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Rochester, NY, United States

Casey J.R.,Legacy Pediatrics | Pichichero M.E.,Rochester General Hospital
Clinical Pediatrics | Year: 2014

We determined the cost of care for 2 diagnosis and management approaches for acute otitis media (AOM) among children 6 to 30 months old. A case-control design was used. Cases included 208 children diagnosed with AOM based on a bulging tympanic membrane (TM) and treated with amoxicillin/clavulanate. Controls (5:1 ratio) included 1020 children with AOM diagnosed not requiring bulging of the TM and treated with amoxicillin. Fewer cases (49%) than controls (69%) were diagnosed with AOM (P <.001), fewer were diagnosed with recurrent AOM or AOM treatment failure (0.34 vs 1.6/child; P <.0001), and fewer had insertion of tympanostomy tubes (6.3% vs 14.8%) due to recurrent AOM (P <.0001). The combined direct payments and indirect costs for management of AOM were $539/case versus $1,023/control. Using Rochester NY payments generalized to the US birth cohort, this case diagnosis and treatment strategy could save $1.008 billion per year. © 2014 The Author(s). Source


Kaur R.,Rochester General Hospital | Casey J.,Legacy Pediatrics | Pichichero M.,Rochester General Hospital
Laryngoscope | Year: 2015

Objectives/Hypothesis: Acute otitis media (AOM) is a common bacterial infection in childhood that causes an inflammatory response in the middle ear. Leukocytes produce different inflammatory molecules in vitro when stimulated with Gram-positive and Gram-negative bacteria. The major causes of AOM are Streptococcus pneumoniae, nontypeable Haemophilus influenza, and Moraxella catarrhalis. We sought to assess differences in cytokines, chemokines, and expression of Toll-like receptors (TLRs) at onset of AOM based on bacterial culture results.Study Design: Middle ear fluid (MEF) from 66 children with AOM was studied.Methods: Innate immune genes, cytokines (interleukin [IL]-6, IL-8, IL-10, IL1-ß; tumor necrosis factor-α), chemokines (CCL2, CCL3, CCL4, CCR5, CXCR3), and Toll-like receptors (TLR2, TLR4, TLR9) expression was measured using real-time reverse transcriptase-polymerase chain reaction (RT-PCR) from MEF collected in vivo by tympanocentesis.Results: Culture-positive MEF had higher levels of all cytokines and chemokines (9-300-fold) as compared to MEF that was culture negative. Polymerase chain reaction (PCR)-positive/culture-negative MEF for otopathogens showed significant differences (P<.01) in TLR2, TLR4, and TLR9 expression (6-31-fold), but cytokine and chemokine levels were similar compared to PCR-negative/culture-negative MEF. No significant differences were found in the cytokine/chemokine/TLR levels among the bacterial otopathogen species. However, higher levels of TLRs, and all the cytokine and chemokines were detected when more than one bacterial species was present compared to single otopathogens.Conclusions: Expression levels of proinflammatory cytokines/chemokines and TLRs are elevated in AOM children with a bacterial otopathogen, and are dependent on the number of bacterial species identified. © 2014 The American Laryngological, Rhinological and Otological Society, Inc. Source


Pichichero M.E.,Rochester General Hospital | Casey J.R.,Legacy Pediatrics | Almudevar A.,University of Rochester
Pediatric Infectious Disease Journal | Year: 2013

OBJECTIVE: We recently found that children who experience recurrent otitis media despite individualized care (stringently-defined otitis prone [sOP]) do not develop an antibody response to several vaccine candidate protein antigens expressed by Streptococcus pneumonia (Spn) and Haemophilus influenzae. Here we sought to determine if these same children also failed to develop antibody to routine pediatric vaccinations. STUDY DESIGN: One hundred forty sera collected from children age 6-24 months were analyzed. sOP (n = 34) and age-matched non-sOP (n = 34) children were assessed for IgG concentrations to diphtheria toxoid, tetanus toxoid, pertussis toxoid, filamentous hemagglutinin, pertactin (DTaP), polio, hepatitis B, H. influenzae type b capsule polyribosyl-ribitol- phosphate (PRP) and Spn capsular polysaccharide conjugate vaccine. RESULTS: IgG protective titers to diphtheria toxoid (P = 0.006), tetanus toxoid (P < 0.0001), pertussis toxoid (P < 0.0001), filamentous hemagglutinin (P = 0.001), pertactin (P = 0.005), hepatitis B (P < 0.0001), polio 3 (P = 0.03) and Spn 23F (P = 0.01) but not polio 1,2, PRP or Spn 6B, and 14 were decreased in sOP versus non-sOP children using generalized estimating equations. A high percentage of sOP children had nonprotective antibody values that persisted until 24 months of age despite routine boosters. CONCLUSION: sOP children may fail to achieve protective antibody concentrations after several routine vaccinations. Copyright © 2013 by Lippincott Williams & Wilkins. Source


Xu Q.,Rochester General Hospital | Casey J.R.,Legacy Pediatrics | Pichichero M.E.,Rochester General Hospital
Mucosal Immunology | Year: 2015

Mucosal immunity has a crucial role in controlling human respiratory tract infections. This study characterizes the naturally acquired mucosal antibody levels to three Streptococcus pneumoniae (Spn) protein antigens, pneumococcal histidine triad protein D (PhtD), pneumococcal choline binding protein A (PcpA), and pneumolysin (Ply), and assesses the association of the mucosal antibody levels with occurrence of acute otitis media (AOM) caused by Spn. Both nasopharyngeal (NP) immunoglobulin G (IgG) and IgA levels to all three proteins slightly decreased in children from 6 to 9 months of age and then gradually increased through 24 months of age. Spn NP colonization was associated with higher mucosal antibody levels to all three proteins. However, children with Spn AOM had 5-8-fold lower IgG and 3-6-fold lower IgA levels to the three proteins than children without AOM but asymptomatically colonized with Spn. Antigen-specific antibody levels in the middle ear fluid (MEF) were correlated with antibody levels in the NP. Children with AOM caused by Spn had lower antibody levels in both the MEF and NP than children with AOM caused by other pathogens. These results indicate that higher naturally acquired mucosal antibody levels to PhtD, PcpA and Ply are associated with reduced AOM caused by Spn. © 2015 Society for Mucosal Immunology. Source


Kaur R.,Rochester General Hospital | Casey J.R.,Legacy Pediatrics | Pichichero M.E.,Rochester General Hospital
Pediatric Infectious Disease Journal | Year: 2011

Background: Streptococcus pneumoniae (Spn) is one of the common bacteria responsible for episodic acute otitis media (AOM; non-otitis-prone), recurrent AOM (otitis-prone), and AOM treatment failure (AOMTF) in children. Objective: From a population of 268 children, we sought to compare the serum IgG antibody titers of 5 different Spn proteins (PhtD, LytB, PcpA, PhtE, and Ply) that are vaccine candidates in children with episodic AOM (n = 34), who were otitis prone (n = 35) and who had AOMTF (n = 25) caused by Spn. Methods: Antibody was quantitated by enzyme-linked immunosorbent assay. Results: At their AOM visit, anti-PhtD,-LytB,-PhtE, and-Ply IgG antibody titers in otitis-prone children were significantly lower compared with non-otitis-prone children (P < 0.05) and children with AOMTF (P < 0.05). On comparing acute to convalescent geometric mean IgG antibody titers after AOM against the 5 proteins we found that otitis-prone, AOMTF, and non-otitis-prone children had no significant change in titers (except for PhtE in children with AOMTF), but detailed analysis showed that about one-third of the children in each cohort had a 2-fold rise in antibody to the studied antigens. Although non-otitis-prone children had significant increases (P < 0.001) between 6 and 24 months of age in anti-PhtD, PcpA, PhtE, and Ply IgG antibody titers as a consequence of nasopharyngeal colonization and AOM, otitis-prone children either failed to show rises or the rises were significantly less than the non-otitis-prone children. Conclusion: Otitis-prone and AOMTF children mount less of an IgG serum antibody response as compared with non-otitis-prone children to Spn proteins after AOM and nasopharyngeal colonization. © 2011 Lippincott Williams & Wilkins. Source

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