Ear infections used to be a devastating problem. In 1932, acute otitis media (AOM) and its suppurative complications accounted for 27 percent of all pediatric admissions to Bellevue Hospital. Since the introduction of antibiotics, it has become a much less serious problem. For decades it was taken for granted that all children with AOM should be given antibiotics, not only to treat the disease itself but to prevent complications like mastoiditis and meningitis.
In the 1980s, that consensus began to change. We realized that as many as 80 percent of uncomplicated ear infections resolve without treatment in three days. Many infections are caused by viruses that don’t respond to antibiotics. Overuse of antibiotics leads to the emergence of resistant strains of bacteria. Antibiotics cause side effects. A new strategy of watchful waiting was developed.
Current Medical Guidelines
In 2004, the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) collaborated to issue evidence-based guidelines based on a review of the published evidence. Something was lost in the transmission: The guidelines have been over-simplified and misrepresented, so it’s useful to look at what they actually said. There were six parts:
1. Criteria were specified for accurate diagnosis.
History of acute onset of signs and symptoms
Presence of middle ear effusion (ear drum bulging, lack of mobility, air-fluid level)
Signs and symptoms of middle ear inflammation: Either red ear drum or ear pain interfering with normal activity or sleep
They stressed that AOM must be distinguished from otitis media with effusion (OME). OME is more common, occurs with the common cold, can be a precursor or a consequence of AOM, and is not an indication for antibiotic treatment. Read more »
[There’s a] huge gap between Americans’ wishes about end-of-life care, as expressed in numerous public opinion polls, and what actually happens in too many instances–futile, expensive, often painful procedures performed on people too sick to leave the hospital alive–much less survive with a decent quality of life. Ninety percent of Americans say they want to die at home but only 20 percent do so. Half of Americans die in hospitals and another 25 percent in nursing homes, after a long period of suffering from chronic, incurable conditions that finally become untreatable. An astonishing one out of five die in intensive care units, often unconscious, isolated from loved ones and hooked up to machines that do nothing but prolong an inevitable death.
This happens partly because of the natural human tendency to procrastinate about addressing painful subjects with relatives and partly because doctors are often too pressed for time–and too uncomfortable with death and dying themselves–to respond when patients do bring up such issues. Just try to get a straight answer out of an oncologist, as an 89-year-old friend of mine did when her doctor advised another course of chemotherapy even though her cancer had metastasized to her brain. “Doctor,” she asked, “what chance is there that I’ll have a few months more of life that I can enjoy with my family?” He replied, “We can’t know these things.” She replied, “No, but we can use our common sense,” and declined further treatment. She died a month later in hospice, surrounded by her children, grandchildren and great-grandchildren. What if she hadn’t been clear-minded enough to to speak for herself? What if her children, out of love, guilt or a combination of the two, had subjected her to treatment that she wouldn’t have wanted? That is what advance medical directives are intended to prevent.Read more »
Physicians see nearly one in five patients as “difficult,” report researchers. Not surprisingly, these patients don’t fare as well as others after visiting their doctor.
Researchers took into account both patient and clinician factors associated with being considered “difficult,” as well as assessing the impact on patient health outcomes. They reported results in the Journal of General Internal Medicine.
Researchers assessed 750 adults prior to their visit to a primary care walk-in clinic for symptoms, expectations, and general health; for how they functioned physically, socially and emotionally; and whether they had mental disorders. Immediately after their visit, participants were asked about their satisfaction with the encounter, any unmet expectations, and their levels of trust in their doctor. Two weeks later, researchers checked symptoms again.
Also, clinicians were asked to rate how difficult the encounter was after each visit. Nearly 18 percent were “difficult.” They had more symptoms, worse functional status, used the clinic more frequently and were more likely to have an underlying psychiatric disorder than non-difficult patients. These patients were less satisfied, trusted their physicians less, and had a greater number of unmet expectations. Two weeks later, they were also more likely to experience worsening of their symptoms.
But the label works both ways, as physicians with a more open communication style and those with more experience reported fewer difficult encounters, researchers said.
On a lighter note, TV’s comedy “Seinfeld” dedicated an entire plotline from one of its many episodes to Elaine, her doctor, and the label of being a difficult patient. It’s worth watching here.
*This blog post was originally published at ACP Internist*
If you own a Nintendo Wii, have played World of Warcraft, or seen James Cameron’s cinematic spectacle, then you probably know what an avatar is. And because an avatar is simply a representation of yourself that you design, your avatar’s attributes could be as similar or different to you as you wish. [This editor’s avatar is 6′ 8″, has six-pack abs, wears only fine European clothing, and has the voice of YouTube sensation Ted Williams.]
Do online avatars have any influence on their real-world counterparts? Researchers at the new Virtual Human Interaction Lab (VHIL) at Stanford University think so. According to VHIL, while avatars tend to be idealized versions of their users, evidence has suggested one’s virtual avatar does indeed influence a person.
In one experiment, a female student’s avatar was shown losing weight by running and gaining weight when standing still. As a result, it motivated this student to exercise more over a 24-hour period. In another experiment, watching a student’s avatar progressively age caused him to want to save money instead of spending it on partying.
With advances in technology continually making the world more and more connected with itself, avatars will continue to evolve also. According to Jeremy Bailenson, creator of VHIL, “avatars will soon play an even bigger role in our lives online. How we shape our own avatars and how we interact with others could have profound influences on our behavior.”
Article from the National Science Foundation:Virtual Self…
*This blog post was originally published at Medgadget*
It’s happening more frequently: Requests for medical advice by email. The more I do, the more people I meet. The network grows and friends of friends learn about what I do.
So junior has a little pain and shows at the local ER where the requisite CT shows a little thickening of the ileum. Someone suggests that the family drop me a line. Here’s the problem: There’s more to this than digital correspondence will allow.
While the statistical reality of this child’s situation is that this finding represents a little edema from a virus, the differential is precarious: Crohn’s disease, lymphoma, tuberculous ileitis, eosinophilic enteropathy.
A case of this type requires the thorough exploration of a child’s story and a compulsive exam that takes into consideration the problems in the differential. Worrisome considerations need to be framed and discussed in the context of the child’s total presentation and real likelihood of occurrence. The sensitive dialog surrounding our diagnostic approach to this child requires a relationship. And the various approaches require an element of negotiation with the family. All of this takes time, emotional intelligence, and good clinical judgment.
Children are complicated creatures. Parents are more complicated. Loose, off-the-cuff advice based on shotty information shortchanges both parties.
Of course the easiest response to these regular queries is that my employer, malpractice carrier, and the Texas State Board preclude offering medical advice without an established relationship or the maintenance of a medical record available for peer review. Everybody understands legalese. Few, however, understand the complexity of a properly executed medical encounter.
*This blog post was originally published at 33 Charts*
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