What Are Precautions for Someone Traveling to the Middle East About the Risk of MERS?

Patient Presentation
Ten and twelve-year-old male siblings came to clinic before traveling from the United States to visit relatives in Jordan for 6 weeks. The children were healthy, had current routine vaccinations and had traveled to Jordan 5 years previously. They were visiting major cities and did not plan to visit rural locations or farms. The family was transferring planes in Europe during the visit. The mother was concerned because of the recent media coverage of MERS (Middle East Respiratory Syndrome) in the United States, and wanted to know what she should do about the trip. The pertinent physical examinations revealed healthy boys.

The diagnosis of healthy males was made. The pediatrician confirmed that the boys were fully vaccinated. In the room, he then used the Centers for Disease Control website to look at the specific travel recommendations for Jordan. The boys had previously had typhoid vaccine but because of the time lapse oral typhoid vaccine was prescribed. The risk of rabies was considered small so they did not receive that vaccine. For MERS, the physician discussed that the illness presented with common upper airway symptoms such as fever, cough and shortness of breath. The World Health Organization had increased its alert level and was issuing alerts for travelers to be more aware, and use standard precautions such as hand hygiene and covering coughs more consistently. The physician printed the information for the family and told them to monitor their health closely during and after the visit. If they had any concerns they should seek help in Jordan or call his office promptly after they returned. The physician also noted that although it was not exactly clear how the virus was spread there were clusters of patients who were health care workers. The mother said that none of the family they were staying with were health care providers, but were business and service workers. Nonetheless, the physician recommended using hand sanitizers, washing hands, and common sense at all times.

Discussion
Middle East Respiratory Syndrome (MERS) is a respiratory illness cause by a coronavirus called MERS-CoV. It was first reported in Saudi Arabia in 2012. People with confirmed cases of MERS have developed severe respiratory illness that includes acute onset of cough, shortness of breath, and fever. Other symptoms include gastrointestinal symptoms such as diarrhea. Pneumonia is common, and patients may progress to respiratory failure. Other end organ failure has occurred, particularly kidney failure and septic shock. The death rate is up to ~30% currently. People with compromised immune systems are more at risk.

The exact transmission is not known but it has been shown to spread between people who are in close contact, from infected patients to health care personnel, and there some clustered cases in specific countries. There is no evidence of sustained spreading in community settings. All of the cases to date have been linked to countries in the Arabian Peninsula. The virus has been linked to bats and camels but it is unknown exactly how it is spread between or within species. MERS is different than the SARS virus that was identified in 2003 but both are caused by coronaviruses and have been linked to bats.

Health care providers should be alerted to patients who have traveled to the Arabian Peninsula and surrounding countries within 14 days of travel. People who transited within airports but did not enter the country are not considered at increased risk. Although more common causes of respiratory illness such as influenza are still more common, the risk of MERS should be considered. Vigilant appropriate precautions including consistent use of personal protective equipment should be instituted for health care providers.

A patient with an unexplained respiratory illness that meets the following criteria should be reported to the Centers for Disease Control:

A patient with “Fever (> or equal to38°C, 100.4°F) and pneumonia or acute respiratory distress syndrome (based on clinical or radiologic evidence)
AND EITHER
History of travel from countries in or near the Arabian Peninsula[a] within 14 days before symptom onset
OR
Close contact[b] with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula[a]
OR
Is a member of a cluster of patients with severe acute respiratory illness (such as fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments

“[a]Countries in the Arabian Peninsula and neighboring countries: Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Palestinian territories, Oman, Qatar, Saudi Arabia, Syria, the United Arab Emirates (UAE), and Yemen.
[b]Close contact is defined as a) any person who provided care for the patient, including a health care worker or family member, or had similarly close physical contact; or b) any person who stayed at the same place (lived with or visited) as the patient while the patient was ill.

Learning Point
Public health officials recommend educating the traveling public to the increased risk of MERS and for them to consistently use general public health practices such as hand hygiene, covering coughs, disposing of tissues, and avoiding contact with ill individuals. Patients should monitor their health for acute onset of febrile respiratory illnesses for 14 days after traveling to the Arabian Peninsula.

Questions for Further Discussion
1. How is MERS different than H1N1 virus?
2. Name other zoonotic viruses?
3. Where can you find current pubic health traveler advisories?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Coronavirus Infections and International Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Centers for Disease Control. Middle East Respiratory Syndrome (MERS).
Available from the Internet at http://www.cdc.gov/CORONAVIRUS/MERS/INDEX.HTML (rev. 5/15/14, cited 5/16/14).

Centers for Disease Control. MERS in the Arabian Peninsula.
Available from the Internet at http://wwwnc.cdc.gov/travel/notices/alert/coronavirus-arabian-peninsula-uk (rev. 5/12/14, cited 5/16/14).

Centers for Disease Control. Middle East Respiratory Syndrome (MERS) Frequently Asked Questions.
Available from the Internet at http://www.cdc.gov/coronavirus/MERS/faq.html (rev. 5/12/14, cited 5/16/14).

World Health Organization. Frequently Asked Questions on Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
Available from the Internet at http://www.who.int/csr/disease/coronavirus_infections/faq/en/ (rev. 5/9/14, cited 5/16/14).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • His Weight Gain is Slowing Down

    Patient Presentation

    A 6-month-old male came to clinic for his health supervision visit. His parents had several questions about when he would start crawling and saying full words. They became more concerned when they saw the actual numbers of his weight gain since his 4 month appointment because they had had the sense that he was “slowing down” in his growth. He was breastfeeding every 4 hours for 20 minutes and they had started some cereal with iron in the past month. The past medical history showed a previously healthy, full-term infant with normal growth and development to date. The pertinent physical exam revealed an interactive infant who easily grabbed objects, sat by himself, said consonants and was rolling over. His vital signs were normal. His head circumference and length were consistently about 50%. His weight was slowly decreasing from the 50% at 2 months of age to between the 25%-50% currently. His examination was normal.

    The diagnosis of a healthy male was made with normal growth and development. Although the resident had tried to educate the family that this was normal, the parents were still concerned when the attending physician came to see the infant. She reiterated what the resident had said and when showing the family the growth chart, pointed out the sharp vertical slope during the first 3 months of life, and how the growth curve slope changed over time. She said, “If your son keeps growing at the rate he was in the first few months of life, he is going to be Dad’s size when he is 2 years old.” She went on to say, “I know that seems kind of crazy, but I’ve actually done the calculations and its true, so he has to slow down how fast he’s growing.” She also discussed how in his case, the small, slow difference of being at the 25-50% currently was normal. “We’re also going to continue to watch how he grows and develops. If at any time you are concerned about his weight, just come back and we’ll re-weigh and measure him.” The parents seemed happy with the explanation, but afterwards the resident was skeptical about the growth rates. The attending and resident did a couple of sample calculations between seeing patients that day and the resident was then convinced about the growth rates.

    Case Image

    Discussion
    Since growth is such an important indicator of health in infants and children, parents are appropriately concerned that their children are growing well. A common concern for parents is that the child began at a certain percentile and is crossing growth percentiles but at a normal rate (i.e. moving toward their genetic potential). Some other parents believe that “fat babies” are healthy babies and want to see children growing at the top of the growth charts. Even if they do not believe in the “fat babies” idea, many families of children who are at the normal lower percentiles of the growth chart are worried that their child is not gaining enough weight. A careful review of the growth charts and parental education usually can assuage the concerns for most families.

    Learning Point
    Many parents will notice the normal changes in the growth rates of children particularly over the first 12 months of life, and will raise questions such as the parent above. Again careful review and explaining this normal phenomenon to parents in a way that they can comprehend usually helps the family to understand that their child is normal.

    Newborn and young infants are growing at fantastic rates, almost so much that it is difficult to comprehend the rate. However if these infants were to continue growing at these rates, they would be too large much too soon. Therefore there must be a normal decrease in the growth rate such that the child continues to grow but more slowly. In the figure below, using a starting weight of 3.35 kg (50% for males) and the growth rate for an individual month, the predicted weight that a male infant would have attained was calculated at 2 and 5 years later. Weight gain was assumed to be compounded monthly.

    Using the rate of weight gain between 2-3 months (= 14.5%), the infant would be around the size of an adult male by age 2 or 86.7 kg! This is obviously too great a weight gain for a normal infant. Using the weight gain rate at 6 months of age (=5.64%), the infant would be around 12.5 kg at 2 years of age, which is about the normal average weight of a male infant at that age (= 12.1 kg). And using the weight gain rates at 12 and 24 months of age, the infant would only be 6.1 kg and 5.0 kilograms at 2 years. Obviously this is too small a weight gain for a normal infant. Thus, one can see why there are normal decreases in weight gain rates particularly around 3 and 6 months of life. A growth chart is available to review here,

    Not only is it imperative that the weight gain slow for the infant’s own health, but also for the mother. A breastfeeding mother would need to produce ~66,000 calories or ~940 liters of breastmilk to supply only the weight gain of the infant who was growing at the 3 month old rate over 2 years. This is about an additional 90 calories and 3 liters of fluid/day for the mother to consume that solely would be going toward the weight gain of the infant.

    Questions for Further Discussion
    1. How do the weight gain rates for premature infants compare to normal weight infants?
    2. How do you determine mid-parental height? see How Do I Calculate Mid-Parental Height and Other Growth Parameters?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Child Development and Growth Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Centers for Disease Control. Data Table for Boys Length-for-age and Weight-for-age Charts.
    Available from the Internet at http://www.cdc.gov/growthcharts/who/boys_length_weight.htm (rev. 9/9/10, cited 4/30/14).

    DePaul University, Quantitative Reasoning Center. Compound Interest Formula. Medscape.
    Available from the Internet at https://qrc.depaul.edu/StudyGuide2009/Notes/Savings%20Accounts/Compound%20Interest.htm (rev. 2009, cited 4/30/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Are Probiotics Effective and If So, For What Problems?

    Patient Presentation
    A 6-week-old male came to clinic for his health supervision visit. His mother was concerned because he seemed to have excessive crying more in the evenings but also during the day. The episodes would last 30-60 minutes and were intractable with no soothing techniques helping. The episodes could occur once or more times/day and occurred 5-7 days a week. Between episodes he was a happy baby who was breastfeeding well. He had soft bowel movements 1-2 times per day and the mother did not think he was particularly gassy. His mother denied any rashes. She said that she, her husband and a close friend took turns watching him and they were all very good at handing him over to another person, or putting him down and walking away for a few minutes when they became frustrated with the crying. The past medical history showed a full-term infant with mild jaundice perinatally who did not need phototherapy. The family history was positive for atopic dermatitis in the mother, but no other allergic, immunological or gastrointestinal diseases. The review of systems was negative.

    The pertinent physical exam showed a healthy male with weight and head circumference at the 25%, and height at the 75%. His examination was normal and he was happy and playful during the visit. The diagnosis of a healthy male was made who had colic. The physician recommended to continue some of the soothing techniques and reiterated the need for breaks from the crying. He also said that there were some studies that reported crying improvement with probiotics and that the mother could try it if she wanted to. The patient’s clinical course over the next two months showed that the mother had tried the probiotics with the infant for 1 months and didn’t really see much difference. She felt that the child overall was just generally improving and he was having fewer crying episodes. “When he has them though, they are still just as intense,” she told the physician. However they were only occurring 2-3 days/week. At his 6 month check up, the episodes continued to decrease and were occurring 1-2 days/week.

    Discussion
    Colic is often defined by Wessel’s rule of threes: crying 3 or more hours/per day, 3 or more days per week, for 3 weeks or more. Colic is a diagnosis of exclusion based upon through history and physical examination in a healthy growing child being fed properly. It usually starts at 1-2 weeks of age, stops around 3-4 months and has no predictable long-term outcomes such as behavioral, tempermental or psychological problems.

    Parental and caregiver support is the most important treatment for excessive crying and colic as these infants can be very intense individuals who require a great deal of attention. For more information about crying and colic, see What Should I Do? I Just Can’t Get Him to Stop Crying?

    Learning Point
    “Probiotics are foods that are composed of the same live bacteria that are present in the gut microflora.” They should not be confused with prebiotics which are “…specific nondigestible oligosaccharides that stimulate the growth of certain types of bacteria in the colon…. prebiotics assist the survival of the microflora of the colon, whereas probiotics contribute to the intestinal flora.” Probiotics work by colonizing the bowel, secreting antibacterial substances, competing with other organisms for nutrients and preventing adhesion to the intestinal epithelium and regulation of the immune system.

    According to the current clinical practice guideline of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition society from 2006, probiotic efficacy is supported for acute infectious diarrhea, antibiotic-associated diarrhea, and atopic dermatitis.

    For acute gastroenteritis, Lactobacillus rhamnosus GG (LGG) started as soon as possible at a dose of 10 billion colony forming units/day (1010 CFU) for 5-7 days is recommended by Cincinnati Children’s Hospital. One product that is available is Culturelle® packets, capsules or chewable tablets. Capsules can be opened and placed into a cool-beverage (not warm or hot). LGG has been effective for prevention of atopic dermatitis when used by the child and the mother. A recent metaanalysis found that Lactobacillus reuteri (108 CFU) may be effective for treatment of colic in exclusively breastfed infants.

    Questions for Further Discussion
    1. How common is probiotic or other complementary and alternative medicine use among your patients?
    2. What other potential uses could probiotics have?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Colonic Diseases and Dietary Supplements.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    NASPGHAN Clinical Practice Guideline. Clinical Efficacy of Probiotics: Review of the Evidence With Focus on Children. Journal of Pediatric Gastroenterology and Nutrition
    2006:43:550-557.

    Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Use of Lactobacillus rhamnosus GG in children with acute gastroenteritis. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2011 Apr 15. 6 p.

    Foolad N, Brezinski EA, Chase EP, Armstrong AW. Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol. 2013 Mar;149(3):350-5.

    Freedman SB, Ali S, Oleszczuk M, Gouin S, Hartling L. Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evid Based Child Health. 2013 Jul;8(4):1123-37.

    Bernaola Aponte G, Bada Mancilla CA, Carreazo NY, Rojas Galarza RA. Probiotics for treating persistent diarrhoea in children. Cochrane Database Syst Rev. 2013 Aug 20;8:CD007401.

    Sung V, Collett S, de Gooyer T, Hiscock H, Tang M, Wake M. Probiotics to prevent or treat excessive infant crying: systematic review and meta-analysis. JAMA Pediatr. 2013 Dec;167(12):1150-7.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • This Ear Looks Different

    Patient Presentation
    A 15-month-old male came to clinic with a 2 day history of rhinorrhea, fever to 101.7° F, and fussiness especially at night. His mother was unable to console him the previous night and both looked very tired. He had no cough oreye changes and was drinking but not eating very much. The past medical history showed 2 ear infections in the past. The most recent was 3 months ago. The pertinent physical exam revealed a tired male who was afebrile with normal vital signs and growth parameters between 25-50%. He was well-hydrated. There was mild clear rhinorrhea and normal pharynx. His right ear had a bulging, erythematous tympanic membrane without light reflex. The left tympanic membrane was erythematous without normal landmarks but also had some centripetally radiating lines from the malleus. The tympanic membrane appeared to have a material similar to adherent scale attached to the membrane in between these lines.

    The diagnosis of bilateral otitis media was made and the patient was started on antibiotics. The resident who was seeing the patient said she had never seen a tympanic membrane with these types of changes. The attending physician said that she had and it was a variant of acute otitis media but wasn’t sure exactly what the name was for it. The following day the attending found a picture and papers with descriptions of the normal keratinization of the tympanic membrane and normal healing process of tympanic membrane. The attending still wasn’t sure what to call these specific keratin changes but understood how they occurred.

    Discussion
    The tympanic membrane has two parts, the pars flaccida and the pars tensa. Each has 3 major layers: an external keratinizing squamous epithelial layer, a central connective tissue layer, and an internal epithelial layer. The pars flaccida connective tissue layer is less well-organized than the pars tensa.

    Learning Point
    Normally, there is a centripetal migration of the keratinocytes from the central part of the tympanic membrane (along the malleus) outward to the periphery. An india ink stain of this process can be seen here. The cell migration outward is slow to begin with (i.e. new cells stay near the central area for several weeks) then as they move toward the periphery the migration speed increases. This can easily be seen in keratin patch formation. Keratin layers split during the migration forming patches similar to ice flows or the well-demarcated spots on a giraffe. An image can be seen here.

    Tympanic membrane perforations also appear to heal in a similar way, by the movement of keratinocytes from the malleus area to the periphery as one of the initial activities. Repair of the other layers seems to follow for the tympanic membrane. Most acute perforations heal spontaneously, but others may not causing chronic perforations which are associated with ear discharge, recurrent infections, conductive hearing loss, speech and language delays and cholesteatomas. Chronic supprative otitis media is also increased with chronic perforations and is associated with other intra- and extra-cranial morbidities such as meningitis and abscess. Spontaneous healing is less likely depending on the etiology (i.e. trauma vs spontaneous), large perforation size, presence of ear drainage, pre-existing tympanosclerosis and if wrong interventions are used such as ear syringing.

    Questions for Further Discussion
    1. What causes bullous myringitis?
    2. What are the indications for consultation with an otolaryngologist for tympanic membrane perforation?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Ear Infections and Ear Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Hawkelibrary.com. Tympanic membrane surface migration. Available from the Internet at http://me.hawkelibrary.com/new/main.php?g2_itemId=336 (rev. 11/30/1999, cited 4/15/2014).

    Hawkelibrary.com. Tympanic membrane keratin patches. Available from the Internet at http://me.hawkelibrary.com/new/main.php?g2_itemId=339 (rev. 11/30/1999, cited 4/15/2014).

    Hawkelibrary.com. Tympanic membrane formation of keratin patches. Available from the Internet at http://me.hawkelibrary.com/new/main.php?g2_itemId=348 (rev. 11/30/1999, cited 4/15/2014).

    Orji FT, Agu CC. Determinants of spontaneous healing in traumatic perforation of the tympanic membrane. Clin Otolaryngol. 2008:33;420-6.

    Santa Maria PL, Redmond SL, Atlas MD, Ghassemifar R. Histology of the healing tympanic membrane following perforation in rats. Laryngoscope. 2010 Oct;120(10):2061-70.

    Lou ZC, Tang YM, Yang J. A prospective study evaluating spontaneous healing of aetiology, size and type-different groups of traumatic tympanic membrane perforation. Clin Otolaryngol. 2011:36;450-60.

    Lou Z. Late crust formation as a predictor of healing of traumatic, dry and minor-sized tympanic membrane perforations. J. Otolaryngology. 2013:34;282-386.

    Mei Teh B, Redmond SL, Shen Y, Atlas MD, Marano RJ, Dilley RJ. TGF-alpha/HA complex promotes tympanic membrane keratinocyte migration and proliferation via ErbB1 receptor. Exp Cell Res. 2013 Apr 1;319(6):790-9.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital