Interventions for children with ear discharge occurring at least two weeks following grommet (ventilation tube) insertion

BACKGROUND: Ear discharge (otorrhoea) is common in children with grommets (ventilation/tympanostomy tubes); the proportion of children developing discharge ranges from 25% to 75%. The most common treatment strategies include oral broad-spectrum antibiotics, antibiotic eardrops or those containing a combination of antibiotic(s) and a corticosteroid, and initial observation. Important drivers for one strategy over the other are concerns over the side effects of oral antibiotics and the potential ototoxicity of antibiotic eardrops. OBJECTIVES: To assess the benefits and harms of current treatment strategies for children with ear discharge occurring at least two weeks following grommet (ventilation tube) insertion. SEARCH METHODS: The Cochrane ENT Information Specialist searched the ENT Trials Register, CENTRAL (2016, Issue 5), multiple databases and additional sources for published and unpublished trials (search date 23 June 2016). SELECTION CRITERIA: Randomised controlled trials comparing at least two of the following: oral antibiotics, oral corticosteroids, antibiotic eardrops (with or without corticosteroid), corticosteroid eardrops, microsuction cleaning of the ear canal, saline rinsing of the ear canal, placebo or no treatment. The main comparison of interest was antibiotic eardrops (with or without corticosteroid) versus oral antibiotics. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Primary outcomes were: proportion of children with resolution of ear discharge at short-term follow-up (less than two weeks), adverse events and serious complications. Secondary outcomes were: proportion of children with resolution of ear discharge at intermediate- (two to four weeks) and long-term (four to 12 weeks) follow-up, proportion of children with resolution of ear pain and fever at short-term follow-up, duration of ear discharge, proportion of children with chronic ear discharge, ear discharge recurrences, tube blockage, tube extrusion, health-related quality of life and hearing. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS: We included nine studies, evaluating a range of treatments, with 2132 children who developed acute ear discharge beyond the immediate postoperative period. We judged the risk of bias to be low to moderate in most studies. Antibiotic eardrops (with or without corticosteroid) versus oral antibioticsAntibiotic eardrops with or without corticosteroid were more effective than oral antibiotics in terms of:- resolution of discharge at one week (one study, 42 children, ciprofloxacin eardrops versus amoxicillin: 77% versus 30%; risk ratio (RR) 2.58, 95% confidence interval (CI) 1.27 to 5.22; moderate-quality evidence);- resolution of discharge at two weeks (one study, 153 children, bacitracin-colistin-hydrocortisone eardrops versus amoxicillin-clavulanate: 95% versus 56%; RR 1.70, 95% CI 1.38 to 2.08; moderate-quality evidence);- duration of discharge (two studies, 233 children, ciprofloxacin eardrops versus amoxicillin: median 4 days versus 7 days and bacitracin-colistin-hydrocortisone eardrops versus amoxicillin-clavulanate: 4 days versus 5 days; moderate-quality evidence);- ear discharge recurrences (one study, 148 children, bacitracin-colistin-hydrocortisone eardrops versus amoxicillin-clavulanate: 0 versus 1 episode at six months; low-quality evidence); and- disease-specific quality of life (one study, 153 children, bacitracin-colistin-hydrocortisone eardrops versus amoxicillin-clavulanate: difference in change in median Otitis Media-6 total score (range 6 to 42) at two weeks: -2; low-quality evidence).We found no evidence that antibiotic eardrops were more effective in terms of the proportion of children developing chronic ear discharge or tube blockage, generic quality of life or hearing.Adverse events occurred at similar rates in children treated with antibiotic eardrops and those treated with oral antibiotics, while no serious complications occurred in either of the groups. Other comparisons(a) Antibiotic eardrops with or without corticosteroid were more effective thancorticosteroid eardrops in terms of:- duration of ear discharge (one study, 331 children, ciprofloxacin versus ciprofloxacin-fluocinolone acetonide versus fluocinolone acetonide eardrops: median 5 days versus 7 days versus 22 days; moderate-quality evidence).(b) Antibiotic eardrops were more effective than saline rinsing of the ear canal in terms of:- resolution of ear discharge at one week (one study, 48 children, ciprofloxacin eardrops versus saline rinsing: 77% versus 46%; RR 1.67, 95% CI 1.04 to 2.69; moderate-quality evidence);but not in terms of tube blockage. Since the lower limit of the 95% CI for the effect size for resolution of ear discharge at one week approaches unity, a trivial or clinically irrelevant difference cannot be excluded.(c) Eardrops containing two antibiotics and a corticosteroid (bacitracin-colistin-hydrocortisone) were more effective than no treatment in terms of:- resolution of discharge at two weeks (one study; 151 children: 95% versus 45%; RR 2.09, 95% CI 1.62 to 2.69; moderate-quality evidence);- duration of discharge (one study; 147 children, median 4 days versus 12 days; moderate-quality evidence);- chronic discharge (one study; 147 children; RR 0.08, 95% CI 0.01 to 0.62; low-quality evidence); and- disease-specific quality of life (one study, 153 children, difference in change in median Otitis Media-6 total score (range 6 to 42) between groups at two weeks: -1.5; low-quality evidence).We found no evidence that antibiotic eardrops were more effective in terms of ear discharge recurrences or generic quality of life.(d) Eardrops containing a combination of an antibiotic and a corticosteroid were more effective than eardrops containing antibiotics (low-quality evidence) in terms of:- resolution of ear discharge at short-term follow-up (two studies, 590 children: 35% versus 20%; RR 1.76, 95% CI 1.33 to 2.31); and- duration of discharge (three studies, 813 children);but not in terms of resolution of discharge at intermediate-term follow-up or proportion of children with tube blockage. However, there is a substantial risk of publication bias, therefore these findings should be interpreted with caution. AUTHORS' CONCLUSIONS: We found moderate to low-quality evidence that antibiotic eardrops (with or without corticosteroid) are more effective than oral antibiotics, corticosteroid eardrops and no treatment in children with ear discharge occurring at least two weeks following grommet insertion. There is some limited, inconclusive evidence that antibiotic eardrops are more effective than saline rinsing. There is uncertainty whether antibiotic-corticosteroid eardrops are more effective than eardrops containing antibiotics only

Determinants of quality of life in children with psychiatric disorders

Objective: To assess factors that, in addition to childhood psychopathology, are associated with Quality of Life (QoL) in children with psychiatric problems. Methods: In a referred sample of 252 8 to 18-year-olds, information concerning QoL, psychopathology and a broad range of child, parent, and family/ social network factors was obtained from children, parents, teachers and clinicians. Results: Poor child, parent, and clinician reported QoL was associated with child psychopathology, but given the presence of psychopathology, also with child factors, such as low self-esteem, and poor social skills, and family/social network factors, such as poor family functioning, and poor social support. In multiple linear regression analyses the importance of parent factors, such as parenting stress, was almost negligible. Conclusion: To increase QoL of children with psychiatric problems, treatment of symptoms is important, but outcome might improve if treatment is also focussed on other factors that may affect QoL. Results are discussed in relation to current treatment programs. © Springer 2005

Panel 7: otitis media:treatment and complications

Objective: We aimed to summarize key articles published between 2011 and 2015 on the treatment of (recurrent) acute otitis media, otitis media with effusion, tympanostomy tube otorrhea, chronic suppurative otitis media and complications of otitis media, and their implications for clinical practice. Data Sources: PubMed, Ovid Medline, the Cochrane Library, and Clinical Evidence (BMJ Publishing). Review Methods: All types of articles related to otitis media treatment and complications between June 2011 and March 2015 were identified. A total of 1122 potential related articles were reviewed by the panel members; 118 relevant articles were ultimately included in this summary. Conclusions: Recent literature and guidelines emphasize accurate diagnosis of acute otitis media and optimal management of ear pain. Watchful waiting is optional in mild to moderate acute otitis media; antibiotics do shorten symptoms and duration of middle ear effusion. The additive benefit of adenoidectomy to tympanostomy tubes in recurrent acute otitis media and otitis media with effusion is controversial and age dependent. Topical antibiotic is the treatment of choice in acute tube otorrhea. Symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes. Novel molecular and biomaterial treatments as adjuvants to surgical closure of eardrum perforations seem promising. There is insufficient evidence to support the use of complementary and alternative treatments. Implications for Practice: Emphasis on accurate diagnosis of otitis media, in its various forms, is important to reduce overdiagnosis, overtreatment, and antibiotic resistance. Children at risk for otitis media and its complications deserve special attention

Dynamical Mean-Field Theory

The dynamical mean-field theory (DMFT) is a widely applicable approximation scheme for the investigation of correlated quantum many-particle systems on a lattice, e.g., electrons in solids and cold atoms in optical lattices. In particular, the combination of the DMFT with conventional methods for the calculation of electronic band structures has led to a powerful numerical approach which allows one to explore the properties of correlated materials. In this introductory article we discuss the foundations of the DMFT, derive the underlying self-consistency equations, and present several applications which have provided important insights into the properties of correlated matter.Comment: Chapter in "Theoretical Methods for Strongly Correlated Systems", edited by A. Avella and F. Mancini, Springer (2011), 31 pages, 5 figure

EVA: Laparoscopic instrument tracking based on endoscopic video analysis for psychomotor skills assessment

INTRODUCTION: The EVA (Endoscopic Video Analysis) tracking system a new tracking system for extracting motions of laparoscopic instruments based on non-obtrusive video tracking was developed. The feasibility of using EVA in laparoscopic settings has been tested in a box trainer setup. METHODS: EVA makes use of an algorithm that employs information of the laparoscopic instrument's shaft edges in the image, the instrument's insertion point, and the camera's optical centre to track the 3D position of the instrument tip. A validation study of EVA comprised a comparison of the measurements achieved with EVA and the TrEndo tracking system. To this end, 42 participants (16 novices, 22 residents, and 4 experts) were asked to perform a peg transfer task in a box trainer. Ten motion-based metrics were used to assess their performance. RESULTS: Construct validation of the EVA has been obtained for seven motion-based metrics. Concurrent validation revealed that there is a strong correlation between the results obtained by EVA and the TrEndo for metrics such as path length (p=0,97), average speed (p=0,94) or economy of volume (p=0,85), proving the viability of EVA. CONCLUSIONS: EVA has been successfully used in the training setup showing potential of endoscopic video analysis to assess laparoscopic psychomotor skills. The results encourage further implementation of video tracking in training setups and in image guided surgery

Treatment of rheumatoid arthritis: a global perspective on the use of antirheumatic drugs

Modern therapy for rheumatoid arthritis (RA) is based on knowledge of the severity of the natural history of the disease. RA patients are approached with early and aggressive treatment strategies, methotrexate as an anchor drug, biological targeted therapies in those with inadequate response to methotrexate, and “tight control,” aiming for remission and low disease activity according to quantitative monitoring. This chapter presents a rationale for current treatment strategies for RA with antirheumatic drugs, a review of published reports concerning treatments in clinical cohorts outside of clinical trials, and current treatments at 61 sites in 21 countries in the QUEST-RA database

Transfer of Neuroplasticity from Nucleus Accumbens Core to Shell Is Required for Cocaine Reward

It is well established that cocaine induces an increase of dendritic spines density in some brain regions. However, few studies have addressed the role of this neuroplastic changes in cocaine rewarding effects and have often led to contradictory results. So, we hypothesized that using a rigorous time- and subject-matched protocol would demonstrate the role of this spine increase in cocaine reward. We designed our experiments such as the same animals (rats) were used for spine analysis and behavioral studies. Cocaine rewarding effects were assessed with the conditioned place preference paradigm. Spines densities were measured in the two subdivisions of the nucleus accumbens (NAcc), core and shell. We showed a correlation between the increase of spine density in NAcc core and shell and cocaine rewarding effects. Interestingly, when cocaine was administered in home cages, spine density was increase in NAcc core only. With anisomycin, a protein synthesis inhibitor, injected in the core we blocked spine increase in core and shell and also cocaine rewarding effects. Strikingly, whereas injection of this inhibitor in the shell immediately after conditioning had no effect on neuroplasticity or behavior, its injection 4 hours after conditioning was able to block neuroplasticity in shell only and cocaine-induced place preference. Thus, it clearly appears that the neuronal plasticity in the NAcc core is essential to induce plasticity in the shell, necessary for cocaine reward. Altogether, our data revealed a new mechanism in the NAcc functioning where a neuroplasticity transfer occurred from core to shell