical significance noted with two-sided t-tests: 13.6 (± 4.5) vs 14.2 (± 4.9) at enrollment, 1.4 (± 1.8) vs 4.2 (±4.9) on Day 5, and 0.6 (± 0.9) vs. 2.5 (±6.1) on Day 14 (Table 1). Among the 7 patients, no child had an AOM treatment failure or recurrence. Of the 6 patients in whom bacterial and viral testing have been completed, a bacterial otopathogen was identified in 6 (100%), and a viral pathogen in 3 (50%) children (Table 2). Conclusion. SARS-CoV-2 can occur in children with AOM. It is important that providers maintain a high index of suspicion for COVID-19 even in patients with clinical evidence of AOM, particularly to ensure families are appropriately advised on isolation and quarantine requirements. AOM with SARS-CoV-2 does not appear to be more severe than AOM without SARS-CoV-2.

The traditional Mediterranean diet is effective in the prevention and treatment of acute and recurrent inflammatory diseases of childhood.

In the recent SARS-CoV-2 pandemic, disease severity was found to be more related to the immune system hyper-response than the invasive or destructive capacity of the virus. Similarly, most common childhood diseases, which are generally recurrent and inflammatory, may be caused by a hyper-response or inability of the immune system. Individuals will react differently to causal noxa and outcomes will depend on the balance and maturity of their immune system. Conventionally, childhood diseases are symptomatically treated with little attention being devoted to balancing and stimulating the maturation of the immune system. Recently, there has been an increase in publications that consider lifestyle as an important factor in the maintenance of health. One controversial angle is an abandonment of the traditional diet and the inclusion of foods that are potentially less well-assimilated by the human species. An increasing number of studies are demonstrating the anti-inflammatory effects of the Mediterranean Diet while illustrating the pro-inflammatory effects of many other food types. We believe that the Traditional Mediterranean Diet consists of foods that support the establishment and maintenance of a healthy microbiota and a mature immune system that, in turn, can aid in the prevention of common inflammatory and recurrent diseases of childhood.

Otitis Media Practice During the COVID-19 Pandemic.

The global coronavirus disease-2019 (COVID-19) pandemic has changed the prevalence and management of many pediatric infectious diseases, including acute otitis media (AOM). Coronaviruses are a group of RNA viruses that cause respiratory tract infections in humans. Before the COVID-19 pandemic, coronavirus serotypes OC43, 229E, HKU1, and NL63 were infrequently detected in middle ear fluid (MEF) specimens and nasopharyngeal aspirates in children with AOM during the 1990s and 2000s and were associated with a mild course of the disease. At times when CoV was detected in OM cases, the overall viral load was relatively low. The new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the causative pathogen responsible for the eruption of the COVID-19 global pandemic. Following the pandemic declaration in many countries and by the World Health Organization in March 2020, preventive proactive measures were imposed to limit COVID-19. These included social distancing; lockdowns; closure of workplaces; kindergartens and schools; increased hygiene; use of antiseptics and alcohol-based gels; frequent temperature measurements and wearing masks. These measures were not the only ones taken, as hospitals and clinics tried to minimize treating non-urgent medical referrals such as OM, and elective surgical procedures were canceled, such as ventilating tube insertion (VTI). These changes and regulations altered the way OM is practiced during the COVID-19 pandemic. Advents in technology allowed a vast use of telemedicine technologies for OM, however, the accuracy of AOM diagnosis in those encounters was in doubt, and antibiotic prescription rates were still reported to be high. There was an overall decrease in AOM episodes and admissions rates and with high spontaneous resolution rates of MEF in children, and a reduction in VTI surgeries. Despite an initial fear regarding viral shedding during myringotomy, the procedure was shown to be safe. Special draping techniques for otologic surgery were suggested. Other aspects of OM practice included the presentation of adult patients with AOM who tested positive for SARS-2-CoV and its detection in MEF samples in living patients and in the mucosa of the middle ear and mastoid in post-mortem specimens.

Tympanostomy tubes in the age of quarantine.

OBJECTIVES: After state-mandated COVID-19 quarantine measures were lifted in 2020, pediatric otolaryngologists noticed that many children who were previously scheduled for tympanostomy tube (TT) placement for indications of acute otitis media (AOM) or chronic middle ear effusions (OME) no longer required surgery. This study aims to describe the effect of home-quarantine on pediatric patients with recurrent AOM and OME to increase our understanding of these conditions. METHODS: This was a retrospective review of pediatric patients that were originally scheduled for TT for recurrent AOM and/or OME, but had their procedure cancelled due to COVID-19. The chi-square test was used to compare the proportion of patients who no longer met indications for surgery stratified by original indication. Data was also collected for TT volume in the months before and after the start of the pandemic. RESULTS: Of 59 patients originally scheduled for TT, 31.0% of the 42 patients who returned for follow-up still met indications for a procedure after a period of home-quarantine. Of these, 76.9% had persistent OME, 61.5% had recurrent AOM, and 69.2% had persistent conductive hearing loss. After elective surgery resumed, there was a substantial decrease in the number of TT procedures performed compared to pre-pandemic data. CONCLUSION: After a period of quarantine, many patients previously scheduled for TT experienced resolution of their AOM or OME. Despite a nationwide recovery in outpatient surgical volume across otolaryngology practices, TT volumes remain low one year after the start of the pandemic, suggesting that continued COVID-19 precautionary measures are contributing to this lingering effect.

New Approaches and Technologies to Improve Accuracy of Acute Otitis Media Diagnosis.

Several studies have shown that in recent years incidence of acute otitis media (AOM) has declined worldwide. However, related medical, social, and economic problems for patients, their families, and society remain very high. Better knowledge of potential risk factors for AOM development and more effective preventive interventions, particularly in AOM-prone children, can further reduce disease incidence. However, a more accurate AOM diagnosis seems essential to achieve this goal. Diagnostic uncertainty is common, and to avoid risks related to a disease caused mainly by bacteria, several children without AOM are treated with antibiotics and followed as true AOM cases. The main objective of this manuscript is to discuss the most common difficulties that presently limit accurate AOM diagnosis and the new approaches and technologies that have been proposed to improve disease detection. We showed that misdiagnosis can be dangerous or lead to relevant therapeutic mistakes. The need to improve AOM diagnosis has allowed the identification of a long list of technologies to visualize and evaluate the tympanic membrane and to assess middle-ear effusion. Most of the new instruments, including light field otoscopy, optical coherence tomography, low-coherence interferometry, and Raman spectroscopy, are far from being introduced in clinical practice. Video-otoscopy can be effective, especially when it is used in association with telemedicine, parents' cooperation, and artificial intelligence. Introduction of otologic telemedicine and use of artificial intelligence among pediatricians and ENT specialists must be strongly promoted in order to reduce mistakes in AOM diagnosis.

How Important Are in-Person Clinic Visits during Maintenance Therapy for Pediatric Acute Lymphoblastic Leukemia?

[Formula presented] Background Acute Lymphoblastic Leukemia (ALL) is the most common cancer seen in the pediatric age group. The treatment consists of an initial intensive phase of chemotherapy followed by a prolonged period of maintenance chemotherapy intended to reduce the risk of relapse. Children are commonly seen in clinic every 4-6 weeks for bloodwork and physical examination during the maintenance phase. The COVID-19 pandemic has prompted consideration of alternative means of providing medical care. The objective of this study was to determine the proportion of in-person clinic visits during ALL maintenance therapy for which the outcome of the physical examination resulted in a change of patient management. Methods A retrospective chart review of children diagnosed with precursor-B ALL between January 2017 and December 2018, and who were in maintenance therapy between September 2019 and February 2020, was conducted. All routine maintenance visits were reviewed to identify new physical examination findings and patient outcomes and classified as either “could be managed virtually” or “essential in-person visit”. For the latter, a second classification was conducted to distinguish between visits necessitating a change of management versus not. Results Eighty-five children were diagnosed with precursor B ALL and continued to maintenance treatment during the study period. 10 children were excluded as not meeting the inclusion criteria or not evaluable. Of the remaining 75 children, 54 were male (72%) and 21 female (28%). The median age at diagnosis was 4.83 years (0.73 - 14.8 years). 39 patients (52%) had standard risk ALL, 35 patients (46.7%) had high risk ALL and one patient had Infant ALL (1.3%) A total of 240 routine maintenance visits were included in the final analysis. An abnormal physical exam finding was noted in 20 visits (8.3%) and of these, new findings were noted in 14 (5.8%). 6 visits were classified as essential in-person visits (2 for new bruising, 1 for new limp, 1 for new lymphadenopathy, 1 for acute otitis media, and 1 for new wheezing). Among the 14 visits with new exam findings, only 5 had an impact on patient management and of these, only 2 (0.8%) were classified as obligate in-person visit for requiring immediate management (acute otitis media and wheezing). Conclusion Our results demonstrate that most in-person visits can be provided as virtual visits without affecting patient outcomes. The results of this study provide the foundation for a prospective study that will evaluate the benefits, risks and families' preferences associated with virtual visits and delineate the optimal frequency and timing of in-person clinic visits during ALL maintenance therapy. [Formula presented] Disclosures: No relevant conflicts of interest to declare.

The impact of COVID-19 pandemic on acute otitis media among the pediatric population.

BACKGROUND: The incidence of respiratory diseases has dropped during the school closures at the COVID-19 pandemic including acute otitis media (AOM) among the pediatric population. METHODS: This study included 2090 patients under 12 years old, that were diagnosed with AOM between March 2019 and February 2021 at the otolaryngology and pediatrics emergency room at a public tertiary hospital in Sao Paulo, Brazil. RESULTS: There was a significant drop in number of AOM cases diagnosed during the quarantine. The group before the pandemic represents 87,2% of the total attendings and the first two months of quarantine had the major attendance discrepancy between the same period during pre-pandemic times. CONCLUSION: Quarantine isolation measures and school closures may have helped reduce not only the coronavirus spread but also other infectious diseases such as AOM among the pediatric population.