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Am Fam Physician. 2000;62(10):2344

One Hundred Earaches

(Canada—Canadian Family Physician, May 2000, p. 1081.) Although earache is one of the most common symptoms seen by family physicians throughout the Western world, the accepted optimal treatment strategy for otitis media, the primary cause of earache, varies dramatically from country to country. In many European countries, antibiotics are rarely prescribed for earache, whereas in North America, almost all patients with earache or ear infections receive antibiotics. A Canadian family physician, who changed his practice to follow the guidelines of the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality), reports that only two of 100 patients met the criteria for treatment with antibiotics. The remaining 98 patients were treated symptomatically and were asked to return within two days if their condition did not improve. Only four patients returned within two weeks because of earache. Two of the patients had otitis media, one had otitis externa and one had symptoms of trigeminal neuralgia. The physician advocates public education to change the routine use of antibiotics to treat earache in family practice.

Treatment of URIs in Children

(Hong Kong—Hong Kong Practitioner, May 2000, p. 242.) Upper respiratory tract infections (URIs) are a group of common conditions with symptoms such as cough, sore throat, fever, rhinorrhea, nasal congestion and malaise. URIs account for up to two thirds of pediatric primary care consultations. Although drugs are often prescribed for the treatment of URIs, there is little objective evidence of benefit; some medications may even cause significant risk of adverse effects. Antibiotics have not been shown to improve symptoms or shorten periods of illness when compared with placebo. The use of antibiotics to treat URIs may lead to antibiotic resistance in pathogenic organisms. The most widely used antitussives—codeine, dextromethorphan and diphenhydramine—provided relief comparable to that of placebo. Syrup alone may act as a demulcent and provide antitussive action without side effects. Expectorant and mucolytics have not shown significant benefit in clinical trials and may cause gastric irritation. While antihistamines are often prescribed, they are unlikely to benefit patients with URIs because histamine is not the main mediator of symptoms. In URI with rhinorrhea, antihistamines can dry the nasal mucosa. Similarly, decongestants may be expected to relieve symptoms but have performed poorly in clinical trials. Vitamin C has been used to treat and prevent URIs. However, no consistent prophylactic effect was seen in studies; the duration of symptoms was reduced by about one-half day. Finally, zinc did not reduce the severity or duration of symptoms, but was associated with diarrhea, nausea and oral symptoms, including offensive taste. The optimal treatment of childhood URI appears to be rest, hydration and antipyretics with monitoring for the development of more serious illness.

Disciplining Children Without Spanking

(Canada—Canadian Family Physician, May 2000, p. 1119.) Pediatric experts now believe that spanking and other physical forms of disciplining children are undesirable. This has led many parents to ask family physicians to recommend effective, alternative forms of discipline. When punishing inappropriate behavior, the child, the parents and the context of the problem should be considered. The punishment should be appropriate to the behavior and understandable to the child. Preventing or discouraging bad behavior is also more effective than punishing the child. Preventive measures include avoiding situations that may cause trouble, distracting the child with positive activities, ignoring minor transgressions that have few consequences and rewarding good behavior. Placing children in “time out” is the most effective way to manage disruptive behavior once it has occurred. Parents should be consistent and fair in their interactions with children and should invest in “time in,” i.e., special time each day devoted to the relationship.

Avoiding Dengue Fever in Travelers

(Canada—Canadian Family Physician, May 2000, p. 1126.) Dengue fever is increasing in incidence and is now the most common arbovirus infection among persons who travel to tropical Africa, South and Central America, the Caribbean, Asia and Oceania. Dengue fever is transmitted by mosquitoes of the genus Aedes, which bite during the day and are abundant near stagnant water in urban areas. To avoid dengue fever, travelers should wear clothing that covers the arms and legs and use insect repellant containing diethyltoluamide (DEET). Currently, there is no vaccine to prevent dengue fever. Patients usually present with arthralgias, myalgias, headache and a rash resembling measles. A rarer, more severe form of dengue fever with hemorrhagic fever occurs mainly in persons younger than 15 years.

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