Newly published findings in the literature with commentary

Key Points

To reduce visits for ear pain, try parental education

Nurse-provided anticipatory guidance on handling ear pain safely reduces toddlers' emergency and after-hours clinic visits, according to a study in primary care practices at the Mayo Clinic (Rochester, Minn).

At the 15-month well-child-care visit, nurses pro-vided parents of the 191 children in the intervention group with standardized education about ear pain, and a prescription for antipyrine/benzocaine otic drops. The 10-slide primary teaching tool focused on three goals-identifying ear pain, relieving such pain safely, and recognizing symptoms of more serious illness requiring urgent medical attention. The same information was also given as a handout. Nurses reminded parents of 24-hour medical advice via telephone and discussed appropriate administration of the otic drops, instructing families to withhold the drops in children with tympanostomy tubes or otorrhea. The nurses provided acetaminophen and ibuprofen dosing sheets and discussed nonpharmacologic ways to treat pain. The education took five to 10 minutes per patient.

In addition, a three-year medical record review of the children in the intervention group did not reveal any episodes of mastoiditis. The review also showed no episodes of otolaryngologic, ED, or hospital visits that could be attributed to delay in medical attention or in antibiotic therapy. Finally, over 80% of surveyed parents thought the program helped them avoid after-hours visits, and strongly endorsed it (McWilliams DB et al: Arch Pediatr Adolesc Med 2008;162:151).

Commentary

This work could have a sweeping impact, especially if it can be reproduced in areas with large urban EDs. Patients diverted from the ED will avoid long waits, exposure to other sick children, and antibiotics. Meanwhile, the children in the ED for other complaints could have shorter waits. The authors estimate that the overall savings to the health care system could be $50 for each child. Kudos to these investigators for finding evidence to support the expenditure of health resources on patient/family education.

Does SHS affect cystic fibrosis?

Using data collected by the US Cystic Fibrosis Twin and Sibling Study, researchers examined if secondhand smoke (SHS) exposure is associated with lung function, whether specific gene-environment interactions influence such an association, and whether socioeconomic status affects the relationship between SHS and lung disease severity. Investigators recruited 830 participants from 450 families (132 twins and 698 siblings) from cystic fibrosis (CF) centers, primarily in the United States. Of 812 participants with data about SHS in the home, 188 (23.2%) were exposed. Of 780 participants with data about active maternal smoking during gestation, 129 (16.5%) were exposed.

SHS in the home was linked with decreased lung function for all disease-specific cross-sectional and longitudinal measures of lung function studied. Investigators estimated that the mean reduction in cross-sectional lung function attributed to SHS roughly translates to a decrease of 8.2% predicted one-second forced expiratory volume. Active maternal smoking during gestation did not affect any measure of lung function, but was linked with a significantly lower birth weight.

In examining gene-environment interactions, investigators found that the disease-causing gene CFTR modifies the association between SHS and worse lung function. Certain gene variants, and specific variants of the CF modifier gene TGFb1, amplified the negative effects of SHS.

Socioeconomic status did not appear to confound the relationship between SHS and reduced lung function in patients with CF (Collaco JM et al: JAMA 2008;299:417).

Commentary

This investigation shows that environmental smoke is bad for children with CF, worse with particular genotypes of CF, and worse still with CF and certain modifier genes. And, this study has wider implications as well. More human genome research may clarify how environment and genetics interact to modify presentation, severity, and progression of diseases like CF.