Acute otitis media: who needs posttreatment follow-up?

OBJECTIVE: Because the optimal timing for follow-up of acute otitis media (AOM) is unknown and clinicians' recommendations for timing follow-up are highly variable, a study was conducted to determine which risk factors or symptoms could predict the resolution, recurrence, or persistence of AOM after treatment completion. METHODS: Three hundred four children from a general pediatric practice in a staff-model health maintenance organization, ages 6 months to 4 years diagnosed with AOM were enrolled in a prospective study of the clinical outcome of AOM at 10 to 21 days from diagnosis. Risk factors, symptoms, and parental observations were obtained by questionnaire at both the initial and follow-up visit 10 to 21 days later. At the follow-up visit, the clinical outcome of resolved AOM or persisting AOM was determined by the examining clinician. RESULTS: One hundred eighty-one patients returned for follow-up between 10 to 21 days; 24.9% had AOM at follow-up. Parental impression of resolved ear infection and the absence of symptoms at follow-up identified 97.1% of children with resolved AOM. Other factors associated with increased risk of AOM at follow-up were age < or = 15 months and a family history of recurrent AOM in a sibling. CONCLUSIONS: Because parental judgement of ear status and observation of symptoms appear to accurately identify those children with resolved AOM, a follow-up strategy is proposed in which posttreatment follow-up may be selectively offered to children whose parent(s) feels the infection has not resolved, children whose symptoms persist, or children at higher risk for AOM such as those < or = 15 months or with a family history of recurrent otitis.

Effects of inhaled capsaicin in heart-lung transplant patients and asthmatic subjects.

We have studied the effects on FEV1 of inhaled capsaicin in concentrations of 3 x 10(-6) to 3 x 10(-1) mg/ml and methacholine (1 to 16 mg/ml) in 15 heart-lung transplant (HLT) patients who had undergone recent transbronchial lung biopsy to determine the relationships in chronically denervated lungs between these different forms of airway hyperreactivity and inflammation. A total of 10 normal subjects and 17 asthmatic subjects were included for comparison. Capsaicin caused bronchodilation in eight HLT patients (FEV1 rising by 6.4 to 26.8%) and bronchoconstriction in two (fall in FEV1 of 7.2 and 7.6%). By contrast, seven asthmatic subjects developed bronchoconstriction after capsaicin (fall in FEV1 5.6 to 40.4%); the remaining 10 asthmatic subjects showed no response. Bronchial hyperresponsiveness to methacholine was most evident in the asthmatic subjects, but six HLT patients demonstrated a > or = to 20% fall in FEV1 with < or = 8 mg/ml of methacholine. All normal subjects were nonresponsive to both agents, and all normal and asthmatic subjects, unlike HLT patients, coughed with capsaicin. No relationship existed between the methacholine and capsaicin responses. In the HLT patients neither form of airway responsiveness was related to the degree of inflammation seen on transbronchial lung biopsy. The results suggest that in normal subjects, although it provokes cough, inhaled capsaicin causes little airway narrowing.(ABSTRACT TRUNCATED AT 250 WORDS)

Diurnal variation in FEV1 after heart-lung transplantation.

We have examined the diurnal variation in forced expiratory volume in one second (FEV1) in 25 heart-lung transplantation patients over a four week period in order to study the pathophysiological mechanisms underlying the increased mortality and morbidity which occurs at night in asthma. These patients do not have pulmonary autonomic nervous reflexes, but often have muscarinic receptor hypersensitivity. They also develop mixed cell infiltration of the lung tissue in the course of infection or rejection. Thus, they show many features in common with asthma. Seventeen patients (68%) showed a significant diurnal variation in airway calibre (mean amplitude of FEV1 was 4.6% (SD 3.7%)), which is similar to that reported in normal adults. One patient had a diurnal variation of 34.5% during an episode of rejection. This variation fell to 6.9% after steroid therapy, a change often seen in asthma. There was a correlation between increased amplitude of the variation and the presence in transbronchial biopsies of airway submucosal eosinophils and lymphocytes, associated with a histological diagnosis of acute rejection and with epithelial damage. No association was seen with muscarinic receptor sensitivity. The variation in FEV1 showed no alteration from the normal day/night synchronization, and the peak values were around 1300 h. We conclude that the diurnal variation in FEV1 after heart-lung transplantation is not dependent on autonomic nerve reflexes or muscarinic receptor sensitivity, but is related to the consequences of inflammation described above.

Information and service needs among active and former family caregivers of persons with Alzheimer's disease.

This study interprets results of a needs assessment completed by active and former caregivers of relatives with Alzheimer's disease (AD). Self-administered questionnaires yielded data about information and service needs at the time of diagnosis and at the time of the survey. Implications point to the need for high-quality educational material throughout the caregiving career, improved training for health professionals about AD, and an important role for former caregivers as resources to disseminate knowledge about AD to still-active caregivers and others in their own communities.

Neurodevelopmental readiness for adolescence: studies of an assessment instrument for 9- to 14-year-old children.

The Pediatric Examination of Educational Readiness at Middle Childhood (PEERAMID) is a neurodevelopmental examination for 9- to 14-year-old children. The examination was designed largely for use by developmental-behavioral pediatricians as a way of assessing certain critical developmental functions, including attention, memory, language, and motor coordination in children with school problems. Preliminary field testing of the PEERAMID was carried out in one community, and subsequently a revised version was standardized on randomly selected subjects from three communities near Boston, Massachusetts, and on groups of children from those towns said to be having significant problems at school. Additionally, the examination was used for the evaluation of 106 consecutive patients referred to the School Function Program at The Children's Hospital in Boston. Statistically significant performance differences discriminated between children with normal academic performance and those with school problems in the community as well as in the referral setting. It was discovered that children with school problems tended to have clusters of dysfunction, whereas normally achieving youngsters more often harbored no developmental dysfunctions or perhaps one or two areas of difficulty. It is believed that the PEERAMID can be a useful instrument in serving as part of a pediatric contribution to a multidisciplinary assessment in children in this age group.