Prospective comparison of handheld pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children.

OBJECTIVES: To compare pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children and to determine if a significant difference exists in sensitivity and specificity based on patient age and/or experience of the examiner. METHODS: A prospective study of 102 patients, or 201 ears, enrolled over a 1-year period in a tertiary medical center. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for staff and resident-performed pneumatic otoscopy, staff and resident-performed binocular microscopy, and tympanometry. Tympanometry data were stratified for age. A kappa correlation was used to compare each tool to myringotomy result (gold standard) and to compare staff versus resident. RESULTS: Binocular microscopy by staff pediatric otolaryngologist was the most sensitive, 88.0% (95% CI 81.4-94.7), and specific, 89% (95% CI 83.1-94.9). Resident binocular microscopy revealed a sensitivity of 81.5% (95% CI 73.6-89.5) and specificity 78.9% (95% CI 71.2-86.6). Staff was more sensitive and specific than resident at pneumatic otoscopy, sensitivity 67.9% (95% CI 57.6-78.3) and specificity 81.4% (95% CI 73.8-88.9) versus 57.7% (95% CI 46.7-68.7) and 78.4% (95% CI 70.4-86.4). Tympanometry had a much lower specificity for ages 5-12 months than for older children. CONCLUSIONS: Binocular microscopy by staff pediatric otolaryngologist revealed the best sensitivity and specificity. Pneumatic otoscopy even performed by an inexperienced examiner is more sensitive and specific than tympanometry. The tympanometer is less specific in children under 1 year of age.

Mitoxantrone and cytarabine induction, high-dose cytarabine, and etoposide intensification for pediatric patients with relapsed or refractory acute myeloid leukemia: Children's Cancer Group Study 2951.

PURPOSE: To evaluate the response rate, survival, and toxicity of mitoxantrone and cytarabine induction, high-dose cytarabine and etoposide intensification, and further consolidation/maintenance therapies, including bone marrow transplantation, in children with relapsed, refractory, or secondary acute myeloid leukemia (AML). To evaluate response to 2-chlorodeoxyadenosine (2-CDA) and etoposide (VP-16) in patients who did not respond to mitoxantrone and cytarabine. PATIENTS AND METHODS: Patients with relapsed/refractory AML (n = 101) and secondary AML (n = 13) were entered. RESULTS: Mitoxantrone and cytarabine induction achieved a remission rate of 76% for relapsed/refractory patients and 77% for patients with secondary AML, with a 3% induction mortality rate. Cytarabine and etoposide intensification exceeded the acceptable toxic death rate of 10%. The response rate of 2-CDA/VP-16 was 8%. Two-year overall survival was estimated at 24% and was better than historical control data. Patients with secondary AML had similar outcomes to relapsed or refractory patients. Initial remission longer than 1 year was the most important prognostic factor for patients with primary AML (2-year survival rate, 75%), whereas for patients with primary AML, with less than 12 months of initial remission, survival was 13% and was similar to that of refractory patients (6%). CONCLUSION: Mitoxantrone and cytarabine induction is effective with reasonable toxicity in patients with relapsed/refractory or secondary AML. The cytarabine and etoposide intensification regimen should be abandoned because of toxicity. Patients with relapsed AML with initial remissions longer than 1 year have a relatively good prognosis.