(Great Britain—The Practitioner, July 2000, p. 608.) All forms of serous otitis media, or “glue ear,” resolve spontaneously, but may take several months. Spontaneous resolution is particularly likely in the summer months; the incidence of glue ear in children falls from 20 percent in the winter months to around 4 percent in the summer. Cases that persist or involve speech or hearing difficulties should be referred for surgical assessment. Myringotomy and insertion of ear tubes usually produce relief of symptoms. Tubes are extruded in about nine to 12 months and reinsertion is required in 20 to 30 +percent of children if symptoms recur. Studies have shown that combining adenoidectomy with insertion of tubes produces the optimal clearing of middle ear effusions. Medical treatments of glue ear have not demonstrated effective clearing of effusions or long-term benefit. Any short-term relief of symptoms should be balanced against possible adverse effects, especially when treating glue ear with steroids and antibiotics. Techniques of Eustachian tube inflation using a nasal balloon designed for use in children have shown short-term benefit for at least three months.
Slow Language Development
(Great Britain—The Practitioner, July 2000, p. 636.) By one year of age, most children are able to use two to three words and know the meaning of more. By two years of age, children should use words to ask for what they need and may talk incessantly. A delay in speech development is a common concern of parents and a reason for physician consultation. The most common causes of delayed speech are simple delay, understimulation, hearing impairment, global developmental delay, a specific language disorder, and autism or Asperger's syndrome. A complete physical examination and detailed history should determine the probability of hearing, neurologic or developmental disorders. The history should also establish how the child spends his or her day and the degree of stimulation the child receives. Many children with simple speech delay do not live in language-rich environments. Parents and caretakers should communicate with and read to children, avoid using television as a babysitter and encourage children to ask for their needs.
(Canada—Canadian Family Physician, July 2000, p. 1460.) The incidence of necrotizing fasciitis caused by Group A streptococcal infection may be increasing, but the condition is still extremely rare. Fewer than two cases per 100,000 persons were reported in one Norwegian study. Approximately 71 percent of cases in a study in Canada occurred in patients with chronic illnesses such as renal failure, diabetes and alcoholism. Local skin trauma is implicated in about one half of all cases. Other risk factors include male gender, increased age and winter months. The mortality rate is at least 5 percent in patients with necrotizing fasciitis alone, but the rate increases with age, hypotension, bacteremia and the use of nonsteroidal antiinflammatory drugs. Successful management of necrotizing fasciitis depends on early surgical debridement, high-dose intravenous antibiotics (i.e., penicillin G and clindamycin) plus supportive therapy. Hyperbaric oxygen and intravenous immune globulin therapies have also been tried experimentally.
Depression During Pregnancy
(Australia—Australian Family Physician, July 2000, p. 663.) For most women, pregnancy is a time of well-being. However, a few women develop clinical depression during pregnancy and up to 14 percent of mothers become depressed during the postpartum period. The principal risk factor for pregnancy-related depression is a previous depressive episode plus life stress, particularly conflict related to pregnancy or motherhood. Becoming pregnant during a depressive episode is also a significant risk factor for ongoing depression. In general, the use of medication is decreased during the first trimester, but there is little evidence of teratogenicity associated with the tricyclic antidepressants or fluoxetine. In the final trimester, fluoxetine has been shown to cause prematurity and neonatal irritability. Many medications are also found in breast milk, leading some investigators to recommend close monitoring of infants for side effects, particularly those related to the use of selective serotonin reuptake inhibitors. Cognitive therapy and supportive strategies are strongly encouraged to help reduce or replace medication in patients who experience depression during pregnancy and the puerperium.