Publications by authors named "Herman Avner-Cohen"

17 Publications

  • Page 1 of 1

High rates of serology testing for coeliac disease, and low rates of endoscopy in serologically positive children and adults in Israel: lessons from a large real-world database.

Eur J Gastroenterol Hepatol 2020 03;32(3):329-334

Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel.

Background: Although coeliac disease is common worldwide, little is known regarding screening patterns in unselected populations, and on real-life adherence to professional guidelines for coeliac disease diagnosis and management.

Objective: To explore current practices in the diagnosis and management of coeliac disease, using data from a large Health Maintenance Organization in Israel that covers 54% of the population.

Methods: A population-based electronic database of about 4.5 million individuals was reviewed during the period of 1 January 2008 to 31 December 2015. Rates and results of coeliac disease serology testing and endoscopy procedures were examined. Subgroup analysis was performed by age, sex, ethnicity and socioeconomic status.

Results: Coeliac disease serology cumulative testing rate was 17.1% and 8.9% in the paediatric and adult population, respectively. The cumulative incidence of positive coeliac disease serology was 0.45% in children and 0.17% in adults, and was associated with age, sex, ethnicity and socioeconomic status sub-groups (P-value < 0.01). Gastrointestinal endoscopies were not subsequently performed in 44.1% of children and 47.1% of adults with positive coeliac disease serology. Within the study period, 36% of children and 56% of adults never achieved coeliac disease serology normalization.

Conclusion: In a large real-life database, screening for coeliac disease was common. However, confirmatory intestinal biopsies were under-utilized, and coeliac disease serology often remained positive over a long period time in both children and adults.
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http://dx.doi.org/10.1097/MEG.0000000000001613DOI Listing
March 2020

Burnout and intentions to quit the practice among community pediatricians: associations with specific professional activities.

Isr J Health Policy Res 2019 Jan 4;8(1). Epub 2019 Jan 4.

Schneider Children's Hospital, Petah Tikva, Israel.

Background: Burnout is an occupational disease expressed by loss of mental and physical energy due to prolonged and unsuccessful coping with stressors at work. A prior survey among Israeli pediatricians published in 2006 found a correlation between burnout and job structure match, defined as the match between engagement with, and satisfaction from, specific professional activities. The aims of the present study were to characterize the current levels of burnout and its correlates among community pediatricians, to identify changes over time since the prior survey, and to identify professional activities that may reduce burnout.

Methods: A questionnaire was distributed among pediatricians both at a medical conference and by a web-based survey.

Results: Of the 518 pediatricians approached, 238 (46%) responded to the questionnaire. High burnout levels were identified in 33% (95% CI:27-39%) of the respondents. Higher burnout prevalence was found among pediatricians who were not board-certified, salaried, younger, and working long hours. The greater the discrepancy between the engagement of the pediatrician and the satisfaction felt in the measured professional activities, the greater was the burnout level (p < 0.01). The following activities were especially associated with burnout: administrative work (frequent engagement, disliked duty) and research and teaching (infrequent engagement, satisfying activities). A comparison of the engagement-satisfaction match between 2006 and 2017 showed that the discrepancy had increased significantly in research (p < 0.001), student tutoring (P < 0.001), continuing medical education and participation in professional conferences (P = 0.0074), management (p = 0.043) and community health promotion (P = 0.006). A significant correlation was found between burnout and thoughts of quitting pediatrics or medicine (p < 0.001).

Conclusions: Healthcare managers should encourage diversification of the pediatrician's job by enabling greater engagement in the identified "anti-burnout" professional activities, such as: participation in professional consultations, management, tutoring students and conducting research.
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http://dx.doi.org/10.1186/s13584-018-0268-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6318951PMC
January 2019

Simulated Driving Skills Evaluation of Teenagers With Attention Deficit Hyperactivity Disorder Before Driving Lessons.

Am J Occup Ther 2017 May/Jun;71(3):7103220010p1-7103220010p8

Herman Avner Cohen, MD, is Associate Professor, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and Pediatrician, Pediatric Ambulatory Community Clinic, Petach Tikva, Israel.

Objective: We evaluated the driving skills of teenagers with attention deficit hyperactivity disorder (ADHD) during simulated driving before starting driving lessons and observed whether methylphenidate (MPH) affected their performance.

Method: Sixty teenagers ages 15-18 yr were included; 29 teenagers with ADHD were tested with and without MPH, and 31 teenagers (control group) were tested once. All participants were tested on the STISIM Drive™ simulator.

Results: The number of center-line crossings was higher in the group without MPH treatment than in the control group and the MPH-treated group. The group without MPH treatment had more road-edge excursions compared with the control group and drove faster than the MPH-treated group.

Conclusion: Adolescents with ADHD without MPH treatment demonstrated impaired performance more often while driving the simulator, resembling characteristics found during on-road driving among teenagers with ADHD. Trainer awareness is a primary intervention before taking driving lessons to help teenagers achieve safe driving performance.
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http://dx.doi.org/10.5014/ajot.2017.020164DOI Listing
April 2017

Efficacy and tolerability of a polysaccharide-resin-honey based cough syrup as compared to carbocysteine syrup for children with colds: a randomized, single-blinded, multicenter study.

World J Pediatr 2017 Feb 15;13(1):27-33. Epub 2016 Jul 15.

Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Background: Available pediatric treatments for acute cough are limited by lack of demonstrated efficacy. The objective of this trial is to compare the effects of a polysaccharide-resin-honey based cough syrup, and carbocysteine syrups on nocturnal and daytime cough associated with childhood upper respiratory tract infections (URIs).

Methods: Using a single-blind randomization design, the study recruited children from 4 general pediatric community clinics. Participants included 150 children aged 2 to 5 years with an URI, nocturnal and daytime cough and illness duration of ≤7 days. To be eligible, children had to be free of medication on the day before presentation. A survey was administered to parents on 4 consecutive days beginning from the day of presentation in clinic. Children received the study preparation on the first evening and then 3 times per day for 3 further days. Main outcome measures were cough frequency, cough severity, bothersome nature of cough, and quality of sleep for both child and parent.

Results: Both preparations were well tolerated and cough improved over the study period. After one night and on all survey days, there was a significantly better result for polysaccharide-resin-honey (P<0.05) for all the main outcome measures. The trend of improvement over the 4 days was steeper for polysaccharide-resin-honey (P<0.05) with regards to all cough parameters.

Conclusions: Both polysaccharide-resin-honey and carbocysteine cough syrups were well tolerated in children over 2 years of age. The polysaccharide-resin-honey syrup was associated with a more rapid and greater improvement in all clinical cough symptoms measured, beginning from the first night of therapy. Both nocturnal and daytime cough improved, as did sleep quality for both children and parents.
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http://dx.doi.org/10.1007/s12519-016-0048-4DOI Listing
February 2017

A survey of energy drink and alcohol mixed with energy drink consumption.

Isr J Health Policy Res 2015 1;4:55. Epub 2015 Dec 1.

Pediatric Ambulatory Community Clinic, Clalit Health Services, Petach Tikva, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Energy drink consumption among youth is increasing despite recommendations by the American Academy of Pediatrics to eliminate consumption by youth. This study provides information on consumption of energy drinks and alcohol mixed with energy drinks (AmED) in a sample of Israeli youth and how consumer knowledge about the risks affects consumption rates.

Methods: The study was conducted in three Tel Aviv public schools, with a total enrollment of 1,253 students in grades 8 through 12. Among them, 802 students completed a 49-item questionnaire about energy drink and AmED consumption, for a 64 % response rate Non-responders included 451 students who were absent or refused to participate. All students in the same school were administered the questionnaire on the same day.

Results: Energy drinks are popular among youth (84.2 % have ever drunk). More tenth through twelfth grade students consumed energy drinks than eighth and ninth grade students. Students who began drinking in elementary school (36.8 %) are at elevated risk for current energy drink (P < .001) and AmED (P = .002) use. Knowledge about amounts consumed and recommended allowances is associated with less consumption (OR 1.925; 95 %CI 1.18-3.14).

Discussion: The association between current AmED consumption and drinking ED at a young age is important. Boys and those who start drinking early have a greater risk of both ED and AmED consumption. The characteristics of early drinkers can help increase awareness of potential at-risk youth, such as junior and senior high school students with less educated or single parents.

Conclusions: Risks posed by early use on later energy drink and AmED consumption are concerning. We suggest that parents should limit accessibility. Increased knowledge about acceptable and actual amounts of caffeine in a single product might decrease consumption.
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http://dx.doi.org/10.1186/s13584-015-0052-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4665319PMC
December 2015

Seasonality of asthma: a retrospective population study.

Pediatrics 2014 Apr 10;133(4):e923-32. Epub 2014 Mar 10.

Pediatric Ambulatory Community Clinic, Petach Tikva, Israel;

Objectives: Seasonal variations in asthma are widely recognized, with the highest incidence during September. This retrospective population study aimed to investigate whether this holds true in a large group of asthmatic children in primary care and to assess the impact of age, gender, urban/rural living, and population sector.

Methods: The key study outcomes were the diagnosis of asthma exacerbations and asthma medication prescriptions, recorded by family physicians during 2005 to 2009. These were analyzed by "week of diagnosis" in Clalit Health Services' electronic medical record database. Regression models were built to assess relative strength of secular trends, seasonality, and age-group in explaining the incidence of asthma exacerbations.

Results: A total of 919,873 children aged 2 to 15 years were identified. Of these, 82,234 (8.9%) were asthmatic, 61.6% boys and 38.4% girls; 49.1% aged 2 to 5 years, 24.1% 6 to 9 years, and 26.8% 10 to 15 years. We observed a 2.01-fold increase in pediatric asthma exacerbations and 2.28-fold increase in prescriptions of asthma bronchodilator medications during September (weeks 37-39 vs weeks 34-36) compared with August. The association between the opening of school and the incidence of asthma-related visits to the primary care physician was greatest in children aged 2 to 5 years (odds ratio, 2.15) and 6 to 11 years (1.90-fold). Adolescents (age 12-15 years) had a lesser peak (1.81-fold). In late fall there was a second rise, lasting with fluctuations throughout winter, with a trough in summer.

Conclusions: Returning to school after summer is strongly associated with an increased risk for asthma exacerbations and unscheduled visits to the primary care physician.
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http://dx.doi.org/10.1542/peds.2013-2022DOI Listing
April 2014

Effect of honey on nocturnal cough and sleep quality: a double-blind, randomized, placebo-controlled study.

Pediatrics 2012 Sep 6;130(3):465-71. Epub 2012 Aug 6.

Pediatric Ambulatory Community Clinic, Petach Tikva, Israel.

Objectives: To compare the effects of a single nocturnal dose of 3 honey products (eucalyptus honey, citrus honey, or labiatae honey) to placebo (silan date extract) on nocturnal cough and difficulty sleeping associated with childhood upper respiratory tract infections (URIs).

Methods: A survey was administered to parents on 2 consecutive days, first on the day of presentation, when no medication had been given the previous evening, and the following day, when the study preparation was given before bedtime, based on a double-blind randomization plan. Participants included 300 children aged 1 to 5 years with URIs, nocturnal cough, and illness duration of ≤ 7 days from 6 general pediatric community clinics. Eligible children received a single dose of 10 g of eucalyptus honey, citrus honey, labiatae honey, or placebo administered 30 minutes before bedtime. Main outcome measures were cough frequency, cough severity, bothersome nature of cough, and child and parent sleep quality.

Results: In all 3 honey products and the placebo group, there was a significant improvement from the night before treatment to the night of treatment. However, the improvement was greater in the honey groups for all the

Main Outcome Measures:

Conclusions: Parents rated the honey products higher than the silan date extract for symptomatic relief of their children's nocturnal cough and sleep difficulty due to URI. Honey may be a preferable treatment for cough and sleep difficulty associated with childhood URI.
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http://dx.doi.org/10.1542/peds.2011-3075DOI Listing
September 2012

Inverse association between Helicobacter pylori and pediatric asthma in a high-prevalence population.

Helicobacter 2012 Feb;17(1):30-5

Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel.

Background: Helicobacter pylori-associated disease has led to aggressive diagnostic and eradication protocols that are partially responsible for the decrease in prevalence of H. pylori carriage. Recent evidence indicates that in low-prevalence populations, H. pylori may have protective effects on allergic diseases. The aim of this study was to explore the relationship between pediatric asthma and H. pylori infection in a population with high prevalence of H. pylori infection.

Materials And Methods: A national referral laboratory was screened for all (13) C urea breath tests performed in children aged 5-18 years between 2007 and 2008, for patient demographics and physician-diagnosed asthma. Data concerning asthma-associated medication usage were extracted from electronic medical records and databases. Data were analyzed using a stepwise logistic regression model.

Results: During the study period, 6959 patients underwent urea breath testing (average age 12.4±3.5years). Of these, 3175/6959 (45.6%) were positive for H. pylori, and 578/6959 (8.3%) had asthma. Rates of asthma in H. pylori-positive and H. pylori-negative children were 7.3 and 9.1%, respectively (odds ratio 0.82; 95% confidence interval (CI) 0.69-0.98; p=.032). We also confirmed that male gender, urban residence, and age are associated with childhood asthma.

Conclusions: We demonstrate an inverse association between H. pylori and pediatric asthma in a population with a high prevalence of H. pylori.
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http://dx.doi.org/10.1111/j.1523-5378.2011.00895.xDOI Listing
February 2012

Primary care screening for childhood obesity: a population-based analysis.

Isr Med Assoc J 2007 Nov;9(11):782-6

Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.

Background: The prevalence of obesity among children and adolescents in the western world has increased dramatically.

Objectives: To assess the efficacy of routine childhood obesity screening by primary physicians in the pediatric population in Israel and the utilization of health services by overweight children.

Methods: The electronic medical records of children aged 60-83 months registered in 39 pediatric primary care centers between January 2001 and October 2004 (n=21,799) were reviewed. Those in whom height and weight were documented during a clinic visit (index visit) were classified as overweight, at risk of overweight, or normal weight according to body mass index percentiles. The number of visits to the pediatrician, laboratory tests and health care costs 12 months after the index visit were calculated.

Results: Anthropomorphic measurements were performed in 1556 of the 15,364 children (10.1%) who visited the clinic during the study period. Of these, 398 (25.6%) were overweight, 185 (11.9%) were at risk of overweight, and 973 (62.5%) were normal weight. Children in the first two groups visited the clinic slightly more often than the third group, but the differences were not statistically significant (P = 0.12), and they had significantly more laboratory tests than the rest of the children visiting the clinics (P = 0.053). Health care costs were 6.6% higher for the overweight than the normal-weight children.

Conclusions: Electronic medical records are a useful tool for population-based health care assessments. Current screening for obesity in children during routine care in Israel is insufficient and additional education of community pediatricians in diagnosis and intervention is urgently needed.
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November 2007

Survey of parents, nurses, and school principals on their perceptions of the controversial role of schools in health promotion.

Pediatr Int 2006 Feb;48(1):44-7

Ministry of Health, HaSharon District, Petah Tiqva, Israel.

Background: The aim of this paper was to study the perceptions of parents, nurses, and school principals of the role of the health services in elementary schools.

Methods: A questionnaire was distributed to the heads of parents' committees, school nurses, and school principals of 35 randomly selected elementary public schools in Israel. Respondents were asked to qualify the degree of importance of the traditional and contemporary roles of the school health-care team.

Results: Response rates were 80.0% for parents, 100% for nurses, and 97.1% for principals. All respondents agreed that both the traditional and new roles are very important. Nurses rated three interconnected roles significantly lower than parents and school principals: 'Evaluation of students with behavioral problems', 'Evaluation of students with low academic performance', and 'Follow up and care of students with behavioral problems and low performance'.

Conclusions: Nurses, parents and school principals in Israel agree that the traditional roles of health teams in elementary schools, that is, providing first aid and ensuring school hygiene, are very important. Most are ready to accept a move from an illness-based to a social-based model, with less time spent on screening and surveillance and more on identifying and managing special needs of children and staff.
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http://dx.doi.org/10.1111/j.1442-200X.2006.02168.xDOI Listing
February 2006

Antipyretic treatment in young children with fever: acetaminophen, ibuprofen, or both alternating in a randomized, double-blind study.

Arch Pediatr Adolesc Med 2006 Feb;160(2):197-202

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: To compare the antipyretic benefit of acetaminophen or ibuprofen monotherapy with an alternating regimen of both drugs in young children aged 6 to 36 months.

Design: Randomized, double-blind, parallel-group trial.

Setting: Three primary pediatric community ambulatory centers in central Israel.

Participants: A total of 464 children aged 6 to 36 months with fever.

Intervention: Infants were assigned to receive either acetaminophen (12.5 mg/kg per dose every 6 hours) (n = 154) or ibuprofen (5 mg/kg per dose every 8 hours) (n = 155) or to receive alternating acetaminophen and ibuprofen (every 4 hours) (n = 155) for 3 days after a loading dose.

Main Outcome Measures: Temperature, stress score, amount of antipyretic received, total days that the infant or caregiver was absent from day care or work, respectively, at the 3-day time point, recurrence of fever, and number of emergency department visits.

Results: The group given the alternating regimen was characterized by a lower mean temperature, more rapid reduction of fever, receiving less antipyretic medication, less stress, and less absenteeism from day care as compared with the other groups; all of the differences were statistically significant (P< .001). None of the regimens were associated with a significantly higher number of emergency department visits (P = .65) or serious long-term complications (P = .66). The drug used for initial loading had no effect on outcome in any of the groups.

Conclusions: An alternating treatment regimen of acetaminophen (12.5 mg/kg per dose) and ibuprofen (5 mg/kg per dose) every 4 hours for 3 days, regardless of the initial loading medication, is more effective than monotherapy in lowering fever in infants and children.
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http://dx.doi.org/10.1001/archpedi.160.2.197DOI Listing
February 2006

Pediatrician attitudes to exclusion of ill children from child-care centers in Israel: pressure on ambulatory practices.

Patient Educ Couns 2006 Feb 26;60(2):164-70. Epub 2005 Oct 26.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: The exclusion of ill children from child-care centers may be associated with high social, economic and medical costs.

Objective: To assess the opinions of pediatricians working in an outpatient setting in Israel on the exclusion/return of children in child-care centers.

Methods: A questionnaire on practices of exclusion/return of children in child-care centers, in general and according to specific signs and symptoms, was administered to a random computer-selected cross-sectional sample of 192 primary care community pediatricians in Israel.

Results: One hundred and seventy-three pediatricians completed the questionnaires, for a response rate of 90%; 147 were board-certified and 26 were not. About half the pediatricians felt pressured by parents requesting antibiotic therapy to accelerate the return of their sick child to the child-care center. The majority also believed their practice was overloaded by often unnecessary demands for medical notes by the child-care centers before children could return. More than half based their decision to exclude children on "common sense" and the remainder, on accepted guidelines. Except for scabies and lice, there were no significant correlations between the physicians' stipulation for a note on return of the child and the specific illness guidelines.

Conclusions: This study shows that a high proportion of pediatricians based their exclusion practices on "common sense" and personal understanding instead of established guidelines, and that the guidelines did not affect their opinion on the duration of illness that warrant a note. Furthermore, half were subjected to parental pressure to employ inappropriate practices. These findings, combined with our earlier survey of child-care centers staff, indicate that better education of parents and day-care staff about ill child-care-center-exclusion policy in Israel would increase their common understanding with pediatricians.
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http://dx.doi.org/10.1016/j.pec.2004.12.010DOI Listing
February 2006

Parents' and medical personnel's beliefs about infant teething.

Patient Educ Couns 2005 Apr;57(1):122-5

Pediatric Ambulatory Medical Center, Petah Tikva, Israel.

Many symptoms are attributed to teething. Little evidence exists to support these beliefs, despite their implications on clinical management. This study attempted to investigate parental and medical personnel's beliefs about teething. The study was conducted by means of a questionnaire, submitted to 55 pediatricians and 130 nurses. A parent survey was conducted simultaneously. We evaluated 462 questionnaires. An association of teeth eruption with infant morbidity was believed to exist by 76% of the responders, mostly by parents and nurses, and less so by physicians. Irritability, fever, and loose stools/diarrhea were believed to be the most common symptoms associated to teeth eruption. We conclude that almost all parents, the majority of nurses, and many physicians believe that teething is associated with the appearance of symptoms, most of which are minor and relate to discomfort rather than physical illness, but a substantial minority still ascribes potentially serious symptoms to teething.
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http://dx.doi.org/10.1016/j.pec.2004.05.005DOI Listing
April 2005

Exclusion of ill children from child-care centers in Israel.

Patient Educ Couns 2005 Jan;56(1):93-7

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

The aim of the study was to examine criteria for ill children in child-care centers. A questionnaire on practices of exclusion/return of children according to specific signs and symptoms was mailed to the directors of care centers in central Israel. Thirty-six of the 60 questionnaires (60%) were returned by mail and the reminded were completed in personal visits to the CCCs achieving a response rate of 100%. About half (51.7%) used "common sense" and "personal feelings" to exclude children and to allow their return, and 29 (48.3%) used the guidelines of the Ministries of Education and Health or other authorities. The percentage of centers excluding children by signs/symptoms was as follows: high fever (>38 degrees C), 100%; low-grade fever, 76.7%; asthma exacerbation, 80.0%; heavy cough, 75.0%; eye discharge or conjunctivitis, 83.3%; diarrhea and vomiting more than twice per day, 100%; rash, 72.3%; otalgia, 46.7%; and infected skin lesion, 66.7%. Only four centers excluded children with head lice. Most centers required a physician's note on return of a child after high fever (76.7%), eye discharge or conjunctivitis (48.3%), and from 75 to 80%, respectively, for frequent vomiting and bloody or mucinous diarrhea. The results show that exclusion practices among child-care centers (CCCs) vary widely, suggesting the need for the establishment of a uniform exclusion and return policy in Israel, with distribution of clear, up-to-date guidelines on the prevention and control of communicable diseases to all day-care centers. In a simple way, this study identified attitudes concerning the exclusion/return of sick children in CCCs and was useful for the discussion of the related policy with CCCs responsible and national health and educational authorities.
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http://dx.doi.org/10.1016/j.pec.2003.12.012DOI Listing
January 2005

Naturopathic treatment for ear pain in children.

Pediatrics 2003 May;111(5 Pt 1):e574-9

Pediatric and Adolescent Ambulatory Community Clinic of the General Health Services, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: Otitis media is 1 of the most frequent diseases of early infancy and childhood and 1 of the most common reasons for children to visit a physician. In the past 2 decades, there has been a substantial increase in the diagnosis of otitis media worldwide. In the United States, 93% of all children have had at least 1 episode of acute otitis media (AOM) by 7 years of age. Otalgia is the hallmark of AOM. Most affected children either complain of earache or manifest behavior that the parents interpret as indicating ear pain. Treatment of the ear pain early in the course of AOM decreases both parental anxiety and the child's discomfort and accelerates the healing process. The objective of this study was to determine the efficacy and tolerability of naturopathic versus traditional treatment for the management of otalgia commonly associated with AOM in children.

Methods: The study was designed as a double-blind trial in an outpatient community clinic. A total of 171 children who were aged 5 to 18 years and had otalgia and clinical findings associated with middle-ear infection were studied. The children were randomly assigned to receive treatment with Naturopathic Herbal Extract Ear Drops (NHED) or anesthetic ear drops, with or without amoxicillin. On enrollment, the children were assigned by computer-numbered randomization to receive NHED (contents: allium sativum, verbascum thapsus, calendula flores, hypericum perfoliatum, lavender, and vitamin E in olive oil) 5 drops 3 times daily, alone (group A) or together with a topical anesthetic (amethocaine and phenazone in glycerin) 5 drops 3 times daily (group B), or oral amoxicillin 80 mg/kg/d (maximum 500 mg/dose) divided into 3 doses with either NHED 5 drops 3 times daily (group C) or topical anesthetic 5 drops 3 times daily (group D). A double-blind design was used, and all ear drops were placed in identical bottles. Treatment was initiated by the nurse in all cases. A single physician (M.S.) evaluated and treated all of the patients included in the study and recorded all of the data. The presence or absence of ear pain was assessed over 3 days with a visual analog scale. Ear pain was assessed by a specially devised observational instrument based on previous reports. One side of the instrument consisted of a linear numbered scale, from 1 (no pain) to 10 (worst possible pain), and a corresponding color scale, ranging from blue to dark red. The reverse side contained a scale of 5 facial expressions, ranging from broad smile (no pain) to a sad and crying face (worst possible pain), and a corresponding color scale, ranging from blue to dark red.

Results: There were no significant between-group differences in patient age or gender, degree of fever, main symptoms, associated symptoms, and severity or laterality of acute otitis media. Each group had a statistically significant improvement in ear pain over the course of the 3 days. Patients who were given ear drops alone had a better response than patients who were given ear drops together with amoxicillin. Results were better in the NHED group than in the controls. Nevertheless, the findings indicated that the pain was mostly (80%) self-limited and could be explained simply by the time elapsed. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend topical medications as the first line of treatment for ear pain in the absence of systemic infection or serious underlying disease. Because no evidence was found that systemic antibiotics alone improved treatment outcome, if antibiotics do not change the natural course of otitis media, then the main goal of treatment, as in the present study, should be to alleviate the ear pain. The alternative, naturopathic herbal extract medications, may offer many new possibilities in the management of ear pain associated with AOM. Primary care physicians should be aware that at least 10% of their patients may have tried 1 or more forms of alternative/complementary medicine before presenting for consultation. As it was widely reported in the medical literature, these herb, these herbal extracts have the potential to meet all of the requirements of appropriate medication that could be routinely used in the pediatric patient, namely in vitro bacteriostatic and bacteriocidal activity against common pathogens, immunostimulation ability, antioxidant activity, and anti-inflammatory effects. They are also well-absorbed with good penetration into the tissue surrounding the tympanic membrane. They have been found to enhance local immunologic activity. Finally, herbal extracts are well-tolerated (owing to their long elimination time), easy to administer, and less expensive than the new antibiotics. There are no documented side effects. On the basis of our findings that the group with the most significant treatment effects (NHED with topical anesthetic) explained only 7.3% of the total pain reduction, we propose that sometimes the general practitioner or pediatrician needs to give the human body a chance to repair itself. Nevertheless, if the physician believes that there is an indication for some treatment, especially if the parents are anxious, then a local treatment such as one used in our study might be adequate.

Conclusions: This study suggests that in cases of ear pain caused by AOM in children in which active treatment, besides a simple 2- to 3-day waiting period, is needed, an herbal extract solution may be beneficial. Concomitant antibiotic treatment is apparently not contributory.
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http://dx.doi.org/10.1542/peds.111.5.e574DOI Listing
May 2003

Compliance of primary care doctors with asthma guidelines and related education programs: the employment factor.

Isr Med Assoc J 2002 Jun;4(6):403-6

Pediatric and Adolescent Ambulatory Community Clinic Klaht Health Services, Petah Tigva, Israel.

Background: Primary care physicians' adherence to accepted asthma guidelines is necessary for the proper care of asthma patients.

Objectives: To investigate the compliance of primary care physicians with clinical guidelines for asthma treatment and their participation in related educational programs, and to evaluate the influence of their employment status.

Methods: A questionnaire was administered to a random sample of 1,000 primary care practitioners (pediatricians and family physicians) in Israel.

Results: The response rate was 64%. Of the physicians who participated, 473 (75%) had read and consulted the guidelines but only 192 (29%) had participated in an educational program on asthma management in the last 12 months. The younger the responding physician (fewer years in practice), the more likely his/her attendance in such a program (p < 0.0001). After consulting the guidelines 189 physicians (40%) had modified their treatment strategies. Significantly more self-employed than salaried physicians had read the guidelines and participated in educational programs; physicians who were both self-employed and salaried fell somewhere between these groups. This trend was not influenced by the number of years in practice.

Conclusions: All primary care physicians should update their knowledge more often. The publication of guidelines on asthma must be followed by their proper dissemination and utilization. Our study suggests that major efforts should be directed at the population of employed physicians.
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June 2002

Physicians', nurses', and parents' attitudes to and knowledge about fever in early childhood.

Patient Educ Couns 2002 Jan;46(1):61-5

Schneider Children's Medical Center of Israel, Petah Tiqva, 49100, Israel.

This study investigated physicians', nurses' and parents' approach to fever in early childhood. A total of 2059 questionnaires was completed by the three groups. Though most of the responders (59.8%) believed that fever is a helpful bodily mechanism of the body, there was a significant difference between physicians (85.8%) and nurses and parents (63.9 and 43.1%, respectively) (P<0.001). The majority of parents (62.7%) believed it necessary to treat children with low-grade fever (<38 degrees C) without any other sign of illness, whereas the physicians and nurses did not (10.8 and 30.2%, respectively). Regarding antipyretic medication, 92.3% of the physicians and 84% of the nurses would start treatment for a fever 38-40 degrees C, whereas 38.8% of parents would do so for a fever of 37-38 degrees C. Febrile seizure served as a reason for antipyretic treatment for 34.3% of the nurses and 20% of the parents, compared to 8.7% of the physicians. Finally, fear of brain damage due to fever was noted in almost twice as many nurses as physicians (11.8% versus 7.2%) and in three times as many parents (24.0%) as physicians. Parents and some nurses consider fever a risk factor for serious morbidity, mostly febrile convulsions and brain damage, even though these associations have long since been disproven.
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http://dx.doi.org/10.1016/s0738-3991(01)00160-4DOI Listing
January 2002