A comparison of the experiences, challenges and coping strategies for parents of children with autism residing in the United States and The Arab World.

Most research on autism has targeted White Americans. Although challenges and coping mechanisms are present for all parents, some aspects are influenced by culture. This study aims to compare the experiences, challenges and coping strategies for parents of children with autism residing in the US and Arab countries. A survey, available in both English and Arabic, was posted electronically on social media support groups for parents of children with autism in Arab countries and the US. The survey covered experiences, challenges and coping strategies for raising a child with autism spectrum disorder. 165 surveys were collected from 15 Arab countries and 235 surveys were collected from 32 US states. On a scale from 1 to 5, with 5 being highest satisfaction, US parents reported a higher satisfaction for the overall diagnostic process with median score of 3.0 compared to 2.5 for parents in Arab countries. Parents in both countries reported information seeking/self-education about autism and acceptance and/or religion as the 2 most valuable coping strategies. Lower satisfaction with all aspects of the diagnosis process was found among parents in Arab countries compared to those residing in the US. Lack of community support for Arab parents was also a more significant challenge compared to US parents. With such poor community support for Arab parents, it is pivotal to expand upon initiatives that minimize the stigma and shame associated with an autism diagnosis to ultimately reduce challenges and allow for better parental experiences.

Factors and scenarios influencing Arab Americans' preference for male versus female physicians.

As the Arab American community sees an increase in female physicians, knowledge of patients' perceptions is necessary to foster the physician-patient relationship. The objective of this study was to better understand physician gender preference among Arab Americans when given a range of selected medical scenarios. An anonymous survey was distributed electronically through social media. The survey elicited gender preferences of Arab Americans given different scenarios. Data was collected from 325 participants. No physician gender preference was noted for 6 out of 7 scenarios with the exception for sensitive medical issues. Same-sex gender preference was noted in the cases of sensitive medical issues, routine medical visits, medical emergencies, and minor medical procedures. Predominant visitations to male physicians across specialties was found. The current study shows that although most Arab Americans expressed no preference for physician gender, the majority currently visit male physicians. The study highlights similarities to other populations in terms of same-sex physician gender preference when it comes to patient choices. Our study shows, however, that physicians' experience and empathy were leading criteria as opposed to gender or Arab identity when it came to physician selection by Arab American patients.

Sociodemographic Factors Associated With Decreased Compliance to Prescribed Rehabilitation After Surgical Treatment of Knee Injuries in Pediatric Patients.

BACKGROUND: Rehabilitation is an important component of care in postsurgical knee patients, especially as it pertains to return to preinjury activity level. Despite the established significance of rehabilitation in improving outcomes after certain surgical procedures, there is a lack of investigation into compliance rates and factors that affect compliance in pediatric patients. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate sociodemographic factors associated with noncompliance in pediatric patients after knee surgery to characterize health disparities in this population. Our hypothesis was that certain sociodemographic factors would be associated with decreased compliance. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective review of medical records was used to gather data on compliance rate, demographics, and socioeconomic factors for pediatric patients undergoing rehabilitation after knee surgery. Compliance rate was determined by counting the total scheduled appointments, cancellations, and no-shows (defined as visits for which patients did not show up and did not provide notification of cancellation). Various types of knee injuries were included in this study. Data were evaluated using bivariate analyses in addition to hierarchical linear and binary logistic regression to assess for associations between sociodemographic factors and compliance rate. RESULTS: Our total sample size was 186 patients. When compared with patients from non-single-parent households, patients from single-parent households were found to have a lower rate of physical therapy compliance (72.2% vs 80.1%; P < .001), were less likely to reach the 85% compliance threshold (9.1% vs 42.4%; P < .001), and had an increased amount of cancellations and no-shows (16.7 vs 11.7 visits; P = .02). Although a small sample size, Hispanic/Latino patients were shown to have a lower achievement of the 85% compliance threshold compared with non-Hispanic/Latino patients (0% vs 38.2%; P = .04). Increased distance from the rehabilitation clinic was associated with lower achievement of the 85% compliance threshold (P = .033). CONCLUSION: Overall, there were several significant demographic and socioeconomic variables associated with rehabilitation compliance, specifically single-parent status, distance to rehabilitation clinic, and ethnicity. These results suggest potential predictors of decreased compliance that warrant prospective investigation.

Adopting otitis media practice guidelines increases adherence within a large primary care network.

AIM: Unnecessary antibiotic prescriptions to treat otitis media (OM) contribute to adverse drug reactions, increased cost and antibiotic resistance. Clinical care guidelines can help promote consistent treatment of conditions such as OM. This study evaluates adherence before and after implementation of an institutional guideline for the diagnosis and treatment of paediatric OM. METHODS: A retrospective chart review was performed to collect encounter information for paediatric patients seen within a primary care clinic network and diagnosed with OM before and after full implementation of a clinical care guideline. Patient cohorts from 2013 and 2016 were compared to determine which factors, including age, symptoms and diagnosis, were associated with treatment guideline adherence. RESULTS: Comparison of encounters from 2013 (n = 418) to 2016 (n = 635) revealed a significant difference in adherence to the 2013 Michigan Medicine Otitis Media Guideline. Overall adherence increased from 61.2% in 2013 to 70.6% in 2016 (χ2  = 9.85, P < 0.0017). Antibiotic use for acute OM decreased from 99.7% in 2013 to 96.7% in 2016 (χ2  = 10.04, P = 0.0015). Antibiotic prescriptions for OM with effusion decreased significantly from 42.9% in 2013 to 17.4% in 2016 (χ2  = 11.93, P < 0.0006). CONCLUSION: Implementation of an institutional OM clinical practice guideline contributed to a significant increase in overall treatment adherence of OM for paediatric patients between the 2013 and 2016 cohorts. The number of antibiotic prescriptions for paediatric patients diagnosed with acute OM or OM with effusion significantly decreased from 2013 to 2016.

Sociodemographic Predictors of Patient Age at Time of Cleft Lip and Palate Repair.

OBJECTIVE: To identify the impact of sociodemographic and health variables on the age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation. DESIGN: A retrospective, noninterventional quality assessment, and quality improvement study was designed. SETTING: This institutional study was performed at Michigan Medicine in Ann Arbor, MI. PATIENTS: All patients born between 2011 and 2014 who received surgical cleft repair, excluded those who were adopted (n = 165). MAIN OUTCOME MEASURE: The age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation. RESULTS: Cleft lip repair was performed significantly later for patients identifying as Asian (18 weeks, P = .01), patients with Child Protective Services contact (19 weeks, P = .01), patients with a significant comorbidity (14 weeks, P = .02), and patients who underwent preliminary lip adhesion surgery (19 weeks, P < .01). Cleft palate repair was performed significantly later for patients identifying racially as Asian (19 weeks, P = .03) and other (22 weeks, P = .03). Preliminary speech and language evaluation were performed significantly later for patients identifying as black (55 weeks, P = .03) and patients diagnosed with an isolated cleft lip (71 weeks, P < .01). CONCLUSIONS: Timing of cleft lip, cleft palate repair, and primary speech and language evaluation are subject to variation which may be predicted by clinically accessible factors. By identifying race, Child Protective Services contact, and care variables as significant predictors of increased patient age at time of intervention, multidisciplinary cleft care teams can proactively allocate patient support resources.

Assessing Knowledge, Physician Interactions and Patient-Reported Barriers to Colorectal Cancer Screening Among Arab Americans in Dearborn, Michigan.

Colorectal cancer (CRC) is the second leading cause of cancer related deaths among men and women in the United States (Haggar and Boushey in Clin Colon Rectal Surg 22:191-197, 2009). Screening tests have shown to be successful at early detection of precancerous polyps. Between 2000 and 2010, there was a 72% growth in the population that identifies having an Arabic-speaking ancestry (Arab American Institute in https://www.aaiusa.org/demographics , 2011). Despite this, little research has been conducted to assess this unique community's knowledge regarding CRC. Given that low screening rates can be attributed to lack of knowledge, this study was designed to address CRC knowledge and screening barriers in an Arab American community. Between February 2016 and June 2017, an anonymous survey was conducted in English or Arabic among 131 patients from cancer programs at the Arab Community Center for Economic and Social Services (ACCESS) in Dearborn, MI. Program participants were expected to have greater insight and awareness about cancer risk than the general population. Knowledge deficiencies surrounding CRC and the screening process were identified. 70% of participants did not know what a colon polyp is and over 89% were not aware of their individual risk for CRC. 45.8% have never had a CRC screening and leading barriers included screening costs, lack of health insurance, and lack of advice by physicians. The goal of this study was to serve as a tool to healthcare providers by identifying evident gaps in medical knowledge surrounding CRC. In order to help better serve and educate patients, healthcare providers and community organizations are encouraged to fight the stigma and help to reduce misunderstandings.

Sociodemographic Factors Associated With Adherence to Referrals From the Pediatric Emergency Department.

BACKGROUND: Outpatient referrals constitute a critical component of emergency medical care. However, barriers to care after emergency department (ED) visits have not been investigated thoroughly. OBJECTIVE: The purpose of this study was to determine the impact of sociodemographic variables on referral attendance after ED visits. METHODS: A retrospective cohort study was designed. Patients aged 0-17 years who visited the C.S. Mott Children's Hospital ED in 2016 and received a referral were included. Multiple referrals for 1 patient were counted as independent encounters for statistical analysis. RESULTS: Chart review was performed on 6120 pediatric ED encounters, producing a total of 822 referrals to University of Michigan Health System outpatient clinics. Referral attendance did not differ by race, ethnicity, language, or religion. Older age was associated with decreased attendance at referrals (p = 0.043). Patients who were black and female (p = 0.019), patients with public health insurance (p = 0.004), and patients residing in areas with either high rates of unemployment (p = 0.003), or lower high school education rates (p = 0.006) demonstrated decreased attendance. Patients referred to pediatric neurology had lower attendance rates (p < 0.001), and those referred to pediatric orthopedic surgery attended referrals more often (p = 0.006). CONCLUSIONS: This study provides an overview of the impact of sociodemographic and departmental factors on attendance at outpatient follow-up referrals. Significant disparities exist with respect to referral attendance after emergency medical care. Informed resource allocation may be utilized to improve care for these at-risk patient populations.

Knowledge Assessment and Screening Barriers for Breast Cancer in an Arab American Community in Dearborn, Michigan.

Breast cancer (BC) is the most common malignancy afflicting women during their lifetime. Screening for breast cancer can reduce mortality through early cancer detection. Lack of knowledge is an important barrier leading to low screening rates. Little research has evaluated breast cancer knowledge and barriers to receiving appropriate screening among Arab Americans. Given that the Arab American population has grown approximately 47% since 2000, this study was designed to assess breast cancer knowledge and screening barriers in an Arab American community. An anonymous survey addressing knowledge assessment and screening for breast cancer was distributed at the Arab Community Center for Economics and Social Services in Dearborn, MI between June 2015 and August 2017. The survey was modified based on a similar study that was conducted Among Adult Saudi women in a primary health care setting. 102 non-BC survivors, 48 BC survivors and 50 men participated in this study. Gaps in knowledge around the role of age and family history, as well as cancer presentation were noted among the participants. Additionally, 51% of non-BC survivors over the age of 40 years have not had a screening mammogram in the past 2 years with leading causes being absence of symptoms, lack of health insurance, and absence of family history. Healthcare providers and community organizations should work towards increasing knowledge levels, reducing misconceptions and improving screening rates for breast cancer among Arab Americans. Increasing community outreach and education and navigating the community's health beliefs and practices can optimize the process of information delivery to community members.

Antibiotic prescription patterns for management of acute otitis media in Lebanon.

OBJECTIVES: The high incidence of Acute Otitis Media (AOM) along with low antibiotic efficacy in the treatment of AOM is particularly favorable for the emergence of antimicrobial resistance. The promotion of more conservative antibiotic prescription habits has become an important focus of governments and academic societies. Little is known about the awareness and use of AOM practice guidelines by physicians in the Middle East. Our aim is to characterize AOM management in Lebanon by using an anonymous survey instrument to uncover potential disparities in treatment trends and evaluate differences in clinical guideline adherence patterns. METHODS: A total of 75 practicing physicians were anonymously surveyed in Beirut, Saida, Nabatieh, Bekaa and Tripoli, Lebanon. The survey tool used was previously used in Amman, Jordan by our colleagues at the University of Michigan. The survey we used assessed awareness of and adherence to practice guidelines by prompting responses to hypothetical AOM cases. Differences in performance between various physician groups were noted. RESULTS: Overall, physician participants answered 67% of the survey questions correctly. Trainees did better overall in terms of AOM management (62% correct responses as compared to 48% in attending physicians, p = 0.0175). Trainees also performed better in terms of their ability to manage cases of potential AOM in two-year old children and their ability to choose the appropriate medications (79% correct response rate compared to 71% in attending physicians, p = 0.0278). Participants who reported guideline adherence most or all of the time had a 67% correct response rate in regards to their ability to diagnosis AOM, compared to a 57% correct response rate in those who reported adhering sometimes or rarely to the guidelines (p = 0.0489). In the cases requiring antibiotic treatment for body temp of over 39C with/without otalgia, only 47-57% of participants identified the appropriate antibiotic regimen. CONCLUSION: There are areas of potential improvement in adherence to clinical guidelines in the management, diagnosis, and treatment of AOM by Lebanese physicians. Conducting interventions among physicians to improve awareness of clinical guidelines and current treatment recommendations in Lebanon will likely improve adherence to guidelines, enhance clinical outcomes, and may help advance the fight against antimicrobial resistance.

Sociodemographic Predictors of Missed Appointments Among Patients With Cleft Lip and Palate.

OBJECTIVE: To identify disparities in compliance of and care for patients with cleft lip and/or palate (CL/P) by determining the impact of sociodemographic variables on the rate of missed appointments and Child Protective Services (CPS) involvement. DESIGN: A retrospective, noninterventional quality assessment and quality improvement study were designed. SETTING: This institutional study was performed at the University of Michigan in Ann Arbor, Michigan. PATIENTS: All patients born between January 1, 2011, and December 31, 2014, who underwent surgical CL/P repair, excluding those with fewer than 5 appointments (n = 178). MAIN OUTCOME MEASURE: The rate of missed appointments, calculated as the total number of no-show appointments divided by the total number of scheduled appointments. All appointments from CL/P diagnosis to data collection were considered, including those outside of plastic surgery. RESULTS: The average patient was 4.5 years of age and had 49 total scheduled appointments. The overall rate of missed appointments was 9.6%, with 66.8% of patients missing at least 1 scheduled visit. Patients who were black ( P = .04), not affiliated with a religion ( P = .01), Medicaid users ( P = .01), from an unstable social background ( P = .01), or received need-based financial assistance ( P = .00) were significantly more likely to miss appointments. Child Protective Services was involved with 3.9% of patients. CONCLUSIONS: Disparities exist in attendance rates among patients with CL/P, and at-risk patient populations have been identified. The allocation of cleft care resources must be efficiently planned in order to enhance the quality of care for at-risk individuals.

Disseminated Mycobacterium Avium Complex in an Adolescent with Perinatally-Acquired HIV Infection.

Mycobacterium avium complex (MAC) is the most frequent nontuberculous mycobacteria implicated in opportunistic infections that define acquired immunodeficiency syndrome. With highly active antiretroviral therapy, disseminated MAC (dMAC) has become a rare entity. This unique case of dMAC was diagnosed in an adolescent with newly diagnosed perinatally-acquired HIV infection whose initial CD4 cell count was severely depleted and viral load was extremely high. While maximized treatment regimen had not been able to control his dMAC, improvement was noted when granulocyte macrophage colony-stimulating factor (GM-CSF) was added. GM-CSF should be considered as an adjunctive therapy in patients with refractory dMAC.

School-Based Health Education in Yucatan, Mexico about the Chikungunya Virus and Mosquito Illness Prevention.

The Chikungunya virus (CHIKV) has been rapidly spreading throughout Latin America, utilizing pre-existing vectors to infiltrate the immunologically naïve populations. With the current rise of the Zika Virus, there is an urgent need for more rigorous vector control efforts to prevent further Zika breakout. We designed a school-based education module on CHIKV and mosquito prevention and presented it to the local students of ages of 6-18 in a rural town called Sudzal in Yucatan, Mexico. We distributed questionnaires before and after education to test the students' knowledge of CHIKV and mosquito prevention. Chi-squared test was performed to determine the efficacy of the presentation in increasing their knowledge. The education presentation has proven to effectively educate the local residents in several critical methods of mosquito prevention, increasing the average test scores by 67% post-education. These include applying repellent, staying hydrated during recuperation, and cleaning indoor water containers to eliminate breeding sites (P<0.001). Furthermore, the questionnaire captured the residents' behavioral patterns regarding CHIKV and mosquito prevention and identified cultural, ecological, and socioeconomic factors hindering effective implementation of vector control.

The use of practice guidelines in the management of pediatric cases of Acute Otitis Media in Amman, Jordan.

OBJECTIVES: The widespread emergence of antimicrobial resistance has led many healthcare institutions to adopt more conservative antibiotic prescription practice guidelines for the treatment of acute otitis media (AOM). Little is known about the awareness and use of such guidelines by physicians in Jordan. Our aim was to pilot an anonymous survey instrument that would assess AOM treatment trends as well as awareness of and adherence to practice guidelines in Amman. By qualitatively assessing the management of AOM we could illuminate possible disparities in treatment trends, evaluate variability in practice guideline adherence, and help focus efforts of future educational programs that pertain to pediatric AOM management. METHODS: A total of 71 practicing physicians were anonymously surveyed in Amman, Jordan. The survey assessed awareness of and adherence to practice guidelines by prompting responses to hypothetical AOM cases. Differences in performance between various physician groups were noted. RESULTS: In total, participants answered 61.2% of the questions correctly. It was found that trainees would prescribe more appropriate antibiotics relative to attending physicians (p = 0.008). It was found that medical physicians followed guidelines more appropriately relative to ENT surgeons (64.2% of questions answered correctly vs. 58.1% of questions answered correctly; p = 0.015) and that physicians who report adhering to guidelines all/most of the time followed guidelines more appropriately relative to those who report adhering only sometimes or never (64.0% of questions answered correctly vs. 58.0% of questions answered correctly; p = 0.011). Also, cases that dealt with children were the most difficult for participants to diagnose as compared with cases that dealt with adults. CONCLUSION: We conducted the first known qualitative analysis of otitis media practices in Amman and found numerous shortcomings in AOM guideline familiarity. Awareness of practice guidelines can lead to more appropriate AOM management, but there is variability between groups in guideline familiarity and utilization. Interventions that promote more conservative antibiotic prescriptions could be targeted towards groups that prescribe antibiotics less appropriately relative to their colleagues e.g. attending physicians and ENT surgeons. Interventions could also target physicians who manage pediatric AOM cases as participants had the most difficulty in properly diagnosing cases that involved children and infants.

Lemierre Syndrome Presenting as Acute Mastoiditis in a 2-Year-Old Girl with Congenital Dwarfism.

Lemierre syndrome is defined by septic thrombophlebitis of the internal jugular vein caused by Fusobacterium. Historically, these infections originate from the oropharynx and typically are seen in older children, adolescents and young adults. More recently, otogenic sources in younger children have been described with increasing frequency. We present a case of a two-year old, who initially developed an otitis media with perforation of the tympanic membrane and went on to develop mastoiditis and non-occlusive thrombosis of the venous sinus and right internal jugular vein. Fusobacterium necrophorum was grown from operative cultures of the mastoid, ensuing computed tomography scan revealed occlusion of the internal jugular vein and the patient was successfully treated with clindamycin, ciprofloxacin and enoxaparin. This case demonstrates the importance of considering Fusobacterium in otogenic infections and the consideration of Lemierre syndrome when F. necrophorum is identified.

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS): Experience at a Tertiary Referral Center.

BACKGROUND: Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) is an autoimmune disorder presenting with obsessive compulsive disorder and/or tics. Like Sydenham's chorea, its presumed pathogenesis consists of autoantibodies cross-reacting with neurons in response to a group A beta-hemolytic streptococcal infection (GASI). There are currently no diagnostic laboratory findings and management ranges from antibiotic prophylaxis to intravenous immunoglobulin to plasmapheresis. The diagnosis remains controversial, resulting in inconsistent referrals and significant patient anxiety. METHODS: A retrospective study was performed on all patients referred to the Pediatric Infectious Disease Division with a pre-referral diagnosis of PANDAS. Patients were analyzed by demographics, medical history, co-morbidities, symptoms, prior treatment, laboratory tests, management strategies, and treatment outcomes. RESULTS: From 2003 to 2013, there were 21 patients with a pre-referral diagnosis of PANDAS. Only five met the diagnostic criteria. No patient at referral had an objective scale to monitor symptoms. Eight referrals had a major psychiatric disorder, and none fulfilled diagnostic criteria (p<0.01). DISCUSSION: The majority of the patients referred with a pre-diagnosis of PANDAS do not fulfill diagnostic criteria nor do they have objective criteria for symptom monitoring. Major psychiatric disorders do not seem to be associated with PANDAS, and better physician education may prevent misdiagnoses. Multidisciplinary management is recommended.

Analysis of the Nature of IRB Contingencies Required for Informed Consent Document Approval.

The University of Michigan Human Research Protection Program formed a six-member committee to analyze the nature of Institutional Review Board (IRB) staff and board contingencies for the approval of informed consent documents. Of the 100 studies examined, 87% had one or more informed consent contingencies. "Omissions" in documentation (40%) and "better clarity" (24%) accounted for the majority, while "word-smithing" accounted for only 10%. This is one of the first studies to examine the nature of IRB contingencies as they relate to informed consent documents. Educational efforts targeting completeness in documentation and clarity on the part of study teams, and discouraging "word-smithing" on the part of IRBs, could reduce the number of informed consent contingencies and expedite the IRB approval process.

Access to Safe Water and Personal Hygiene Practices in the Kulandia Refugee Camp (Jerusalem).

Diarrheal illness, frequently associated with fecal-oral transmission, is one of the leading causes of death worldwide. It is commonly preventable through the implementation of safe water practices. This experiment concerns how to best implement safe water practices in a quasi-permanent refugee camp setting with limited ability for structural changes. Specifically, we explore how health promotion activities that help identify target groups for hygiene interventions can play a role in disease prevention. An anonymous survey was conducted at the United Nations Relief and Works Agency Health Clinic in the Kulandia refugee camp to assess the safe water and personal hygiene practices. Demographic and social characteristics, accessible water and personal hygiene characteristics, and gastrointestinal (GI) burden for individuals and their households were assessed. A total of 96 individuals were enrolled; 62 females and 34 males. Approximately 58% of the sample had soap available and washed hands before and after eating and when preparing food. Piped water was the main source of drinking water (62%), while 31% of our sample utilized tanker-trucks. 93% of participants had access to toilet facilities, with 86% of these facilities being private households. 55% practice extra water hygiene measures on their household drinking water source. 51.3% considered vendor cleanliness when they were buying food. 51% had received formal health education. 68.8% had been taught by their parents, but only 55.2% were teaching their children and 15.6% had consistent access to a health professional for hygiene inquiries. Individual variables and hygiene practices associated with lower rates of diarrheal illnesses included having water piped into the home, proper hand washing, adequate soap availability, proper consideration of vendor cleanliness, higher income, levels of education, health hygiene education, and having access to healthcare professions to discuss hygiene related matters. This is the first study to assess the water and personal hygiene practices at the Kulandia refugee ramp. This study demonstrates that hygiene education and better practices are closely associated with the rate at which individuals and households suffer from diarrheal illnesses within the Kulandia refugee camp. There are significant hygiene deficits in the camp, which likely result from a lack of formal hygiene education and a lack of awareness concerning the connection between diarrheal illness and hygiene. With respect to practices, our results elucidate several areas where basic, communal programming - including lessons on appropriate hand washing and food preparation - will likely improve hygiene practices and decrease overall GI burden.

Staphylococcus lugdunensis: Novel Organism causing Cochlear Implant Infection.

A majority of cochlear implant infections are caused by Staphylococcus aureus or Pseudomonas aeruginosa. Reported here is a pediatric patient with a cochlear implant infection caused by methicillin-resistant Staphylococcus lugdunensis, a coagulase-negative Staphylococcus that has only recently been determined to be clinically relevant (1988). Unlike other coagulase-negative Staphylococcus, it is more aggressive, carrying a greater potential for tissue destruction. In pediatrics, the organism is uncommon, poorly described, and generally pan-susceptible. Described herein is the presentation and management of this unusual organism in a pediatric setting.

Otitis media: diagnosis and treatment.

Acute otitis media is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever. Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid. Management of acute otitis media should begin with adequate analgesia. Antibiotic therapy can be deferred in children two years or older with mild symptoms. High-dose amoxicillin (80 to 90 mg per kg per day) is the antibiotic of choice for treating acute otitis media in patients who are not allergic to penicillin. Children with persistent symptoms despite 48 to 72 hours of antibiotic therapy should be reexamined, and a second-line agent, such as amoxicillin/clavulanate, should be used if appropriate. Otitis media with effusion is defined as middle ear effusion in the absence of acute symptoms. Antibiotics, decongestants, or nasal steroids do not hasten the clearance of middle ear fluid and are not recommended. Children with evidence of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist.