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PED-EM-L  February 2012

PED-EM-L February 2012

Subject:

Re: question about strep

From:

Kevin Powell <[log in to unmask]>

Reply-To:

Kevin Powell <[log in to unmask]>

Date:

Wed, 22 Feb 2012 02:52:12 -0600

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There was a heated discussion about this 21 months ago. The threads are
attached, though I can't really recommend wasting time on them since only 3
of the 44 posts cited any literature.
If really interested, see references in the posts for
5/27/2010 21:04
5/28/2010 18:05
6/01/2010 17:11

Kevin Powell MD PhD FAAP
Associate Professor of Pediatrics
Saint Louis University


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Hello everyone, Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep test and they're coming back positive. One of our PAs is claiming that he's had 5-10 positives in the past 2 months. It seems pretty unusual for strep pharyngitis to be present in a child < 2 years old (from what I recall). Any thoughts? Is the disease profile changing? They're all carriers? Thanks, Fred For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
It's been so long since I tested anyone under age 3 that I can't remember. Rheumatic fever is rare enough and I don't know of any cases under age 3. Taj Madiwale, MD Univ of Tennessee TC Thompson Children's Hospital > Date: Thu, 27 May 2010 18:03:46 -0700 > From: [log in to unmask] > Subject: Rapid Strep Test < 2 years old > To: [log in to unmask] > > Hello everyone, > > Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep test and they're coming back positive. One of our PAs is claiming that he's had 5-10 positives in the past 2 months. It seems pretty unusual for strep pharyngitis to be present in a child < 2 years old (from what I recall). > > Any thoughts? Is the disease profile changing? They're all carriers? > > Thanks, > Fred > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html _________________________________________________________________ Hotmail has tools for the New Busy. Search, chat and e-mail from your inbox. http://www.windowslive.com/campaign/thenewbusy?ocid=PID28326::T:WLMTAGL:ON:W L:en-US:WM_HMP:042010_1 For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
From the Red Book (AAP Committee on Infectious Diseases), 2009: "Toddlers (1 through 3 years of age) with GAS respiratory tract infection initially can have serous rhinitis and then develop a protracted illness with moderate fever, irritability, and anorexia (streptococcal fever). The classic presentation of streptococcal upper respiratory tract infection as acute pharyngitis is uncommon in children younger than 3 years of age. Rheumatic fever also is rare in children younger than 3 years of age." The rest of the chapter is silent on treatment in this age group. It has been my practice not to test or treat in children < 3 y.o. unless there is difficulty in eradicating Strep from a family, but this is usually the domain of the PCP, not me. James Chamberlain, MD Division Chief, Emergency Medicine Children's National Medical Center 111 Michigan Avenue, NW Washington, DC 20010 202.476.3253 (O) 202.476.3573 (F) 202.476.5433 (Emergency Access) -----Original Message----- From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Fred Wu Sent: Thursday, May 27, 2010 9:04 PM To: [log in to unmask] Subject: Rapid Strep Test < 2 years old Hello everyone, Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep test and they're coming back positive. One of our PAs is claiming that he's had 5-10 positives in the past 2 months. It seems pretty unusual for strep pharyngitis to be present in a child < 2 years old (from what I recall). Any thoughts? Is the disease profile changing? They're all carriers? Thanks, Fred For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Any explanation on all the positive rapid strep tests in the below age group? Is it all GAS respiratory tract infection? Fred -----Original Message----- From: Chamberlain, Jim [mailto:[log in to unmask]] Sent: Thursday, May 27, 2010 7:04 PM To: Fred Wu; [log in to unmask] Subject: RE: Rapid Strep Test < 2 years old From the Red Book (AAP Committee on Infectious Diseases), 2009: "Toddlers (1 through 3 years of age) with GAS respiratory tract infection initially can have serous rhinitis and then develop a protracted illness with moderate fever, irritability, and anorexia (streptococcal fever). The classic presentation of streptococcal upper respiratory tract infection as acute pharyngitis is uncommon in children younger than 3 years of age. Rheumatic fever also is rare in children younger than 3 years of age." The rest of the chapter is silent on treatment in this age group. It has been my practice not to test or treat in children < 3 y.o. unless there is difficulty in eradicating Strep from a family, but this is usually the domain of the PCP, not me. James Chamberlain, MD Division Chief, Emergency Medicine Children's National Medical Center 111 Michigan Avenue, NW Washington, DC 20010 202.476.3253 (O) 202.476.3573 (F) 202.476.5433 (Emergency Access) -----Original Message----- From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Fred Wu Sent: Thursday, May 27, 2010 9:04 PM To: [log in to unmask] Subject: Rapid Strep Test < 2 years old Hello everyone, Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep test and they're coming back positive. One of our PAs is claiming that he's had 5-10 positives in the past 2 months. It seems pretty unusual for strep pharyngitis to be present in a child < 2 years old (from what I recall). Any thoughts? Is the disease profile changing? They're all carriers? Thanks, Fred For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Occasional positives, perhaps carriers. On Thu, May 27, 2010 at 9:03 PM, Fred Wu <[log in to unmask]> wrote: > Hello everyone, > > Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep > test and they're coming back positive. One of our PAs is claiming that he's > had 5-10 positives in the past 2 months. It seems pretty unusual for strep > pharyngitis to be present in a child < 2 years old (from what I recall). > > Any thoughts? Is the disease profile changing? They're all carriers? > > Thanks, > Fred > > For more information, send mail to [log in to unmask] with the > message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > -- "I would rather be the kind of person who makes molehills out of mountains, then mountains out of molehills." For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Toddlers (1-3 y/o) with GAS respiratory tract infection usually have a serous rhinitis and then develop a protracted illness with moderate fever, irritability and anorexia.  The classic presentation of streptococcal URI as acute pharyngitis is uncommon in children younger than 3 y/o.  Rheumatic fever also is rare in children younger than 3 years of age.  This is out of the Red Book.  Testing is generally limited to daycares where there are outbreaks and other at risk kids.   Robert J. Cooper, MD, FAAP Orlando Medical Director After Hours Pediatrics [log in to unmask] ________________________________ From: Fred Wu <[log in to unmask]> To: [log in to unmask] Sent: Thu, May 27, 2010 9:03:46 PM Subject: Rapid Strep Test < 2 years old Hello everyone, Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep test and they're coming back positive. One of our PAs is claiming that he's had 5-10 positives in the past 2 months. It seems pretty unusual for strep pharyngitis to be present in a child < 2 years old (from what I recall). Any thoughts? Is the disease profile changing? They're all carriers? Thanks, Fred For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Sarah Long, the esteemed Infectious Disease doc, told me many years ago that strep is merely a disease of crowding. Therefore, when children didn't crowd together much before the advent of daycare, they didn't get sick w strep much until starting school. If children are enrolled in daycare, there's no reason why they can't get strep throat. James Reingold, M.D. Cardon Children's Hospital Mesa, AZ > Date: Thu, 27 May 2010 18:03:46 -0700 > From: [log in to unmask] > Subject: Rapid Strep Test < 2 years old > To: [log in to unmask] > > Hello everyone, > > Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep test and they're coming back positive. One of our PAs is claiming that he's had 5-10 positives in the past 2 months. It seems pretty unusual for strep pharyngitis to be present in a child < 2 years old (from what I recall). > > Any thoughts? Is the disease profile changing? They're all carriers? > > Thanks, > Fred > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html _________________________________________________________________ The New Busy is not the too busy. Combine all your e-mail accounts with Hotmail. http://www.windowslive.com/campaign/thenewbusy?tile=multiaccount&ocid=PID283 26::T:WLMTAGL:ON:WL:en-US:WM_HMP:042010_4 For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
We did have a rash of positive streps last month. I once had 8 positives in one 8 hour shift that got me wondering about it. We have also had a couple of retropharyngeal abscesses due to Gp A strep. this month, things seem to be quieting down. How can one justify not treating a kid with positive strep, high fever and even sometimes a classic rash? Usha Sethuraman Children's Hospital of Michigan For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
But do they have the disease? A pos strep and a high fever isn't something I'd treat. Not unless it's a classic throat picture. Usually these kiddies have a red throat with fever and I wouldn't treat that in spite of the +RST. I also consider the fact the incidence of a neg rxn to a drug is higher than the amount of improvement such that they're really better off without Abs. -----Original Message----- >From: "Sethuraman, Usha" <[log in to unmask]> >Sent: May 28, 2010 10:45 AM >To: [log in to unmask] >Subject: FW: reg strep positives > >We did have a rash of positive streps last month. I once had 8 positives in one 8 hour shift that got me wondering about it. We have also had a couple of retropharyngeal abscesses due to Gp A strep. >this month, things seem to be quieting down. >How can one justify not treating a kid with positive strep, high fever and even sometimes a classic rash? >Usha Sethuraman >Children's Hospital of Michigan > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
If, then, it can represent itself as just a rhinitis, how often and WHO do you test? It seems to me we're looking awfully hard for something that doesn't need to be treated. -----Original Message----- >From: Kevin Powell <[log in to unmask]> >Sent: May 28, 2010 7:04 PM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >Along with the Red Book information cited by others, may I add 3 articles >from Clinical Pediatrics, July/August 1999 > >http://cpj.sagepub.com/cgi/content/abstract/38/6/357 states that: >The incidence of both true infection and carrier state gradually increased >with age. Nevertheless, true streptococcal pharyngitis was found even in >patients younger than 1 year and its percentage related to carriers did not >increase with age and was ?50% in all age groups up to 4 years. The authors >conclude that true GABHS pharyngitis may present in the first year of life. > >and > >http://cpj.sagepub.com/cgi/reprint/38/6/361 >is entitled >Group A Streptococcal Pharyngotonsillitis in Children Less Than 2 Years of >Age More Common Than is Thought > >So to answer Fred's questions, based on these articles, Group A strep in >toddlers is a real URI. It is not as easily recognized because the tonsils >early on don't look like those of older kids -- often just purulent >rhinitis. It is not just a carrier state. The idea that toddlers can't get >strep is outdated by over 10 years. In my clinic, I haven't tested for it >often or routinely, but I treat it when found. > >Kevin Powell MD PhD FAAP >SSM Cardinal Glennon Children's Medical Center >Associate Professor of Pediatrics >Saint Louis University > > > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
But the reason we treat Strep is to prevent rheumatic fever. Children this age don't get RF. Data on symptom resolution suggests a minimally faster improvement if treated. So why expose all these kids to antibiotics? Kevin Powell <[log in to unmask]> wrote: Along with the Red Book information cited by others, may I add 3 articles from Clinical Pediatrics, July/August 1999 http://cpj.sagepub.com/cgi/content/abstract/38/6/357 states that: The incidence of both true infection and carrier state gradually increased with age. Nevertheless, true streptococcal pharyngitis was found even in patients younger than 1 year and its percentage related to carriers did not increase with age and was ?50% in all age groups up to 4 years. The authors conclude that true GABHS pharyngitis may present in the first year of life. and http://cpj.sagepub.com/cgi/reprint/38/6/361 is entitled Group A Streptococcal Pharyngotonsillitis in Children Less Than 2 Years of Age More Common Than is Thought So to answer Fred's questions, based on these articles, Group A strep in toddlers is a real URI. It is not as easily recognized because the tonsils early on don't look like those of older kids -- often just purulent rhinitis. It is not just a carrier state. The idea that toddlers can't get strep is outdated by over 10 years. In my clinic, I haven't tested for it often or routinely, but I treat it when found. Kevin Powell MD PhD FAAP SSM Cardinal Glennon Children's Medical Center Associate Professor of Pediatrics Saint Louis University For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
You talk about treating the disease; are you equating a + strep with the disease? #2 is less than 24 hours; not worth a course of Ab's #3 the latest I've read is that there is no relationship. #4 What's the incidence of PSGN in this age group? #5 doesn't occur in this age group Nope, haven't convinced me yet to test or treat these kids with Ab's. -----Original Message----- >From: Kevin Powell <[log in to unmask]> >Sent: May 29, 2010 1:26 PM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >I treat strep infections > 1.. to reduce contagion > 2.. to speed healing and reduce suffering > 3.. to reduce suppurative sequelae > 4.. to reduce other sequelae, such as glomerulonephritis > 5.. to prevent rheumatic fever >roughly in that order. > >I think the 1990 era teaching that treatment didn't reduce length of illness >was supplanted by 2000 with data showing 1 day fewer of symptoms by treating >typical strep pharyngitis in older children. No data in the toddlers. There >are lots of places in ER medicine where I would like to reduce exposing kids >to antibiotics. Disease with a proven bacterial pathogen is way down the >list. > >{SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR >findings would be high on my list. This past year I've been working as a >hospitalist for pulmonology and I am frustrated with the number of consults >weekly that involve telling parents their child with recurrent pneumonias >doesn't have an immunodeficiency, he has undertreated asthma.} > >The risk/benefit of testing will be different in toddlers. As I said >before, I don't routinely test for strep in toddlers with sore throats - far >too many viral illnesses. But if a sib has strep or other factors raise the >concern, it is appropriate to test toddlers and, unless shown an applicable >Bayesian analysis, I would recommend treating the disease when it is found. > >If an institution has a protocol in place to do rapid streps in triage on >all children with fevers or sore throats, I have minimal experience >practicing that way and defer to others to cite references on that protocol >applied to toddlers. > >Kevin Powell MD PhD FAAP >SSM Cardinal Glennon Children's Medical Center >Associate Professor of Pediatrics >Saint Louis University > >-----Original Message----- >From: Chamberlain, Jim [mailto:[log in to unmask]] >Sent: Saturday, May 29, 2010 8:52 AM >To: Kevin Powell; [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > > >But the reason we treat Strep is to prevent rheumatic fever. Children this >age don't get RF. Data on symptom resolution suggests a minimally faster >improvement if treated. So why expose all these kids to antibiotics? > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Antibiotics have not been shown to impact post-strep GN. The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur. Mike Falk Sent from my iPhone On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: You talk about treating the disease; are you equating a + strep with the disease? #2 is less than 24 hours; not worth a course of Ab's #3 the latest I've read is that there is no relationship. #4 What's the incidence of PSGN in this age group? #5 doesn't occur in this age group Nope, haven't convinced me yet to test or treat these kids with Ab's. -----Original Message----- From: Kevin Powell <[log in to unmask]> Sent: May 29, 2010 1:26 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I treat strep infections 1.. to reduce contagion 2.. to speed healing and reduce suffering 3.. to reduce suppurative sequelae 4.. to reduce other sequelae, such as glomerulonephritis 5.. to prevent rheumatic fever roughly in that order. I think the 1990 era teaching that treatment didn't reduce length of illness was supplanted by 2000 with data showing 1 day fewer of symptoms by treating typical strep pharyngitis in older children. No data in the toddlers. There are lots of places in ER medicine where I would like to reduce exposing kids to antibiotics. Disease with a proven bacterial pathogen is way down the list. {SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR findings would be high on my list. This past year I've been working as a hospitalist for pulmonology and I am frustrated with the number of consults weekly that involve telling parents their child with recurrent pneumonias doesn't have an immunodeficiency, he has undertreated asthma.} The risk/benefit of testing will be different in toddlers. As I said before, I don't routinely test for strep in toddlers with sore throats - far too many viral illnesses. But if a sib has strep or other factors raise the concern, it is appropriate to test toddlers and, unless shown an applicable Bayesian analysis, I would recommend treating the disease when it is found. If an institution has a protocol in place to do rapid streps in triage on all children with fevers or sore throats, I have minimal experience practicing that way and defer to others to cite references on that protocol applied to toddlers. Kevin Powell MD PhD FAAP SSM Cardinal Glennon Children's Medical Center Associate Professor of Pediatrics Saint Louis University -----Original Message----- From: Chamberlain, Jim [mailto:[log in to unmask]] Sent: Saturday, May 29, 2010 8:52 AM To: Kevin Powell; [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old But the reason we treat Strep is to prevent rheumatic fever. Children this age don't get RF. Data on symptom resolution suggests a minimally faster improvement if treated. So why expose all these kids to antibiotics? For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
This debate presents a nice example of conventional teachings that carry a lot of weight despite a paucity of evidence. 1. “GAS is unusual in infants and toddlers.” This is nothing more than a self-fulfilling tenant. If you don’t look for it, you won’t find it. 2. “Infants and toddlers don’t get rheumatic fever.” RF is rare, but autoimmune diseases as a group are not. GAS has already been associated with neurologic, cardiac and renal autoimmune disorders. We don't know the dormancy period nor the cascade of triggers. GAS in infancy might very well be a risk factor. We just don't know. 3. “They’re just carriers.” This is particularly worrisome. It's based on an overly constricted idea as to what the signs and symptoms of Strep are supposed to be. Just trying to maintain a questioning attitude, D.J. Scherzer, MD PEM Nationwide Children's Columbus, OH For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). Manoj Manoj K. Mittal, MD, MRCP (UK) Division of Emergency Medicine The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia, PA ________________________________________ From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] Sent: Sunday, May 30, 2010 1:34 AM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old Antibiotics have not been shown to impact post-strep GN. The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur. Mike Falk Sent from my iPhone On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: You talk about treating the disease; are you equating a + strep with the disease? #2 is less than 24 hours; not worth a course of Ab's #3 the latest I've read is that there is no relationship. #4 What's the incidence of PSGN in this age group? #5 doesn't occur in this age group Nope, haven't convinced me yet to test or treat these kids with Ab's. -----Original Message----- From: Kevin Powell <[log in to unmask]> Sent: May 29, 2010 1:26 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I treat strep infections 1.. to reduce contagion 2.. to speed healing and reduce suffering 3.. to reduce suppurative sequelae 4.. to reduce other sequelae, such as glomerulonephritis 5.. to prevent rheumatic fever roughly in that order. I think the 1990 era teaching that treatment didn't reduce length of illness was supplanted by 2000 with data showing 1 day fewer of symptoms by treating typical strep pharyngitis in older children. No data in the toddlers. There are lots of places in ER medicine where I would like to reduce exposing kids to antibiotics. Disease with a proven bacterial pathogen is way down the list. {SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR findings would be high on my list. This past year I've been working as a hospitalist for pulmonology and I am frustrated with the number of consults weekly that involve telling parents their child with recurrent pneumonias doesn't have an immunodeficiency, he has undertreated asthma.} The risk/benefit of testing will be different in toddlers. As I said before, I don't routinely test for strep in toddlers with sore throats - far too many viral illnesses. But if a sib has strep or other factors raise the concern, it is appropriate to test toddlers and, unless shown an applicable Bayesian analysis, I would recommend treating the disease when it is found. If an institution has a protocol in place to do rapid streps in triage on all children with fevers or sore throats, I have minimal experience practicing that way and defer to others to cite references on that protocol applied to toddlers. Kevin Powell MD PhD FAAP SSM Cardinal Glennon Children's Medical Center Associate Professor of Pediatrics Saint Louis University -----Original Message----- From: Chamberlain, Jim [mailto:[log in to unmask]] Sent: Saturday, May 29, 2010 8:52 AM To: Kevin Powell; [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old But the reason we treat Strep is to prevent rheumatic fever. Children this age don't get RF. Data on symptom resolution suggests a minimally faster improvement if treated. So why expose all these kids to antibiotics? For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
I am 41 and just recovered from Acute Rheumatic Fever that developed after an adequately treated GAS pharyngitis. (Without going into detail, diagnosis was arrived at by meeting Jones Criteria and having no other positives in my rheumatologic workup...rheumatology and infectious disease (Duke) evaluated me and concur) I am a white male, European descent, and never lived off the North American continent...shouldn't have happened. Try to incorporate that into this discussion....even I am not sure how it fits in or what one could learn from it. R. David Smith, MD Children's Acute Care Medical Director, Peds Emergency Christus Schumpert, Sutton Children's Hospital, Shreveport, LA Cape Fear Valley Medical Center, Fayetteville, NC ________________________________ From: "Mittal, Manoj K" <[log in to unmask]> To: [log in to unmask] Sent: Sun, May 30, 2010 10:18:20 AM Subject: Re: Rapid Strep Test < 2 years old How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). Manoj Manoj K. Mittal, MD, MRCP (UK) Division of Emergency Medicine The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia, PA ________________________________________ From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] Sent: Sunday, May 30, 2010 1:34 AM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old Antibiotics have not been shown to impact post-strep GN.  The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur.  Mike Falk Sent from my iPhone On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: You talk about treating the disease; are you equating a + strep with the disease? #2 is less than 24 hours; not worth a course of Ab's #3 the latest I've read is that there is no relationship. #4 What's the incidence of PSGN in this age group? #5 doesn't occur in this age group Nope, haven't convinced me yet to test or treat these kids with Ab's. -----Original Message----- From: Kevin Powell <[log in to unmask]> Sent: May 29, 2010 1:26 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I treat strep infections 1.. to reduce contagion 2.. to speed healing and reduce suffering 3.. to reduce suppurative sequelae 4.. to reduce other sequelae, such as glomerulonephritis 5.. to prevent rheumatic fever roughly in that order. I think the 1990 era teaching that treatment didn't reduce length of illness was supplanted by 2000 with data showing 1 day fewer of symptoms by treating typical strep pharyngitis in older children. No data in the toddlers. There are lots of places in ER medicine where I would like to reduce exposing kids to antibiotics. Disease with a proven bacterial pathogen is way down the list. {SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR findings would be high on my list. This past year I've been working as a hospitalist for pulmonology and I am frustrated with the number of consults weekly that involve telling parents their child with recurrent pneumonias doesn't have an immunodeficiency, he has undertreated asthma.} The risk/benefit of testing will be different in toddlers.  As I said before, I don't routinely test for strep in toddlers with sore throats - far too many viral illnesses. But if a sib has strep or other factors raise the concern, it is appropriate to test toddlers and, unless shown an applicable Bayesian analysis, I would recommend treating the disease when it is found. If an institution has a protocol in place to do rapid streps in triage on all children with fevers or sore throats, I have minimal experience practicing that way and defer to others to cite references on that protocol applied to toddlers. Kevin Powell MD PhD FAAP SSM Cardinal Glennon Children's Medical Center Associate Professor of Pediatrics Saint Louis University -----Original Message----- From: Chamberlain, Jim [mailto:[log in to unmask]] Sent: Saturday, May 29, 2010 8:52 AM To: Kevin Powell; [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old But the reason we treat Strep is to prevent rheumatic fever. Children this age don't get RF. Data on symptom resolution suggests a minimally faster improvement if treated. So why expose all these kids to antibiotics? For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:               http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
I, for one, don't test nor treat adults for strep. -----Original Message----- >From: "Mittal, Manoj K" <[log in to unmask]> >Sent: May 30, 2010 10:18 AM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). >Manoj >Manoj K. Mittal, MD, MRCP (UK) >Division of Emergency Medicine >The Children's Hospital of Philadelphia >University of Pennsylvania School of Medicine >Philadelphia, PA >________________________________________ >From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] >Sent: Sunday, May 30, 2010 1:34 AM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >Antibiotics have not been shown to impact post-strep GN. The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur. Mike Falk > >Sent from my iPhone > >On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: > >You talk about treating the disease; are you equating a + strep with the disease? >#2 is less than 24 hours; not worth a course of Ab's >#3 the latest I've read is that there is no relationship. >#4 What's the incidence of PSGN in this age group? >#5 doesn't occur in this age group >Nope, haven't convinced me yet to test or treat these kids with Ab's. > >-----Original Message----- >From: Kevin Powell <[log in to unmask]> >Sent: May 29, 2010 1:26 PM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >I treat strep infections >1.. to reduce contagion >2.. to speed healing and reduce suffering >3.. to reduce suppurative sequelae >4.. to reduce other sequelae, such as glomerulonephritis >5.. to prevent rheumatic fever >roughly in that order. > >I think the 1990 era teaching that treatment didn't reduce length of illness >was supplanted by 2000 with data showing 1 day fewer of symptoms by treating >typical strep pharyngitis in older children. No data in the toddlers. There >are lots of places in ER medicine where I would like to reduce exposing kids >to antibiotics. Disease with a proven bacterial pathogen is way down the >list. > >{SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR >findings would be high on my list. This past year I've been working as a >hospitalist for pulmonology and I am frustrated with the number of consults >weekly that involve telling parents their child with recurrent pneumonias >doesn't have an immunodeficiency, he has undertreated asthma.} > >The risk/benefit of testing will be different in toddlers. As I said >before, I don't routinely test for strep in toddlers with sore throats - far >too many viral illnesses. But if a sib has strep or other factors raise the >concern, it is appropriate to test toddlers and, unless shown an applicable >Bayesian analysis, I would recommend treating the disease when it is found. > >If an institution has a protocol in place to do rapid streps in triage on >all children with fevers or sore throats, I have minimal experience >practicing that way and defer to others to cite references on that protocol >applied to toddlers. > >Kevin Powell MD PhD FAAP >SSM Cardinal Glennon Children's Medical Center >Associate Professor of Pediatrics >Saint Louis University > >-----Original Message----- >From: Chamberlain, Jim [mailto:[log in to unmask]] >Sent: Saturday, May 29, 2010 8:52 AM >To: Kevin Powell; [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > > >But the reason we treat Strep is to prevent rheumatic fever. Children this >age don't get RF. Data on symptom resolution suggests a minimally faster >improvement if treated. So why expose all these kids to antibiotics? > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > > >Fergus Thornton >read my blog @ http://docdownunder.wordpress.com > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > > > > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
From: "Mittal, Manoj K" <[log in to unmask]> >How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? --> I have not been following the thread, so I hope this answer fits here... We do not test ED patients for strep. It is rare for us to see patients presenting with "sore throat". There are many things civi's here DON'T know are primary care, but this one they seem to understand... When we do see the occasional one (which is not a quinsy or something else) and diagnose a throat infection, we tend to treat with antibiotics any which show purulent exudate. The rest we advise to review with their GP after 48hrs of symptomatic treatment, which they should get over-the-counter. The 1st line antibiotic we do use when we treat is Penicillin V. I have not looked at this for a while. Does anyone out there have good evidence for me to read on the benefit of testing? I would appreciate it. Honestly have not had any experience with testing for as long as I can remember - wouldn't know HOW to test... _________________________________________________________________ http://clk.atdmt.com/UKM/go/197222280/direct/01/ Do you have a story that started on Hotmail? Tell us now For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Anecdotal. While I'm sympathetic to what happened to you, even you know that we can't base clinical decisions on one case. We have to base our decisions on statistical probability not on one case. In fact your case proves what we're saying: antibiotics shouldn't be used in this (or any? age group. Didn't make a difference in your case. -----Original Message----- >From: Dave Smith <[log in to unmask]> >Sent: May 30, 2010 10:20 PM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >I am 41 and just recovered from Acute Rheumatic Fever that developed after an adequately treated GAS pharyngitis. > >(Without going into detail, diagnosis was arrived at by meeting Jones Criteria and having no other positives in my rheumatologic workup...rheumatology and infectious disease (Duke) evaluated me and concur) > >I am a white male, European descent, and never lived off the North American continent...shouldn't have happened. > >Try to incorporate that into this discussion....even I am not sure how it fits in or what one could learn from it. > > >R. David Smith, MD >Children's Acute Care >Medical Director, Peds Emergency >Christus Schumpert, Sutton Children's Hospital, Shreveport, LA >Cape Fear Valley Medical Center, Fayetteville, NC > > > >________________________________ >From: "Mittal, Manoj K" <[log in to unmask]> >To: [log in to unmask] >Sent: Sun, May 30, 2010 10:18:20 AM >Subject: Re: Rapid Strep Test < 2 years old > >How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). >Manoj >Manoj K. Mittal, MD, MRCP (UK) >Division of Emergency Medicine >The Children's Hospital of Philadelphia >University of Pennsylvania School of Medicine >Philadelphia, PA >________________________________________ >From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] >Sent: Sunday, May 30, 2010 1:34 AM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >Antibiotics have not been shown to impact post-strep GN. The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur. Mike Falk > >Sent from my iPhone > >On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: > >You talk about treating the disease; are you equating a + strep with the disease? >#2 is less than 24 hours; not worth a course of Ab's >#3 the latest I've read is that there is no relationship. >#4 What's the incidence of PSGN in this age group? >#5 doesn't occur in this age group >Nope, haven't convinced me yet to test or treat these kids with Ab's. > >-----Original Message----- >From: Kevin Powell <[log in to unmask]> >Sent: May 29, 2010 1:26 PM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >I treat strep infections >1.. to reduce contagion >2.. to speed healing and reduce suffering >3.. to reduce suppurative sequelae >4.. to reduce other sequelae, such as glomerulonephritis >5.. to prevent rheumatic fever >roughly in that order. > >I think the 1990 era teaching that treatment didn't reduce length of illness >was supplanted by 2000 with data showing 1 day fewer of symptoms by treating >typical strep pharyngitis in older children. No data in the toddlers. There >are lots of places in ER medicine where I would like to reduce exposing kids >to antibiotics. Disease with a proven bacterial pathogen is way down the >list. > >{SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR >findings would be high on my list. This past year I've been working as a >hospitalist for pulmonology and I am frustrated with the number of consults >weekly that involve telling parents their child with recurrent pneumonias >doesn't have an immunodeficiency, he has undertreated asthma.} > >The risk/benefit of testing will be different in toddlers. As I said >before, I don't routinely test for strep in toddlers with sore throats - far >too many viral illnesses. But if a sib has strep or other factors raise the >concern, it is appropriate to test toddlers and, unless shown an applicable >Bayesian analysis, I would recommend treating the disease when it is found. > >If an institution has a protocol in place to do rapid streps in triage on >all children with fevers or sore throats, I have minimal experience >practicing that way and defer to others to cite references on that protocol >applied to toddlers. > >Kevin Powell MD PhD FAAP >SSM Cardinal Glennon Children's Medical Center >Associate Professor of Pediatrics >Saint Louis University > >-----Original Message----- >From: Chamberlain, Jim [mailto:[log in to unmask]] >Sent: Saturday, May 29, 2010 8:52 AM >To: Kevin Powell; [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > > >But the reason we treat Strep is to prevent rheumatic fever. Children this >age don't get RF. Data on symptom resolution suggests a minimally faster >improvement if treated. So why expose all these kids to antibiotics? > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > > >Fergus Thornton >read my blog @ http://docdownunder.wordpress.com > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > > > > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > > > > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Dr. Smith, What you have shared speaks simply to the practical limitations of statistics. A caution that we not allow evidence-based medicine to transform into evidence-based madness. An encouragement that phrases like "never, always or shouldn't have happened" (especially when applied to clinical cases) be understood as unrealistic and untrue. My 2 cents, Pamela Ross, MD Associate Professor Emergency Medicine & Pediatrics University of Virginia Health System Charlottesville, Virginia Sent from my Verizon Wireless BlackBerry -----Original Message----- From: Dave Smith <[log in to unmask]> Date: Sun, 30 May 2010 19:20:36 To: <[log in to unmask]> Subject: Re: Rapid Strep Test < 2 years old I am 41 and just recovered from Acute Rheumatic Fever that developed after an adequately treated GAS pharyngitis. (Without going into detail, diagnosis was arrived at by meeting Jones Criteria and having no other positives in my rheumatologic workup...rheumatology and infectious disease (Duke) evaluated me and concur) I am a white male, European descent, and never lived off the North American continent...shouldn't have happened. Try to incorporate that into this discussion....even I am not sure how it fits in or what one could learn from it. R. David Smith, MD Children's Acute Care Medical Director, Peds Emergency Christus Schumpert, Sutton Children's Hospital, Shreveport, LA Cape Fear Valley Medical Center, Fayetteville, NC ________________________________ From: "Mittal, Manoj K" <[log in to unmask]> To: [log in to unmask] Sent: Sun, May 30, 2010 10:18:20 AM Subject: Re: Rapid Strep Test < 2 years old How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). Manoj Manoj K. Mittal, MD, MRCP (UK) Division of Emergency Medicine The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia, PA ________________________________________ From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] Sent: Sunday, May 30, 2010 1:34 AM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old Antibiotics have not been shown to impact post-strep GN.  The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur.  Mike Falk Sent from my iPhone On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: You talk about treating the disease; are you equating a + strep with the disease? #2 is less than 24 hours; not worth a course of Ab's #3 the latest I've read is that there is no relationship. #4 What's the incidence of PSGN in this age group? #5 doesn't occur in this age group Nope, haven't convinced me yet to test or treat these kids with Ab's. -----Original Message----- From: Kevin Powell <[log in to unmask]> Sent: May 29, 2010 1:26 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I treat strep infections 1.. to reduce contagion 2.. to speed healing and reduce suffering 3.. to reduce suppurative sequelae 4.. to reduce other sequelae, such as glomerulonephritis 5.. to prevent rheumatic fever roughly in that order. I think the 1990 era teaching that treatment didn't reduce length of illness was supplanted by 2000 with data showing 1 day fewer of symptoms by treating typical strep pharyngitis in older children. No data in the toddlers. There are lots of places in ER medicine where I would like to reduce exposing kids to antibiotics. Disease with a proven bacterial pathogen is way down the list. {SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR findings would be high on my list. This past year I've been working as a hospitalist for pulmonology and I am frustrated with the number of consults weekly that involve telling parents their child with recurrent pneumonias doesn't have an immunodeficiency, he has undertreated asthma.} The risk/benefit of testing will be different in toddlers.  As I said before, I don't routinely test for strep in toddlers with sore throats - far too many viral illnesses. But if a sib has strep or other factors raise the concern, it is appropriate to test toddlers and, unless shown an applicable Bayesian analysis, I would recommend treating the disease when it is found. If an institution has a protocol in place to do rapid streps in triage on all children with fevers or sore throats, I have minimal experience practicing that way and defer to others to cite references on that protocol applied to toddlers. Kevin Powell MD PhD FAAP SSM Cardinal Glennon Children's Medical Center Associate Professor of Pediatrics Saint Louis University -----Original Message----- From: Chamberlain, Jim [mailto:[log in to unmask]] Sent: Saturday, May 29, 2010 8:52 AM To: Kevin Powell; [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old But the reason we treat Strep is to prevent rheumatic fever. Children this age don't get RF. Data on symptom resolution suggests a minimally faster improvement if treated. So why expose all these kids to antibiotics? For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:               http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Dr. Smith, The GAS pharyngitis that you remember might not have been the one that sensitized you to have an autoimmune response - it might just have spurred it on. The antibiotics you took during your relatively recent illness didn't help because the antibodies were already primed. The sensitizing episode could have been subtle or remote. It's the GAS that goes undetected or untreated (and your own immuno-uniqueness) that sets you up. Your story is important and not just an isolated anecdote. Best of luck to you. D.J. Scherzer -----Original Message----- From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Dave Smith Sent: Sunday, May 30, 2010 10:21 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I am 41 and just recovered from Acute Rheumatic Fever that developed after an adequately treated GAS pharyngitis. (Without going into detail, diagnosis was arrived at by meeting Jones Criteria and having no other positives in my rheumatologic workup...rheumatology and infectious disease (Duke) evaluated me and concur) I am a white male, European descent, and never lived off the North American continent...shouldn't have happened. Try to incorporate that into this discussion....even I am not sure how it fits in or what one could learn from it. R. David Smith, MD Children's Acute Care Medical Director, Peds Emergency Christus Schumpert, Sutton Children's Hospital, Shreveport, LA Cape Fear Valley Medical Center, Fayetteville, NC ________________________________ From: "Mittal, Manoj K" <[log in to unmask]> To: [log in to unmask] Sent: Sun, May 30, 2010 10:18:20 AM Subject: Re: Rapid Strep Test < 2 years old How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). Manoj Manoj K. Mittal, MD, MRCP (UK) Division of Emergency Medicine The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia, PA ________________________________________ From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] Sent: Sunday, May 30, 2010 1:34 AM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old Antibiotics have not been shown to impact post-strep GN.  The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur.  Mike Falk Sent from my iPhone On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: You talk about treating the disease; are you equating a + strep with the disease? #2 is less than 24 hours; not worth a course of Ab's #3 the latest I've read is that there is no relationship. #4 What's the incidence of PSGN in this age group? #5 doesn't occur in this age group Nope, haven't convinced me yet to test or treat these kids with Ab's. -----Original Message----- From: Kevin Powell <[log in to unmask]> Sent: May 29, 2010 1:26 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I treat strep infections 1.. to reduce contagion 2.. to speed healing and reduce suffering 3.. to reduce suppurative sequelae 4.. to reduce other sequelae, such as glomerulonephritis 5.. to prevent rheumatic fever roughly in that order. I think the 1990 era teaching that treatment didn't reduce length of illness was supplanted by 2000 with data showing 1 day fewer of symptoms by treating typical strep pharyngitis in older children. No data in the toddlers. There are lots of places in ER medicine where I would like to reduce exposing kids to antibiotics. Disease with a proven bacterial pathogen is way down the list. {SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR findings would be high on my list. This past year I've been working as a hospitalist for pulmonology and I am frustrated with the number of consults weekly that involve telling parents their child with recurrent pneumonias doesn't have an immunodeficiency, he has undertreated asthma.} The risk/benefit of testing will be different in toddlers.  As I said before, I don't routinely test for strep in toddlers with sore throats - far too many viral illnesses. But if a sib has strep or other factors raise the concern, it is appropriate to test toddlers and, unless shown an applicable Bayesian analysis, I would recommend treating the disease when it is found. If an institution has a protocol in place to do rapid streps in triage on all children with fevers or sore throats, I have minimal experience practicing that way and defer to others to cite references on that protocol applied to toddlers. Kevin Powell MD PhD FAAP SSM Cardinal Glennon Children's Medical Center Associate Professor of Pediatrics Saint Louis University -----Original Message----- From: Chamberlain, Jim [mailto:[log in to unmask]] Sent: Saturday, May 29, 2010 8:52 AM To: Kevin Powell; [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old But the reason we treat Strep is to prevent rheumatic fever. Children this age don't get RF. Data on symptom resolution suggests a minimally faster improvement if treated. So why expose all these kids to antibiotics? For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:               http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html ----------------------------------------- Confidentiality Notice: The following mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. 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Of course it is anecdotal but it raises many interesting questions.  The most relevant of which is whether we can hang our hats on the idea that rheumatic fever "never" happens outside of certain age ranges.  While I was unusual in a whole host of ways, I don't know that you can say that it shows that treatment doesn't matter in all cases...just that sometimes, people get treated and still get RF.  Since we have to base our decisions on overall risks and probabilities and not just one case as you noted, and since the decline of RF in the States seems to be attributable to the onset of antibiotics and the routine treatment of strep, it still begs the question of whether or not we are kidding ourselves by not treating in non-traditional age groups just because "they don't get RF." ________________________________ From: Fergus Thornton <[log in to unmask]> To: [log in to unmask] Sent: Mon, May 31, 2010 8:59:50 PM Subject: Re: Rapid Strep Test < 2 years old Anecdotal.  While I'm sympathetic to what happened to you, even you know that we can't base clinical decisions on one case.  We have to base our decisions on statistical probability not on one case.  In fact your case proves what we're saying: antibiotics shouldn't be used in this (or any? age group.  Didn't make a difference in your case. -----Original Message----- >From: Dave Smith <[log in to unmask]> >Sent: May 30, 2010 10:20 PM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >I am 41 and just recovered from Acute Rheumatic Fever that developed after an adequately treated GAS pharyngitis. > >(Without going into detail, diagnosis was arrived at by meeting Jones Criteria and having no other positives in my rheumatologic workup...rheumatology and infectious disease (Duke) evaluated me and concur) > >I am a white male, European descent, and never lived off the North American continent...shouldn't have happened. > >Try to incorporate that into this discussion....even I am not sure how it fits in or what one could learn from it. > > >R. David Smith, MD >Children's Acute Care >Medical Director, Peds Emergency >Christus Schumpert, Sutton Children's Hospital, Shreveport, LA >Cape Fear Valley Medical Center, Fayetteville, NC > > > >________________________________ >From: "Mittal, Manoj K" <[log in to unmask]> >To: [log in to unmask] >Sent: Sun, May 30, 2010 10:18:20 AM >Subject: Re: Rapid Strep Test < 2 years old > >How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). >Manoj >Manoj K. Mittal, MD, MRCP (UK) >Division of Emergency Medicine >The Children's Hospital of Philadelphia >University of Pennsylvania School of Medicine >Philadelphia, PA >________________________________________ >From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] >Sent: Sunday, May 30, 2010 1:34 AM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >Antibiotics have not been shown to impact post-strep GN.  The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur.  Mike Falk > >Sent from my iPhone > >On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: > >You talk about treating the disease; are you equating a + strep with the disease? >#2 is less than 24 hours; not worth a course of Ab's >#3 the latest I've read is that there is no relationship. >#4 What's the incidence of PSGN in this age group? >#5 doesn't occur in this age group >Nope, haven't convinced me yet to test or treat these kids with Ab's. > >-----Original Message----- >From: Kevin Powell <[log in to unmask]> >Sent: May 29, 2010 1:26 PM >To: [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > >I treat strep infections >1.. to reduce contagion >2.. to speed healing and reduce suffering >3.. to reduce suppurative sequelae >4.. to reduce other sequelae, such as glomerulonephritis >5.. to prevent rheumatic fever >roughly in that order. > >I think the 1990 era teaching that treatment didn't reduce length of illness >was supplanted by 2000 with data showing 1 day fewer of symptoms by treating >typical strep pharyngitis in older children. No data in the toddlers. There >are lots of places in ER medicine where I would like to reduce exposing kids >to antibiotics. Disease with a proven bacterial pathogen is way down the >list. > >{SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR >findings would be high on my list. This past year I've been working as a >hospitalist for pulmonology and I am frustrated with the number of consults >weekly that involve telling parents their child with recurrent pneumonias >doesn't have an immunodeficiency, he has undertreated asthma.} > >The risk/benefit of testing will be different in toddlers.  As I said >before, I don't routinely test for strep in toddlers with sore throats - far >too many viral illnesses. But if a sib has strep or other factors raise the >concern, it is appropriate to test toddlers and, unless shown an applicable >Bayesian analysis, I would recommend treating the disease when it is found. > >If an institution has a protocol in place to do rapid streps in triage on >all children with fevers or sore throats, I have minimal experience >practicing that way and defer to others to cite references on that protocol >applied to toddlers. > >Kevin Powell MD PhD FAAP >SSM Cardinal Glennon Children's Medical Center >Associate Professor of Pediatrics >Saint Louis University > >-----Original Message----- >From: Chamberlain, Jim [mailto:[log in to unmask]] >Sent: Saturday, May 29, 2010 8:52 AM >To: Kevin Powell; [log in to unmask] >Subject: Re: Rapid Strep Test < 2 years old > > >But the reason we treat Strep is to prevent rheumatic fever. Children this >age don't get RF. Data on symptom resolution suggests a minimally faster >improvement if treated. So why expose all these kids to antibiotics? > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: >              http://listserv.brown.edu/ped-em-l.html > > >Fergus Thornton >read my blog @ http://docdownunder.wordpress.com > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: >                http://listserv.brown.edu/ped-em-l.html > > > > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: >                http://listserv.brown.edu/ped-em-l.html > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: >                http://listserv.brown.edu/ped-em-l.html > > > > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: >                http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
I want to play devil's advocate for a moment on another set of perspectives: 1.  What is the impact of not treating in terms of outcomes not considered by studies? What I mean by this is that it is all well and good to pound the table and hold up the studies and say, "Best practice says I don't need to test/treat your 2 year old son, Mrs. Smith," but then, how often does Mrs. Smith go to the urgent care down the road where they invariably see a febrile toddler, order blood, urine and a chest xray, and give Rocephin?  Even if she goes to her PMD the next day and they simply do a strep and treat (which I think most PMD's would do despite our urgings to the contrary), she's now incurred another visit to another medical provider, increasing overall costs in the process.  In the former case, the child undergoes a while slew of tests and a treatment we could have prevented.  As I like to say, Evidence-Based Medicine is the beginning of wisdom, not the entirity of it.  We also have to practice "realistic medicine" ."  Over-adherence to dogma may lead to parents seeking other outlets that end up doing far worse  than a script for PenVK.  Writing that script in some (many?) cases would thus be better practice than what the child ended up with even though it may not have been "best practice." 2.  We live in a world of Press-Gainey If your hospital administrators are like ours, they don't really care about the best-practice guidelines...just the satisfaction scores.  When surveys come back giving the doctor a series of 1's because they doctor "didn't do anything about my child's strep throat and I had to go to an urgent care" they want to know what we are doing to improve our scores.  Telling them that strep only gets better a day earlier with treatment and the child wasn't in an age range for rheumatic fever so it didn't matter isn't something they care about.  That's how one ends up with language added to one's contract tying incentives and penalties to Press-Gainey performance. 3.  What's a day worth to a parent/child? When your child is sick, would you like him to be better a day earlier?  As a parent of four, I would have to say my answer is yes.  Most parents I see would say yes as well.  That extra day could be two extra days in some cases and we have no way of knowing for sure...it could also be zero, but few parents would see that as an issue if there is a good chance the illness could be one or two days shorter.  For parents who are working, sometimes in positions where taking more sick days could mean not advancing or at the very least, being seen as unreliable because they are always out with "kid issues," that extra day might mean a lot.  So when we say, "It's not worthwhile because they only get better a day earlier at best," we are making a value judgement about the worth of a day of wellness and the value of the parents' time. As I said, just playing devil's advocate.  I tend to agree in principle with what others have written in this thread.  But we must always remember that there are times when we still may be doing better care, given the balance of all the issues at hand, when we give a little ground on "best care." Dave Smith, MD For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
For those who are interested, We reviewed this cost-effectiveness article as a PEM fellow. This is based on rates of strep in children age 5-17 years old. (didn't assess the extremes of age) They tested the cost effectiveness of 5 options (1) “treat all,” (2) “treat none,” (3) “rapid test,” where only patients with a positive rapid antigen test are treated, (4) “culture,” where only patients with a positive throat culture are treated, and (5) “rapid test with culture  It takes into account, cost of missed GAS, cost of allergic reactions. etc. (doesn't factor in litigation.) It found that for the 5-17 year age range, rapid strep only was the most cost effective strategy. Here is the link... http://www.sepeap.org/archivos/pdf/10624.pdf You could use the data provided to calculate an effective strategy for other age ranges.  I think management at the extremes (for all issues) is where the art of medicine is revealed. These decisions will be based on the risk tolerance of the clinician and the patient/family, severity and duration of illness, phase of the moon, number of patients in the waiting room, etc. Such is ART. -Danny Danny G Thomas MD MPH Assistant Professor of Pediatrics Medical College of Wisconsin On Tue, Jun 1, 2010 at 3:24 PM, Dave Smith <[log in to unmask]> wrote: > Of course it is anecdotal but it raises many interesting questions.  The most relevant of which is whether we can hang our hats on the idea that rheumatic fever "never" happens outside of certain age ranges.  While I was unusual in a whole host of ways, I don't know that you can say that it shows that treatment doesn't matter in all cases...just that sometimes, people get treated and still get RF.  Since we have to base our decisions on overall risks and probabilities and not just one case as you noted, and since the decline of RF in the States seems to be attributable to the onset of antibiotics and the routine treatment of strep, it still begs the question of whether or not we are kidding ourselves by not treating in non-traditional age groups just because "they don't get RF." > > > > > ________________________________ > From: Fergus Thornton <[log in to unmask]> > To: [log in to unmask] > Sent: Mon, May 31, 2010 8:59:50 PM > Subject: Re: Rapid Strep Test < 2 years old > > Anecdotal.  While I'm sympathetic to what happened to you, even you know that we can't base clinical decisions on one case.  We have to base our decisions on statistical probability not on one case.  In fact your case proves what we're saying: antibiotics shouldn't be used in this (or any? age group.  Didn't make a difference in your case. > > -----Original Message----- >>From: Dave Smith <[log in to unmask]> >>Sent: May 30, 2010 10:20 PM >>To: [log in to unmask] >>Subject: Re: Rapid Strep Test < 2 years old >> >>I am 41 and just recovered from Acute Rheumatic Fever that developed after an adequately treated GAS pharyngitis. >> >>(Without going into detail, diagnosis was arrived at by meeting Jones Criteria and having no other positives in my rheumatologic workup...rheumatology and infectious disease (Duke) evaluated me and concur) >> >>I am a white male, European descent, and never lived off the North American continent...shouldn't have happened. >> >>Try to incorporate that into this discussion....even I am not sure how it fits in or what one could learn from it. >> >> >>R. David Smith, MD >>Children's Acute Care >>Medical Director, Peds Emergency >>Christus Schumpert, Sutton Children's Hospital, Shreveport, LA >>Cape Fear Valley Medical Center, Fayetteville, NC >> >> >> >>________________________________ >>From: "Mittal, Manoj K" <[log in to unmask]> >>To: [log in to unmask] >>Sent: Sun, May 30, 2010 10:18:20 AM >>Subject: Re: Rapid Strep Test < 2 years old >> >>How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). >>Manoj >>Manoj K. Mittal, MD, MRCP (UK) >>Division of Emergency Medicine >>The Children's Hospital of Philadelphia >>University of Pennsylvania School of Medicine >>Philadelphia, PA >>________________________________________ >>From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] >>Sent: Sunday, May 30, 2010 1:34 AM >>To: [log in to unmask] >>Subject: Re: Rapid Strep Test < 2 years old >> >>Antibiotics have not been shown to impact post-strep GN.  The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur.  Mike Falk >> >>Sent from my iPhone >> >>On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: >> >>You talk about treating the disease; are you equating a + strep with the disease? >>#2 is less than 24 hours; not worth a course of Ab's >>#3 the latest I've read is that there is no relationship. >>#4 What's the incidence of PSGN in this age group? >>#5 doesn't occur in this age group >>Nope, haven't convinced me yet to test or treat these kids with Ab's. >> >>-----Original Message----- >>From: Kevin Powell <[log in to unmask]> >>Sent: May 29, 2010 1:26 PM >>To: [log in to unmask] >>Subject: Re: Rapid Strep Test < 2 years old >> >>I treat strep infections >>1.. to reduce contagion >>2.. to speed healing and reduce suffering >>3.. to reduce suppurative sequelae >>4.. to reduce other sequelae, such as glomerulonephritis >>5.. to prevent rheumatic fever >>roughly in that order. >> >>I think the 1990 era teaching that treatment didn't reduce length of illness >>was supplanted by 2000 with data showing 1 day fewer of symptoms by treating >>typical strep pharyngitis in older children. No data in the toddlers. There >>are lots of places in ER medicine where I would like to reduce exposing kids >>to antibiotics. Disease with a proven bacterial pathogen is way down the >>list. >> >>{SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR >>findings would be high on my list. This past year I've been working as a >>hospitalist for pulmonology and I am frustrated with the number of consults >>weekly that involve telling parents their child with recurrent pneumonias >>doesn't have an immunodeficiency, he has undertreated asthma.} >> >>The risk/benefit of testing will be different in toddlers.  As I said >>before, I don't routinely test for strep in toddlers with sore throats - far >>too many viral illnesses. But if a sib has strep or other factors raise the >>concern, it is appropriate to test toddlers and, unless shown an applicable >>Bayesian analysis, I would recommend treating the disease when it is found. >> >>If an institution has a protocol in place to do rapid streps in triage on >>all children with fevers or sore throats, I have minimal experience >>practicing that way and defer to others to cite references on that protocol >>applied to toddlers. >> >>Kevin Powell MD PhD FAAP >>SSM Cardinal Glennon Children's Medical Center >>Associate Professor of Pediatrics >>Saint Louis University >> >>-----Original Message----- >>From: Chamberlain, Jim [mailto:[log in to unmask]] >>Sent: Saturday, May 29, 2010 8:52 AM >>To: Kevin Powell; [log in to unmask] >>Subject: Re: Rapid Strep Test < 2 years old >> >> >>But the reason we treat Strep is to prevent rheumatic fever. Children this >>age don't get RF. Data on symptom resolution suggests a minimally faster >>improvement if treated. So why expose all these kids to antibiotics? >> >> >>For more information, send mail to [log in to unmask] with the message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >>              http://listserv.brown.edu/ped-em-l.html >> >> >>Fergus Thornton >>read my blog @ http://docdownunder.wordpress.com >> >>For more information, send mail to [log in to unmask] with the message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >>                http://listserv.brown.edu/ped-em-l.html >> >> >> >> >> >>For more information, send mail to [log in to unmask] with the message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >>                http://listserv.brown.edu/ped-em-l.html >> >>For more information, send mail to [log in to unmask] with the message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >>                http://listserv.brown.edu/ped-em-l.html >> >> >> >> >> >>For more information, send mail to [log in to unmask] with the message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >>                http://listserv.brown.edu/ped-em-l.html > > > Fergus Thornton > read my blog @ http://docdownunder.wordpress.com > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: >                 http://listserv.brown.edu/ped-em-l.html > > > > > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: >                 http://listserv.brown.edu/ped-em-l.html > For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
I agree with you about shortening the course of disease. I disagree that we should lower ourselves so we are practicing at the lowest common denominator. We need to educate our parents (and administrators) about the risks and benefits of medications. Otherwise, we should just put a large vat of amoxicillin in our waiting rooms and let parents decide when they want antibiotics. James Chamberlain, MD Division Chief, Emergency Medicine Children's National Medical Center 111 Michigan Avenue, NW Washington, DC 20010 202.476.3253 (O) 202.476.3573 (F) 202.476.5433 (Emergency Access) -----Original Message----- From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Dave Smith Sent: Tuesday, June 01, 2010 4:29 PM To: [log in to unmask] Subject: Strep--Other Considerations I want to play devil's advocate for a moment on another set of perspectives: 1.  What is the impact of not treating in terms of outcomes not considered by studies? What I mean by this is that it is all well and good to pound the table and hold up the studies and say, "Best practice says I don't need to test/treat your 2 year old son, Mrs. Smith," but then, how often does Mrs. Smith go to the urgent care down the road where they invariably see a febrile toddler, order blood, urine and a chest xray, and give Rocephin?  Even if she goes to her PMD the next day and they simply do a strep and treat (which I think most PMD's would do despite our urgings to the contrary), she's now incurred another visit to another medical provider, increasing overall costs in the process.  In the former case, the child undergoes a while slew of tests and a treatment we could have prevented.  As I like to say, Evidence-Based Medicine is the beginning of wisdom, not the entirity of it.  We also have to practice "realistic medicine" ."  Over-adherence to dogma may lead to parents seeking other outlets that end up doing far worse  than a script for PenVK.  Writing that script in some (many?) cases would thus be better practice than what the child ended up with even though it may not have been "best practice." 2.  We live in a world of Press-Gainey If your hospital administrators are like ours, they don't really care about the best-practice guidelines...just the satisfaction scores.  When surveys come back giving the doctor a series of 1's because they doctor "didn't do anything about my child's strep throat and I had to go to an urgent care" they want to know what we are doing to improve our scores.  Telling them that strep only gets better a day earlier with treatment and the child wasn't in an age range for rheumatic fever so it didn't matter isn't something they care about.  That's how one ends up with language added to one's contract tying incentives and penalties to Press-Gainey performance. 3.  What's a day worth to a parent/child? When your child is sick, would you like him to be better a day earlier?  As a parent of four, I would have to say my answer is yes.  Most parents I see would say yes as well.  That extra day could be two extra days in some cases and we have no way of knowing for sure...it could also be zero, but few parents would see that as an issue if there is a good chance the illness could be one or two days shorter.  For parents who are working, sometimes in positions where taking more sick days could mean not advancing or at the very least, being seen as unreliable because they are always out with "kid issues," that extra day might mean a lot.  So when we say, "It's not worthwhile because they only get better a day earlier at best," we are making a value judgement about the worth of a day of wellness and the value of the parents' time. As I said, just playing devil's advocate.  I tend to agree in principle with what others have written in this thread.  But we must always remember that there are times when we still may be doing better care, given the balance of all the issues at hand, when we give a little ground on "best care." Dave Smith, MD For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
I am a general pediatrician with nearly 30 years of experience. Pardon me, but I bristle at some of the discussion relating to treating and testing for streptococcal infections in children. GAS pharyngitis is not necessarily the benign self-limited illness that some seem to feel it is. Go back and review pediatric texts from the 19th century and death rates of up to 30% were described in scarlet fever epidemics. Death could occur due to exsanguination as soft tissue infection of the anterior neck eroded into great vessels. My crystal ball has never worked well and I seem never to be able to predict who will get a peritonsillar abscess and who will not. Say what you may, antibiotics work for GAS. Children can be significantly ill for several days and are better in a day and normal in two days with a few doses of an inexpensive antibiotic. Perhaps we are not preventing many cases of rhemumatic heart disease, but our patients get better more quickly. They return to school more quickly and their parents get back to work. The societal savings are no doubt significant. Does symptomatic GAS pharyngitis occur in children less than age two? Without a doubt. I see it infrequently but blindly asserting that it doesn't because somebody said it doesn't will lead to errors, unavoidably. I have seen GAS in one year old's and even in an infant in the first two weeks of life who was significantly ill and whose mother had GAS pharyngitis. Choose your victims carefully for testing but if you never look, you will never know. I concede that blanket testing of febrile toddlers by midlevel providers will lead to overdiagnosis but that is an entirely separate issue. Too many times it seems that we are prejudiced against our smallest patients. Some are suggesting not treating children with GAS pharyngitis because of a lack of risk of rheumatic fever and its usual benign course. More suggest not treating ear infections in children. What would you do if you were ill, took time off work, had a painful ear or GAS and your provider suggested observation with treatment in a few days if things didn't improve spontaneously? I am betting you would be looking for a new physician. Yet that is what the current trend seems to be. This is not an issue of overuse of antibiotics. If we could prevent the use of antibiotics for colds and "tonsilitis" and "bronchitis" and eliminate the inaccurate diagnosis of otitis in a febrile child with a "pink ear" the problem would be solved. How many subscribers of this list use pneumatic otoscopy routinely? The vast majority of the time when I evaluate children with "otitis" for their persistent high fevers, they h!  ave clean ears. Those children seen in emergency rooms previously were not appropriately examined and many times have huge amounts of cerumen that someone has miraculously looked right through. Part of what I pledged to do as a physician was try to help people. Over the years I have learned that s__t does happen. Withholding treatment for GAS is an invitation to get your shoes dirty and is a disservice to your patients. Scott Nau, MD Cedar Rapids, IA For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
"Primum non nocere" Giving a course of Ab with a high likelihood of an adverse reaction for <24hr sooner relief violates this. Many of you seem to be looking at this from the perspective of one child (yours!) but multiply this by 10,000/day to get a sense of the unnecessary antibiotics given in the US daily. This is difficult to justify. I'm sorry your kid has one extra day of a sore throat but really . . . . is it worth deluging the world with more antibiotics? -----Original Message----- >From: "Chamberlain, Jim" <[log in to unmask]> >Sent: Jun 1, 2010 10:51 PM >To: [log in to unmask] >Subject: Re: Strep--Other Considerations > >I agree with you about shortening the course of disease. > >I disagree that we should lower ourselves so we are practicing at the lowest common denominator. We need to educate our parents (and administrators) about the risks and benefits of medications. Otherwise, we should just put a large vat of amoxicillin in our waiting rooms and let parents decide when they want antibiotics. > >James Chamberlain, MD >Division Chief, Emergency Medicine >Children's National Medical Center >111 Michigan Avenue, NW >Washington, DC 20010 > >202.476.3253 (O) >202.476.3573 (F) >202.476.5433 (Emergency Access) > >-----Original Message----- >From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Dave Smith >Sent: Tuesday, June 01, 2010 4:29 PM >To: [log in to unmask] >Subject: Strep--Other Considerations > >I want to play devil's advocate for a moment on another set of perspectives: > >1. What is the impact of not treating in terms of outcomes not considered by studies? > >What I mean by this is that it is all well and good to pound the table and hold up the studies and say, "Best practice says I don't need to test/treat your 2 year old son, Mrs. Smith," but then, how often does Mrs. Smith go to the urgent care down the road where they invariably see a febrile toddler, order blood, urine and a chest xray, and give Rocephin? Even if she goes to her PMD the next day and they simply do a strep and treat (which I think most PMD's would do despite our urgings to the contrary), she's now incurred another visit to another medical provider, increasing overall costs in the process. In the former case, the child undergoes a while slew of tests and a treatment we could have prevented. As I like to say, Evidence-Based Medicine is the beginning of wisdom, not the entirity of it. We also have to practice "realistic medicine" ." Over-adherence to dogma may lead to parents seeking other outlets that end up doing far worse > than a script for PenVK. Writing that script in some (many?) cases would thus be better practice than what the child ended up with even though it may not have been "best practice." > >2. We live in a world of Press-Gainey > >If your hospital administrators are like ours, they don't really care about the best-practice guidelines...just the satisfaction scores. When surveys come back giving the doctor a series of 1's because they doctor "didn't do anything about my child's strep throat and I had to go to an urgent care" they want to know what we are doing to improve our scores. Telling them that strep only gets better a day earlier with treatment and the child wasn't in an age range for rheumatic fever so it didn't matter isn't something they care about. That's how one ends up with language added to one's contract tying incentives and penalties to Press-Gainey performance. > >3. What's a day worth to a parent/child? > >When your child is sick, would you like him to be better a day earlier? As a parent of four, I would have to say my answer is yes. Most parents I see would say yes as well. That extra day could be two extra days in some cases and we have no way of knowing for sure...it could also be zero, but few parents would see that as an issue if there is a good chance the illness could be one or two days shorter. For parents who are working, sometimes in positions where taking more sick days could mean not advancing or at the very least, being seen as unreliable because they are always out with "kid issues," that extra day might mean a lot. So when we say, "It's not worthwhile because they only get better a day earlier at best," we are making a value judgement about the worth of a day of wellness and the value of the parents' time. > >As I said, just playing devil's advocate. I tend to agree in principle with what others have written in this thread. But we must always remember that there are times when we still may be doing better care, given the balance of all the issues at hand, when we give a little ground on "best care." > > >Dave Smith, MD > > > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html >Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended >recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. >If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
OK, I've stayed out of this, in part because I agreed with Kevin Powell's comments and didn't want to be redundant, but seriously? When I start to feel streppy because some kid I did a strep test on coughs in my face, I am thrilled when the swab they do at employee health comes back positive. Thanks to the wonders of post-1943 medicine, I know I'll be feeling better in 12 hours and don't need to try to swap my shift the next day, know I will be productive again, know I can manage my own contagion. And of course I take antibiotics! I do lots of pain drops for viral otitis, and am scrupulously parsimonious even when parents of adenoviral children wail and get in my face. I swab children less than three years once or twice a year, I quote the red book, and even when they have exudates and a positive family contact if the rapid is negative, too bad: no antibiotics for you. But in the face of a positive bacterial contagion, the "high likelihood" of an adverse reaction doesn't stop me from gratefully getting treatment myself; bacterial illness is what antibiotics are for. I fight the good fight against antibiotics for viral illnesses on a daily basis, but good heavens, if I have strep, DELUGE me, and that goes double for the patients who entrust their time, health, comfort, and money in me. Double penicillin latte for me, please. -Amy Fergus Thornton <[log in to unmask]> writes: >"Primum non nocere" > >Giving a course of Ab with a high likelihood of an adverse reaction for ><24hr sooner relief >violates this. Many of you seem to be looking at this from the >perspective of one child (yours!) but multiply this by 10,000/day to get >a sense of the unnecessary antibiotics given in the US daily. This is >difficult to justify. I'm sorry your kid has one extra day of a sore >throat but really . . . . is it worth deluging the world with more >antibiotics? > >-----Original Message----- >>From: "Chamberlain, Jim" <[log in to unmask]> >>Sent: Jun 1, 2010 10:51 PM >>To: [log in to unmask] >>Subject: Re: Strep--Other Considerations >> >>I agree with you about shortening the course of disease. >> >>I disagree that we should lower ourselves so we are practicing at the >lowest common denominator. We need to educate our parents (and >administrators) about the risks and benefits of medications. Otherwise, >we should just put a large vat of amoxicillin in our waiting rooms and >let parents decide when they want antibiotics. >> >>James Chamberlain, MD >>Division Chief, Emergency Medicine >>Children's National Medical Center >>111 Michigan Avenue, NW >>Washington, DC 20010 >> >>202.476.3253 (O) >>202.476.3573 (F) >>202.476.5433 (Emergency Access) >> >>-----Original Message----- >>From: Pediatric Emergency Medicine Discussion List >[mailto:[log in to unmask]] On Behalf Of Dave Smith >>Sent: Tuesday, June 01, 2010 4:29 PM >>To: [log in to unmask] >>Subject: Strep--Other Considerations >> >>I want to play devil's advocate for a moment on another set of >perspectives: >> >>1. What is the impact of not treating in terms of outcomes not >considered by studies? >> >>What I mean by this is that it is all well and good to pound the table >and hold up the studies and say, "Best practice says I don't need to >test/treat your 2 year old son, Mrs. Smith," but then, how often does >Mrs. Smith go to the urgent care down the road where they invariably see >a febrile toddler, order blood, urine and a chest xray, and give >Rocephin? Even if she goes to her PMD the next day and they simply do a >strep and treat (which I think most PMD's would do despite our urgings to >the contrary), she's now incurred another visit to another medical >provider, increasing overall costs in the process. In the former >case, the child undergoes a while slew of tests and a treatment we could >have prevented. As I like to say, Evidence-Based Medicine is the >beginning of wisdom, not the entirity of it. We also have to practice >"realistic medicine" ." Over-adherence to dogma may lead to >parents seeking other outlets that end up doing far worse >> than a script for PenVK. Writing that script in some (many?) cases >would thus be better practice than what the child ended up with even >though it may not have been "best practice." >> >>2. We live in a world of Press-Gainey >> >>If your hospital administrators are like ours, they don't really care >about the best-practice guidelines...just the satisfaction scores. When >surveys come back giving the doctor a series of 1's because they doctor >"didn't do anything about my child's strep throat and I had to go to an >urgent care" they want to know what we are doing to improve our scores. >Telling them that strep only gets better a day earlier with treatment and >the child wasn't in an age range for rheumatic fever so it didn't matter >isn't something they care about. That's how one ends up with language >added to one's contract tying incentives and penalties to Press-Gainey >performance. >> >>3. What's a day worth to a parent/child? >> >>When your child is sick, would you like him to be better a day >earlier? As a parent of four, I would have to say my answer is yes. >Most parents I see would say yes as well. That extra day could be two >extra days in some cases and we have no way of knowing for sure...it >could also be zero, but few parents would see that as an issue if there >is a good chance the illness could be one or two days shorter. For >parents who are working, sometimes in positions where taking more sick >days could mean not advancing or at the very least, being seen as >unreliable because they are always out with "kid issues," that extra day >might mean a lot. So when we say, "It's not worthwhile because they >only get better a day earlier at best," we are making a value judgement >about the worth of a day of wellness and the value of the parents' time. >> >>As I said, just playing devil's advocate. I tend to agree in principle >with what others have written in this thread. But we must always >remember that there are times when we still may be doing better care, >given the balance of all the issues at hand, when we give a little ground >on "best care." >> >> >>Dave Smith, MD >> >> >> >> >>For more information, send mail to [log in to unmask] with the >message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html >>Confidentiality Notice: This e-mail message, including any attachments, >is for the sole use of the intended >>recipient(s) and may contain confidential and privileged information. >Any unauthorized review, use, disclosure or distribution is prohibited. >>If you are not the intended recipient, please contact the sender by >reply e-mail and destroy all copies of the original message. >> >>For more information, send mail to [log in to unmask] with the >message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html > > >Fergus Thornton >read my blog @ http://docdownunder.wordpress.com > >For more information, send mail to [log in to unmask] with the >message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Amy Baxter MD Pediatric Emergency Medicine Associates 404 371-1190 For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Another anecdote, but a serious consideration...Group A Strep can cause Necrotizing Fasciitis. A real life story of a surgeon contracting Group A Strep from an infected patient with necrotizing fasciitis. (A fellow surgeon got swabbed for pharyngitis symptoms and was positive for the same strain and treated) This surgeon possibly carried it in his nasopharynx and contaminated macerated skin between his toes with the same strain. He developed toxic shock and necrotizing fasciitis of his leg. Thanks to the wonderful care he received, he survived, leg intact. Jill C Obremskey, MD, MMHC Director Pediatric Emergency Department Fast Track Monroe Caroll Jr Childrens Hospital at Vanderbilt Nashville, TN [log in to unmask] cell: 260-2208 beeper: 835-8396 Assistant: Barbara Crossland 936-3898 -----Original Message----- From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Amy Baxter Sent: Thursday, June 03, 2010 9:19 AM To: [log in to unmask] Subject: Re: Strep--Other Considerations OK, I've stayed out of this, in part because I agreed with Kevin Powell's comments and didn't want to be redundant, but seriously? When I start to feel streppy because some kid I did a strep test on coughs in my face, I am thrilled when the swab they do at employee health comes back positive. Thanks to the wonders of post-1943 medicine, I know I'll be feeling better in 12 hours and don't need to try to swap my shift the next day, know I will be productive again, know I can manage my own contagion. And of course I take antibiotics! I do lots of pain drops for viral otitis, and am scrupulously parsimonious even when parents of adenoviral children wail and get in my face. I swab children less than three years once or twice a year, I quote the red book, and even when they have exudates and a positive family contact if the rapid is negative, too bad: no antibiotics for you. But in the face of a positive bacterial contagion, the "high likelihood" of an adverse reaction doesn't stop me from gratefully getting treatment myself; bacterial illness is what antibiotics are for. I fight the good fight against antibiotics for viral illnesses on a daily basis, but good heavens, if I have strep, DELUGE me, and that goes double for the patients who entrust their time, health, comfort, and money in me. Double penicillin latte for me, please. -Amy Fergus Thornton <[log in to unmask]> writes: >"Primum non nocere" > >Giving a course of Ab with a high likelihood of an adverse reaction for ><24hr sooner relief >violates this. Many of you seem to be looking at this from the >perspective of one child (yours!) but multiply this by 10,000/day to get >a sense of the unnecessary antibiotics given in the US daily. This is >difficult to justify. I'm sorry your kid has one extra day of a sore >throat but really . . . . is it worth deluging the world with more >antibiotics? > >-----Original Message----- >>From: "Chamberlain, Jim" <[log in to unmask]> >>Sent: Jun 1, 2010 10:51 PM >>To: [log in to unmask] >>Subject: Re: Strep--Other Considerations >> >>I agree with you about shortening the course of disease. >> >>I disagree that we should lower ourselves so we are practicing at the >lowest common denominator. We need to educate our parents (and >administrators) about the risks and benefits of medications. Otherwise, >we should just put a large vat of amoxicillin in our waiting rooms and >let parents decide when they want antibiotics. >> >>James Chamberlain, MD >>Division Chief, Emergency Medicine >>Children's National Medical Center >>111 Michigan Avenue, NW >>Washington, DC 20010 >> >>202.476.3253 (O) >>202.476.3573 (F) >>202.476.5433 (Emergency Access) >> >>-----Original Message----- >>From: Pediatric Emergency Medicine Discussion List >[mailto:[log in to unmask]] On Behalf Of Dave Smith >>Sent: Tuesday, June 01, 2010 4:29 PM >>To: [log in to unmask] >>Subject: Strep--Other Considerations >> >>I want to play devil's advocate for a moment on another set of >perspectives: >> >>1.  What is the impact of not treating in terms of outcomes not >considered by studies? >> >>What I mean by this is that it is all well and good to pound the table >and hold up the studies and say, "Best practice says I don't need to >test/treat your 2 year old son, Mrs. Smith," but then, how often does >Mrs. Smith go to the urgent care down the road where they invariably see >a febrile toddler, order blood, urine and a chest xray, and give >Rocephin?  Even if she goes to her PMD the next day and they simply do a >strep and treat (which I think most PMD's would do despite our urgings to >the contrary), she's now incurred another visit to another medical >provider, increasing overall costs in the process.  In the former >case, the child undergoes a while slew of tests and a treatment we could >have prevented.  As I like to say, Evidence-Based Medicine is the >beginning of wisdom, not the entirity of it.  We also have to practice >"realistic medicine" ."  Over-adherence to dogma may lead to >parents seeking other outlets that end up doing far worse >> than a script for PenVK.  Writing that script in some (many?) cases >would thus be better practice than what the child ended up with even >though it may not have been "best practice." >> >>2.  We live in a world of Press-Gainey >> >>If your hospital administrators are like ours, they don't really care >about the best-practice guidelines...just the satisfaction scores.  When >surveys come back giving the doctor a series of 1's because they doctor >"didn't do anything about my child's strep throat and I had to go to an >urgent care" they want to know what we are doing to improve our scores.  >Telling them that strep only gets better a day earlier with treatment and >the child wasn't in an age range for rheumatic fever so it didn't matter >isn't something they care about.  That's how one ends up with language >added to one's contract tying incentives and penalties to Press-Gainey >performance. >> >>3.  What's a day worth to a parent/child? >> >>When your child is sick, would you like him to be better a day >earlier?  As a parent of four, I would have to say my answer is yes.  >Most parents I see would say yes as well.  That extra day could be two >extra days in some cases and we have no way of knowing for sure...it >could also be zero, but few parents would see that as an issue if there >is a good chance the illness could be one or two days shorter.  For >parents who are working, sometimes in positions where taking more sick >days could mean not advancing or at the very least, being seen as >unreliable because they are always out with "kid issues," that extra day >might mean a lot.  So when we say, "It's not worthwhile because they >only get better a day earlier at best," we are making a value judgement >about the worth of a day of wellness and the value of the parents' time. >> >>As I said, just playing devil's advocate.  I tend to agree in principle >with what others have written in this thread.  But we must always >remember that there are times when we still may be doing better care, >given the balance of all the issues at hand, when we give a little ground >on "best care." >> >> >>Dave Smith, MD >> >> >> >> >>For more information, send mail to [log in to unmask] with the >message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html >>Confidentiality Notice: This e-mail message, including any attachments, >is for the sole use of the intended >>recipient(s) and may contain confidential and privileged information. >Any unauthorized review, use, disclosure or distribution is prohibited. >>If you are not the intended recipient, please contact the sender by >reply e-mail and destroy all copies of the original message. >> >>For more information, send mail to [log in to unmask] with the >message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html > > >Fergus Thornton >read my blog @ http://docdownunder.wordpress.com > >For more information, send mail to [log in to unmask] with the >message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Amy Baxter MD Pediatric Emergency Medicine Associates 404 371-1190 For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Dr. Baxter,     Thank you for your personal opinion, but what is the evidence to support your claim. No study has shown that people get better in 12 hours if you treat strep with an antibiotic. I am glad placebo works for you, but I don't think it's a solid foundation for the practice of medicine. I am surprised that you do. Wm Gibson MD ----- Original Message ----- From: "Amy Baxter" <[log in to unmask]> To: <[log in to unmask]> Sent: Thursday, June 03, 2010 9:19 AM Subject: Re: Strep--Other Considerations > OK, I've stayed out of this, in part because I agreed with Kevin Powell's > comments and didn't want to be redundant, but seriously? When I start to > feel streppy because some kid I did a strep test on coughs in my face, I > am thrilled when the swab they do at employee health comes back positive. > Thanks to the wonders of post-1943 medicine, I know I'll be feeling better > in 12 hours and don't need to try to swap my shift the next day, know I > will be productive again, know I can manage my own contagion. And of > course I take antibiotics! > > I do lots of pain drops for viral otitis, and am scrupulously parsimonious > even when parents of adenoviral children wail and get in my face. I swab > children less than three years once or twice a year, I quote the red book, > and even when they have exudates and a positive family contact if the > rapid is negative, too bad: no antibiotics for you. But in the face of a > positive bacterial contagion, the "high likelihood" of an adverse reaction > doesn't stop me from gratefully getting treatment myself; bacterial > illness is what antibiotics are for. I fight the good fight against > antibiotics for viral illnesses on a daily basis, but good heavens, if I > have strep, DELUGE me, and that goes double for the patients who entrust > their time, health, comfort, and money in me. > > Double penicillin latte for me, please. > > -Amy > > Fergus Thornton <[log in to unmask]> writes: >>"Primum non nocere" >> >>Giving a course of Ab with a high likelihood of an adverse reaction for >><24hr sooner relief >>violates this. Many of you seem to be looking at this from the >>perspective of one child (yours!) but multiply this by 10,000/day to get >>a sense of the unnecessary antibiotics given in the US daily. This is >>difficult to justify. I'm sorry your kid has one extra day of a sore >>throat but really . . . . is it worth deluging the world with more >>antibiotics? >> >>-----Original Message----- >>>From: "Chamberlain, Jim" <[log in to unmask]> >>>Sent: Jun 1, 2010 10:51 PM >>>To: [log in to unmask] >>>Subject: Re: Strep--Other Considerations >>> >>>I agree with you about shortening the course of disease. >>> >>>I disagree that we should lower ourselves so we are practicing at the >>lowest common denominator. We need to educate our parents (and >>administrators) about the risks and benefits of medications. Otherwise, >>we should just put a large vat of amoxicillin in our waiting rooms and >>let parents decide when they want antibiotics. >>> >>>James Chamberlain, MD >>>Division Chief, Emergency Medicine >>>Children's National Medical Center >>>111 Michigan Avenue, NW >>>Washington, DC 20010 >>> >>>202.476.3253 (O) >>>202.476.3573 (F) >>>202.476.5433 (Emergency Access) >>> >>>-----Original Message----- >>>From: Pediatric Emergency Medicine Discussion List >>[mailto:[log in to unmask]] On Behalf Of Dave Smith >>>Sent: Tuesday, June 01, 2010 4:29 PM >>>To: [log in to unmask] >>>Subject: Strep--Other Considerations >>> >>>I want to play devil's advocate for a moment on another set of >>perspectives: >>> >>>1. What is the impact of not treating in terms of outcomes not >>considered by studies? >>> >>>What I mean by this is that it is all well and good to pound the table >>and hold up the studies and say, "Best practice says I don't need to >>test/treat your 2 year old son, Mrs. Smith," but then, how often does >>Mrs. Smith go to the urgent care down the road where they invariably see >>a febrile toddler, order blood, urine and a chest xray, and give >>Rocephin? Even if she goes to her PMD the next day and they simply do a >>strep and treat (which I think most PMD's would do despite our urgings to >>the contrary), she's now incurred another visit to another medical >>provider, increasing overall costs in the process. In the former >>case, the child undergoes a while slew of tests and a treatment we could >>have prevented. As I like to say, Evidence-Based Medicine is the >>beginning of wisdom, not the entirity of it. We also have to practice >>"realistic medicine" ." Over-adherence to dogma may lead to >>parents seeking other outlets that end up doing far worse >>> than a script for PenVK. Writing that script in some (many?) cases >>would thus be better practice than what the child ended up with even >>though it may not have been "best practice." >>> >>>2. We live in a world of Press-Gainey >>> >>>If your hospital administrators are like ours, they don't really care >>about the best-practice guidelines...just the satisfaction scores. When >>surveys come back giving the doctor a series of 1's because they doctor >>"didn't do anything about my child's strep throat and I had to go to an >>urgent care" they want to know what we are doing to improve our scores. >>Telling them that strep only gets better a day earlier with treatment and >>the child wasn't in an age range for rheumatic fever so it didn't matter >>isn't something they care about. That's how one ends up with language >>added to one's contract tying incentives and penalties to Press-Gainey >>performance. >>> >>>3. What's a day worth to a parent/child? >>> >>>When your child is sick, would you like him to be better a day >>earlier? As a parent of four, I would have to say my answer is yes. >>Most parents I see would say yes as well. That extra day could be two >>extra days in some cases and we have no way of knowing for sure...it >>could also be zero, but few parents would see that as an issue if there >>is a good chance the illness could be one or two days shorter. For >>parents who are working, sometimes in positions where taking more sick >>days could mean not advancing or at the very least, being seen as >>unreliable because they are always out with "kid issues," that extra day >>might mean a lot. So when we say, "It's not worthwhile because they >>only get better a day earlier at best," we are making a value judgement >>about the worth of a day of wellness and the value of the parents' time. >>> >>>As I said, just playing devil's advocate. I tend to agree in principle >>with what others have written in this thread. But we must always >>remember that there are times when we still may be doing better care, >>given the balance of all the issues at hand, when we give a little ground >>on "best care." >>> >>> >>>Dave Smith, MD >>> >>> >>> >>> >>>For more information, send mail to [log in to unmask] with the >>message: info PED-EM-L >>>The URL for the PED-EM-L Web Page is: >>> http://listserv.brown.edu/ped-em-l.html >>>Confidentiality Notice: This e-mail message, including any attachments, >>is for the sole use of the intended >>>recipient(s) and may contain confidential and privileged information. >>Any unauthorized review, use, disclosure or distribution is prohibited. >>>If you are not the intended recipient, please contact the sender by >>reply e-mail and destroy all copies of the original message. >>> >>>For more information, send mail to [log in to unmask] with the >>message: info PED-EM-L >>>The URL for the PED-EM-L Web Page is: >>> http://listserv.brown.edu/ped-em-l.html >> >> >>Fergus Thornton >>read my blog @ http://docdownunder.wordpress.com >> >>For more information, send mail to [log in to unmask] with the >>message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html > > > > Amy Baxter MD > Pediatric Emergency Medicine Associates > 404 371-1190 > > > For more information, send mail to [log in to unmask] with the > message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
I thoroughly enjoyed Dr. Baxter's post and others. It would be nice that we could exchange our experiences, opinons without deteriorating into personal bashing. The exchanges have led me to a great deal of personal reflection on my practice in general. Over several humbling years of practice I've learned: 1. Absence of evidence is not evidence for absence. 2. It is difficult to call improvement after antibiotic treatment of a bacterial infection a placebo effect. 3. Some "placebo effects" have been due to mechanisms not previously identified. 4. Completely disregarding the patient experience is the best way to get them "doctor hopping", "self doctoring" and foster loss of trust and respect for our noble profession. 5. I don't know everything and neither does the "evidence". Therefore my practice is a combination of science and art. I try to always use my whole brain! LoL Pamela Ross, MD Associate Professor Emergency Medicine & Pediatrics University of Virginia Health System Charlottesville, VA Sent from my Verizon Wireless BlackBerry -----Original Message----- From: William Gibson <[log in to unmask]> Date: Thu, 3 Jun 2010 11:44:36 To: <[log in to unmask]> Subject: Re: Strep--Other Considerations Dr. Baxter,     Thank you for your personal opinion, but what is the evidence to support your claim. No study has shown that people get better in 12 hours if you treat strep with an antibiotic. I am glad placebo works for you, but I don't think it's a solid foundation for the practice of medicine. I am surprised that you do. Wm Gibson MD ----- Original Message ----- From: "Amy Baxter" <[log in to unmask]> To: <[log in to unmask]> Sent: Thursday, June 03, 2010 9:19 AM Subject: Re: Strep--Other Considerations > OK, I've stayed out of this, in part because I agreed with Kevin Powell's > comments and didn't want to be redundant, but seriously? When I start to > feel streppy because some kid I did a strep test on coughs in my face, I > am thrilled when the swab they do at employee health comes back positive. > Thanks to the wonders of post-1943 medicine, I know I'll be feeling better > in 12 hours and don't need to try to swap my shift the next day, know I > will be productive again, know I can manage my own contagion. And of > course I take antibiotics! > > I do lots of pain drops for viral otitis, and am scrupulously parsimonious > even when parents of adenoviral children wail and get in my face. I swab > children less than three years once or twice a year, I quote the red book, > and even when they have exudates and a positive family contact if the > rapid is negative, too bad: no antibiotics for you. But in the face of a > positive bacterial contagion, the "high likelihood" of an adverse reaction > doesn't stop me from gratefully getting treatment myself; bacterial > illness is what antibiotics are for. I fight the good fight against > antibiotics for viral illnesses on a daily basis, but good heavens, if I > have strep, DELUGE me, and that goes double for the patients who entrust > their time, health, comfort, and money in me. > > Double penicillin latte for me, please. > > -Amy > > Fergus Thornton <[log in to unmask]> writes: >>"Primum non nocere" >> >>Giving a course of Ab with a high likelihood of an adverse reaction for >><24hr sooner relief >>violates this. Many of you seem to be looking at this from the >>perspective of one child (yours!) but multiply this by 10,000/day to get >>a sense of the unnecessary antibiotics given in the US daily. This is >>difficult to justify. I'm sorry your kid has one extra day of a sore >>throat but really . . . . is it worth deluging the world with more >>antibiotics? >> >>-----Original Message----- >>>From: "Chamberlain, Jim" <[log in to unmask]> >>>Sent: Jun 1, 2010 10:51 PM >>>To: [log in to unmask] >>>Subject: Re: Strep--Other Considerations >>> >>>I agree with you about shortening the course of disease. >>> >>>I disagree that we should lower ourselves so we are practicing at the >>lowest common denominator. We need to educate our parents (and >>administrators) about the risks and benefits of medications. Otherwise, >>we should just put a large vat of amoxicillin in our waiting rooms and >>let parents decide when they want antibiotics. >>> >>>James Chamberlain, MD >>>Division Chief, Emergency Medicine >>>Children's National Medical Center >>>111 Michigan Avenue, NW >>>Washington, DC 20010 >>> >>>202.476.3253 (O) >>>202.476.3573 (F) >>>202.476.5433 (Emergency Access) >>> >>>-----Original Message----- >>>From: Pediatric Emergency Medicine Discussion List >>[mailto:[log in to unmask]] On Behalf Of Dave Smith >>>Sent: Tuesday, June 01, 2010 4:29 PM >>>To: [log in to unmask] >>>Subject: Strep--Other Considerations >>> >>>I want to play devil's advocate for a moment on another set of >>perspectives: >>> >>>1. What is the impact of not treating in terms of outcomes not >>considered by studies? >>> >>>What I mean by this is that it is all well and good to pound the table >>and hold up the studies and say, "Best practice says I don't need to >>test/treat your 2 year old son, Mrs. Smith," but then, how often does >>Mrs. Smith go to the urgent care down the road where they invariably see >>a febrile toddler, order blood, urine and a chest xray, and give >>Rocephin? Even if she goes to her PMD the next day and they simply do a >>strep and treat (which I think most PMD's would do despite our urgings to >>the contrary), she's now incurred another visit to another medical >>provider, increasing overall costs in the process. In the former >>case, the child undergoes a while slew of tests and a treatment we could >>have prevented. As I like to say, Evidence-Based Medicine is the >>beginning of wisdom, not the entirity of it. We also have to practice >>"realistic medicine" ." Over-adherence to dogma may lead to >>parents seeking other outlets that end up doing far worse >>> than a script for PenVK. Writing that script in some (many?) cases >>would thus be better practice than what the child ended up with even >>though it may not have been "best practice." >>> >>>2. We live in a world of Press-Gainey >>> >>>If your hospital administrators are like ours, they don't really care >>about the best-practice guidelines...just the satisfaction scores. When >>surveys come back giving the doctor a series of 1's because they doctor >>"didn't do anything about my child's strep throat and I had to go to an >>urgent care" they want to know what we are doing to improve our scores. >>Telling them that strep only gets better a day earlier with treatment and >>the child wasn't in an age range for rheumatic fever so it didn't matter >>isn't something they care about. That's how one ends up with language >>added to one's contract tying incentives and penalties to Press-Gainey >>performance. >>> >>>3. What's a day worth to a parent/child? >>> >>>When your child is sick, would you like him to be better a day >>earlier? As a parent of four, I would have to say my answer is yes. >>Most parents I see would say yes as well. That extra day could be two >>extra days in some cases and we have no way of knowing for sure...it >>could also be zero, but few parents would see that as an issue if there >>is a good chance the illness could be one or two days shorter. For >>parents who are working, sometimes in positions where taking more sick >>days could mean not advancing or at the very least, being seen as >>unreliable because they are always out with "kid issues," that extra day >>might mean a lot. So when we say, "It's not worthwhile because they >>only get better a day earlier at best," we are making a value judgement >>about the worth of a day of wellness and the value of the parents' time. >>> >>>As I said, just playing devil's advocate. I tend to agree in principle >>with what others have written in this thread. But we must always >>remember that there are times when we still may be doing better care, >>given the balance of all the issues at hand, when we give a little ground >>on "best care." >>> >>> >>>Dave Smith, MD >>> >>> >>> >>> >>>For more information, send mail to [log in to unmask] with the >>message: info PED-EM-L >>>The URL for the PED-EM-L Web Page is: >>> http://listserv.brown.edu/ped-em-l.html >>>Confidentiality Notice: This e-mail message, including any attachments, >>is for the sole use of the intended >>>recipient(s) and may contain confidential and privileged information. >>Any unauthorized review, use, disclosure or distribution is prohibited. >>>If you are not the intended recipient, please contact the sender by >>reply e-mail and destroy all copies of the original message. >>> >>>For more information, send mail to [log in to unmask] with the >>message: info PED-EM-L >>>The URL for the PED-EM-L Web Page is: >>> http://listserv.brown.edu/ped-em-l.html >> >> >>Fergus Thornton >>read my blog @ http://docdownunder.wordpress.com >> >>For more information, send mail to [log in to unmask] with the >>message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html > > > > Amy Baxter MD > Pediatric Emergency Medicine Associates > 404 371-1190 > > > For more information, send mail to [log in to unmask] with the > message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
We all acknowledge that there is over prescribing of antibiotics and this contributes to resistance. The prescriptions we should be focused on are the clearly viral diseases for which some physicians seem compelled to give antibiotics as if they were anti-pyretics. Red ears come to mind. But we don't need to withhold antibiotics from patients with a documented bacterial disease in which providing treatment has documented benefit (reduction in length of illness even if you chose to ignore the benefits of reducing Rheumatic Fever and suppurative complications because the NNT is too high). And I don't believe that there is a "high likelihood of an adverse reaction" from a course of Pen VK. ________________________________________________________ David F. Soglin, M.D. Chairman, Department of Pediatrics John H. Stroger, Jr. Hospital of Cook County (Cook County Hospital) Cook County Health and Hospitals System 1900 W Polk Suite 1100 Chicago, IL 60612 Telephone: (312)864-4506 Fax: (312)864-9720 Quoting "Pamela Ross, MD" <[log in to unmask]>: > I thoroughly enjoyed Dr. Baxter's post and others. > > It would be nice that we could exchange our experiences, opinons > without deteriorating into personal bashing. > > The exchanges have led me to a great deal of personal reflection on > my practice in general. > > Over several humbling years of practice I've learned: > 1. Absence of evidence is not evidence for absence. > 2. It is difficult to call improvement after antibiotic treatment > of a bacterial infection a placebo effect. > 3. Some "placebo effects" have been due to mechanisms not previously > identified. > 4. Completely disregarding the patient experience is the best way to > get them "doctor hopping", "self doctoring" and foster loss of > trust and respect for our noble profession. > 5. I don't know everything and neither does the "evidence". > Therefore my practice is a combination of science and art. I try to > always use my whole brain! LoL > > Pamela Ross, MD > Associate Professor > Emergency Medicine & Pediatrics > University of Virginia Health System > Charlottesville, VA > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: William Gibson <[log in to unmask]> > Date: Thu, 3 Jun 2010 11:44:36 > To: <[log in to unmask]> > Subject: Re: Strep--Other Considerations > > Dr. Baxter, > Thank you for your personal opinion, but what is the evidence to support > your claim. No study has shown that people get better in 12 hours if you > treat strep with an antibiotic. I am glad placebo works for you, but I > don't think it's a solid foundation for the practice of medicine. I am > surprised that you do. > > Wm Gibson MD > ----- Original Message ----- > From: "Amy Baxter" <[log in to unmask]> > To: <[log in to unmask]> > Sent: Thursday, June 03, 2010 9:19 AM > Subject: Re: Strep--Other Considerations > > >> OK, I've stayed out of this, in part because I agreed with Kevin Powell's >> comments and didn't want to be redundant, but seriously? When I start to >> feel streppy because some kid I did a strep test on coughs in my face, I >> am thrilled when the swab they do at employee health comes back positive. >> Thanks to the wonders of post-1943 medicine, I know I'll be feeling better >> in 12 hours and don't need to try to swap my shift the next day, know I >> will be productive again, know I can manage my own contagion. And of >> course I take antibiotics! >> >> I do lots of pain drops for viral otitis, and am scrupulously parsimonious >> even when parents of adenoviral children wail and get in my face. I swab >> children less than three years once or twice a year, I quote the red book, >> and even when they have exudates and a positive family contact if the >> rapid is negative, too bad: no antibiotics for you. But in the face of a >> positive bacterial contagion, the "high likelihood" of an adverse reaction >> doesn't stop me from gratefully getting treatment myself; bacterial >> illness is what antibiotics are for. I fight the good fight against >> antibiotics for viral illnesses on a daily basis, but good heavens, if I >> have strep, DELUGE me, and that goes double for the patients who entrust >> their time, health, comfort, and money in me. >> >> Double penicillin latte for me, please. >> >> -Amy >> >> Fergus Thornton <[log in to unmask]> writes: >>> "Primum non nocere" >>> >>> Giving a course of Ab with a high likelihood of an adverse reaction for >>> <24hr sooner relief >>> violates this. Many of you seem to be looking at this from the >>> perspective of one child (yours!) but multiply this by 10,000/day to get >>> a sense of the unnecessary antibiotics given in the US daily. This is >>> difficult to justify. I'm sorry your kid has one extra day of a sore >>> throat but really . . . . is it worth deluging the world with more >>> antibiotics? >>> >>> -----Original Message----- >>>> From: "Chamberlain, Jim" <[log in to unmask]> >>>> Sent: Jun 1, 2010 10:51 PM >>>> To: [log in to unmask] >>>> Subject: Re: Strep--Other Considerations >>>> >>>> I agree with you about shortening the course of disease. >>>> >>>> I disagree that we should lower ourselves so we are practicing at the >>> lowest common denominator. We need to educate our parents (and >>> administrators) about the risks and benefits of medications. Otherwise, >>> we should just put a large vat of amoxicillin in our waiting rooms and >>> let parents decide when they want antibiotics. >>>> >>>> James Chamberlain, MD >>>> Division Chief, Emergency Medicine >>>> Children's National Medical Center >>>> 111 Michigan Avenue, NW >>>> Washington, DC 20010 >>>> >>>> 202.476.3253 (O) >>>> 202.476.3573 (F) >>>> 202.476.5433 (Emergency Access) >>>> >>>> -----Original Message----- >>>> From: Pediatric Emergency Medicine Discussion List >>> [mailto:[log in to unmask]] On Behalf Of Dave Smith >>>> Sent: Tuesday, June 01, 2010 4:29 PM >>>> To: [log in to unmask] >>>> Subject: Strep--Other Considerations >>>> >>>> I want to play devil's advocate for a moment on another set of >>> perspectives: >>>> >>>> 1. What is the impact of not treating in terms of outcomes not >>> considered by studies? >>>> >>>> What I mean by this is that it is all well and good to pound the table >>> and hold up the studies and say, "Best practice says I don't need to >>> test/treat your 2 year old son, Mrs. Smith," but then, how often does >>> Mrs. Smith go to the urgent care down the road where they invariably see >>> a febrile toddler, order blood, urine and a chest xray, and give >>> Rocephin? Even if she goes to her PMD the next day and they simply do a >>> strep and treat (which I think most PMD's would do despite our urgings to >>> the contrary), she's now incurred another visit to another medical >>> provider, increasing overall costs in the process. In the former >>> case, the child undergoes a while slew of tests and a treatment we could >>> have prevented. As I like to say, Evidence-Based Medicine is the >>> beginning of wisdom, not the entirity of it. We also have to practice >>> "realistic medicine" ." Over-adherence to dogma may lead to >>> parents seeking other outlets that end up doing far worse >>>> than a script for PenVK. Writing that script in some (many?) cases >>> would thus be better practice than what the child ended up with even >>> though it may not have been "best practice." >>>> >>>> 2. We live in a world of Press-Gainey >>>> >>>> If your hospital administrators are like ours, they don't really care >>> about the best-practice guidelines...just the satisfaction scores. When >>> surveys come back giving the doctor a series of 1's because they doctor >>> "didn't do anything about my child's strep throat and I had to go to an >>> urgent care" they want to know what we are doing to improve our scores. >>> Telling them that strep only gets better a day earlier with treatment and >>> the child wasn't in an age range for rheumatic fever so it didn't matter >>> isn't something they care about. That's how one ends up with language >>> added to one's contract tying incentives and penalties to Press-Gainey >>> performance. >>>> >>>> 3. What's a day worth to a parent/child? >>>> >>>> When your child is sick, would you like him to be better a day >>> earlier? As a parent of four, I would have to say my answer is yes. >>> Most parents I see would say yes as well. That extra day could be two >>> extra days in some cases and we have no way of knowing for sure...it >>> could also be zero, but few parents would see that as an issue if there >>> is a good chance the illness could be one or two days shorter. For >>> parents who are working, sometimes in positions where taking more sick >>> days could mean not advancing or at the very least, being seen as >>> unreliable because they are always out with "kid issues," that extra day >>> might mean a lot. So when we say, "It's not worthwhile because they >>> only get better a day earlier at best," we are making a value judgement >>> about the worth of a day of wellness and the value of the parents' time. >>>> >>>> As I said, just playing devil's advocate. I tend to agree in principle >>> with what others have written in this thread. But we must always >>> remember that there are times when we still may be doing better care, >>> given the balance of all the issues at hand, when we give a little ground >>> on "best care." >>>> >>>> >>>> Dave Smith, MD >>>> >>>> >>>> >>>> >>>> For more information, send mail to [log in to unmask] with the >>> message: info PED-EM-L >>>> The URL for the PED-EM-L Web Page is: >>>> http://listserv.brown.edu/ped-em-l.html >>>> Confidentiality Notice: This e-mail message, including any attachments, >>> is for the sole use of the intended >>>> recipient(s) and may contain confidential and privileged information. >>> Any unauthorized review, use, disclosure or distribution is prohibited. >>>> If you are not the intended recipient, please contact the sender by >>> reply e-mail and destroy all copies of the original message. >>>> >>>> For more information, send mail to [log in to unmask] with the >>> message: info PED-EM-L >>>> The URL for the PED-EM-L Web Page is: >>>> http://listserv.brown.edu/ped-em-l.html >>> >>> >>> Fergus Thornton >>> read my blog @ http://docdownunder.wordpress.com >>> >>> For more information, send mail to [log in to unmask] with the >>> message: info PED-EM-L >>> The URL for the PED-EM-L Web Page is: >>> http://listserv.brown.edu/ped-em-l.html >> >> >> >> Amy Baxter MD >> Pediatric Emergency Medicine Associates >> 404 371-1190 >> >> >> For more information, send mail to [log in to unmask] with the >> message: info PED-EM-L >> The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html >> > > For more information, send mail to [log in to unmask] with > the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > > For more information, send mail to [log in to unmask] with > the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
AND (while we're on anecdotes) ... periorbital cellulitis! I had a toddler recently who dropped his sippy cup onto his left eye causing a small abrasion (which the parents didn't think much of at the time), who then presented to the ED several days later highly febrile with a very severe periorbital cellulitis, culture of which (from the abrasion area, which was mildly purulent) grew Group A Strep. His examination in the ED also revealed exudative tonsillitis, Quick Strep positive (so at the time of admission I strongly suspected Group A strep as the cause of his periorbital cellulitis). Peter Auerbach, MD, FAAEM, FAAP > Date: Thu, 3 Jun 2010 11:26:38 -0500 > From: [log in to unmask] > Subject: Re: Strep Outcomes--Necrotizing Fasciitis > To: [log in to unmask] > > Another anecdote, but a serious consideration...Group A Strep can cause Necrotizing Fasciitis. A real life story of a surgeon contracting Group A Strep from an infected patient with necrotizing fasciitis. (A fellow surgeon got swabbed for pharyngitis symptoms and was positive for the same strain and treated) This surgeon possibly carried it in his nasopharynx and contaminated macerated skin between his toes with the same strain. He developed toxic shock and necrotizing fasciitis of his leg. Thanks to the wonderful care he received, he survived, leg intact. > > Jill C Obremskey, MD, MMHC > Director Pediatric Emergency Department Fast Track > Monroe Caroll Jr Childrens Hospital at Vanderbilt > Nashville, TN > [log in to unmask] > cell: 260-2208 > beeper: 835-8396 > Assistant: Barbara Crossland 936-3898 > > -----Original Message----- > From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Amy Baxter > Sent: Thursday, June 03, 2010 9:19 AM > To: [log in to unmask] > Subject: Re: Strep--Other Considerations > > OK, I've stayed out of this, in part because I agreed with Kevin Powell's > comments and didn't want to be redundant, but seriously? When I start to > feel streppy because some kid I did a strep test on coughs in my face, I > am thrilled when the swab they do at employee health comes back positive. > Thanks to the wonders of post-1943 medicine, I know I'll be feeling better > in 12 hours and don't need to try to swap my shift the next day, know I > will be productive again, know I can manage my own contagion. And of > course I take antibiotics! > > I do lots of pain drops for viral otitis, and am scrupulously parsimonious > even when parents of adenoviral children wail and get in my face. I swab > children less than three years once or twice a year, I quote the red book, > and even when they have exudates and a positive family contact if the > rapid is negative, too bad: no antibiotics for you. But in the face of a > positive bacterial contagion, the "high likelihood" of an adverse reaction > doesn't stop me from gratefully getting treatment myself; bacterial > illness is what antibiotics are for. I fight the good fight against > antibiotics for viral illnesses on a daily basis, but good heavens, if I > have strep, DELUGE me, and that goes double for the patients who entrust > their time, health, comfort, and money in me. > > Double penicillin latte for me, please. > > -Amy > > Fergus Thornton <[log in to unmask]> writes: > >"Primum non nocere" > > > >Giving a course of Ab with a high likelihood of an adverse reaction for > ><24hr sooner relief > >violates this. Many of you seem to be looking at this from the > >perspective of one child (yours!) but multiply this by 10,000/day to get > >a sense of the unnecessary antibiotics given in the US daily. This is > >difficult to justify. I'm sorry your kid has one extra day of a sore > >throat but really . . . . is it worth deluging the world with more > >antibiotics? > > > >-----Original Message----- > >>From: "Chamberlain, Jim" <[log in to unmask]> > >>Sent: Jun 1, 2010 10:51 PM > >>To: [log in to unmask] > >>Subject: Re: Strep--Other Considerations > >> > >>I agree with you about shortening the course of disease. > >> > >>I disagree that we should lower ourselves so we are practicing at the > >lowest common denominator. We need to educate our parents (and > >administrators) about the risks and benefits of medications. Otherwise, > >we should just put a large vat of amoxicillin in our waiting rooms and > >let parents decide when they want antibiotics. > >> > >>James Chamberlain, MD > >>Division Chief, Emergency Medicine > >>Children's National Medical Center > >>111 Michigan Avenue, NW > >>Washington, DC 20010 > >> > >>202.476.3253 (O) > >>202.476.3573 (F) > >>202.476.5433 (Emergency Access) > >> > >>-----Original Message----- > >>From: Pediatric Emergency Medicine Discussion List > >[mailto:[log in to unmask]] On Behalf Of Dave Smith > >>Sent: Tuesday, June 01, 2010 4:29 PM > >>To: [log in to unmask] > >>Subject: Strep--Other Considerations > >> > >>I want to play devil's advocate for a moment on another set of > >perspectives: > >> > >>1. What is the impact of not treating in terms of outcomes not > >considered by studies? > >> > >>What I mean by this is that it is all well and good to pound the table > >and hold up the studies and say, "Best practice says I don't need to > >test/treat your 2 year old son, Mrs. Smith," but then, how often does > >Mrs. Smith go to the urgent care down the road where they invariably see > >a febrile toddler, order blood, urine and a chest xray, and give > >Rocephin? Even if she goes to her PMD the next day and they simply do a > >strep and treat (which I think most PMD's would do despite our urgings to > >the contrary), she's now incurred another visit to another medical > >provider, increasing overall costs in the process. In the former > >case, the child undergoes a while slew of tests and a treatment we could > >have prevented. As I like to say, Evidence-Based Medicine is the > >beginning of wisdom, not the entirity of it. We also have to practice > >"realistic medicine" ." Over-adherence to dogma may lead to > >parents seeking other outlets that end up doing far worse > >> than a script for PenVK. Writing that script in some (many?) cases > >would thus be better practice than what the child ended up with even > >though it may not have been "best practice." > >> > >>2. We live in a world of Press-Gainey > >> > >>If your hospital administrators are like ours, they don't really care > >about the best-practice guidelines...just the satisfaction scores. When > >surveys come back giving the doctor a series of 1's because they doctor > >"didn't do anything about my child's strep throat and I had to go to an > >urgent care" they want to know what we are doing to improve our scores. > >Telling them that strep only gets better a day earlier with treatment and > >the child wasn't in an age range for rheumatic fever so it didn't matter > >isn't something they care about. That's how one ends up with language > >added to one's contract tying incentives and penalties to Press-Gainey > >performance. > >> > >>3. What's a day worth to a parent/child? > >> > >>When your child is sick, would you like him to be better a day > >earlier? As a parent of four, I would have to say my answer is yes. > >Most parents I see would say yes as well. That extra day could be two > >extra days in some cases and we have no way of knowing for sure...it > >could also be zero, but few parents would see that as an issue if there > >is a good chance the illness could be one or two days shorter. For > >parents who are working, sometimes in positions where taking more sick > >days could mean not advancing or at the very least, being seen as > >unreliable because they are always out with "kid issues," that extra day > >might mean a lot. So when we say, "It's not worthwhile because they > >only get better a day earlier at best," we are making a value judgement > >about the worth of a day of wellness and the value of the parents' time. > >> > >>As I said, just playing devil's advocate. I tend to agree in principle > >with what others have written in this thread. But we must always > >remember that there are times when we still may be doing better care, > >given the balance of all the issues at hand, when we give a little ground > >on "best care." > >> > >> > >>Dave Smith, MD > >> > >> > >> > >> > >>For more information, send mail to [log in to unmask] with the > >message: info PED-EM-L > >>The URL for the PED-EM-L Web Page is: > >> http://listserv.brown.edu/ped-em-l.html > >>Confidentiality Notice: This e-mail message, including any attachments, > >is for the sole use of the intended > >>recipient(s) and may contain confidential and privileged information. > >Any unauthorized review, use, disclosure or distribution is prohibited. > >>If you are not the intended recipient, please contact the sender by > >reply e-mail and destroy all copies of the original message. > >> > >>For more information, send mail to [log in to unmask] with the > >message: info PED-EM-L > >>The URL for the PED-EM-L Web Page is: > >> http://listserv.brown.edu/ped-em-l.html > > > > > >Fergus Thornton > >read my blog @ http://docdownunder.wordpress.com > > > >For more information, send mail to [log in to unmask] with the > >message: info PED-EM-L > >The URL for the PED-EM-L Web Page is: > > http://listserv.brown.edu/ped-em-l.html > > > > Amy Baxter MD > Pediatric Emergency Medicine Associates > 404 371-1190 > > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Is there evidence that treating strept pharyngitis decreases the incidence of peritonsillar abscess? If so, wouldnt that be a good reason to treat it too. Have you or your child ever had their throat cut open to drain one? don On Jun 3, 2010, at 1:02 PM, Peter Auerbach wrote: > AND (while we're on anecdotes) ... periorbital cellulitis! > > > I had a toddler recently who dropped his sippy cup onto his left eye > causing > > a small abrasion (which the parents didn't think much of at the time), > who > > then presented to the ED several days later highly febrile with a very severe > periorbital > > cellulitis, culture of which (from the abrasion area, which was mildly > > purulent) grew Group A Strep. > > > His examination in the ED also revealed exudative tonsillitis, Quick > Strep > > positive (so at the time of admission I strongly suspected Group A > > strep as the cause of his periorbital cellulitis). > > > > Peter Auerbach, MD, FAAEM, FAAP > > >> Date: Thu, 3 Jun 2010 11:26:38 -0500 >> From: [log in to unmask] >> Subject: Re: Strep Outcomes--Necrotizing Fasciitis >> To: [log in to unmask] >> >> Another anecdote, but a serious consideration...Group A Strep can cause Necrotizing Fasciitis. A real life story of a surgeon contracting Group A Strep from an infected patient with necrotizing fasciitis. (A fellow surgeon got swabbed for pharyngitis symptoms and was positive for the same strain and treated) This surgeon possibly carried it in his nasopharynx and contaminated macerated skin between his toes with the same strain. He developed toxic shock and necrotizing fasciitis of his leg. Thanks to the wonderful care he received, he survived, leg intact. >> >> Jill C Obremskey, MD, MMHC >> Director Pediatric Emergency Department Fast Track >> Monroe Caroll Jr Childrens Hospital at Vanderbilt >> Nashville, TN >> [log in to unmask] >> cell: 260-2208 >> beeper: 835-8396 >> Assistant: Barbara Crossland 936-3898 >> >> -----Original Message----- >> From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Amy Baxter >> Sent: Thursday, June 03, 2010 9:19 AM >> To: [log in to unmask] >> Subject: Re: Strep--Other Considerations >> >> OK, I've stayed out of this, in part because I agreed with Kevin Powell's >> comments and didn't want to be redundant, but seriously? When I start to >> feel streppy because some kid I did a strep test on coughs in my face, I >> am thrilled when the swab they do at employee health comes back positive. >> Thanks to the wonders of post-1943 medicine, I know I'll be feeling better >> in 12 hours and don't need to try to swap my shift the next day, know I >> will be productive again, know I can manage my own contagion. And of >> course I take antibiotics! >> >> I do lots of pain drops for viral otitis, and am scrupulously parsimonious >> even when parents of adenoviral children wail and get in my face. I swab >> children less than three years once or twice a year, I quote the red book, >> and even when they have exudates and a positive family contact if the >> rapid is negative, too bad: no antibiotics for you. But in the face of a >> positive bacterial contagion, the "high likelihood" of an adverse reaction >> doesn't stop me from gratefully getting treatment myself; bacterial >> illness is what antibiotics are for. I fight the good fight against >> antibiotics for viral illnesses on a daily basis, but good heavens, if I >> have strep, DELUGE me, and that goes double for the patients who entrust >> their time, health, comfort, and money in me. >> >> Double penicillin latte for me, please. >> >> -Amy >> >> Fergus Thornton <[log in to unmask]> writes: >>> "Primum non nocere" >>> >>> Giving a course of Ab with a high likelihood of an adverse reaction for >>> <24hr sooner relief >>> violates this. Many of you seem to be looking at this from the >>> perspective of one child (yours!) but multiply this by 10,000/day to get >>> a sense of the unnecessary antibiotics given in the US daily. This is >>> difficult to justify. I'm sorry your kid has one extra day of a sore >>> throat but really . . . . is it worth deluging the world with more >>> antibiotics? >>> >>> -----Original Message----- >>>> From: "Chamberlain, Jim" <[log in to unmask]> >>>> Sent: Jun 1, 2010 10:51 PM >>>> To: [log in to unmask] >>>> Subject: Re: Strep--Other Considerations >>>> >>>> I agree with you about shortening the course of disease. >>>> >>>> I disagree that we should lower ourselves so we are practicing at the >>> lowest common denominator. We need to educate our parents (and >>> administrators) about the risks and benefits of medications. Otherwise, >>> we should just put a large vat of amoxicillin in our waiting rooms and >>> let parents decide when they want antibiotics. >>>> >>>> James Chamberlain, MD >>>> Division Chief, Emergency Medicine >>>> Children's National Medical Center >>>> 111 Michigan Avenue, NW >>>> Washington, DC 20010 >>>> >>>> 202.476.3253 (O) >>>> 202.476.3573 (F) >>>> 202.476.5433 (Emergency Access) >>>> >>>> -----Original Message----- >>>> From: Pediatric Emergency Medicine Discussion List >>> [mailto:[log in to unmask]] On Behalf Of Dave Smith >>>> Sent: Tuesday, June 01, 2010 4:29 PM >>>> To: [log in to unmask] >>>> Subject: Strep--Other Considerations >>>> >>>> I want to play devil's advocate for a moment on another set of >>> perspectives: >>>> >>>> 1. What is the impact of not treating in terms of outcomes not >>> considered by studies? >>>> >>>> What I mean by this is that it is all well and good to pound the table >>> and hold up the studies and say, "Best practice says I don't need to >>> test/treat your 2 year old son, Mrs. Smith," but then, how often does >>> Mrs. Smith go to the urgent care down the road where they invariably see >>> a febrile toddler, order blood, urine and a chest xray, and give >>> Rocephin? Even if she goes to her PMD the next day and they simply do a >>> strep and treat (which I think most PMD's would do despite our urgings to >>> the contrary), she's now incurred another visit to another medical >>> provider, increasing overall costs in the process. In the former >>> case, the child undergoes a while slew of tests and a treatment we could >>> have prevented. As I like to say, Evidence-Based Medicine is the >>> beginning of wisdom, not the entirity of it. We also have to practice >>> "realistic medicine" ." Over-adherence to dogma may lead to >>> parents seeking other outlets that end up doing far worse >>>> than a script for PenVK. Writing that script in some (many?) cases >>> would thus be better practice than what the child ended up with even >>> though it may not have been "best practice." >>>> >>>> 2. We live in a world of Press-Gainey >>>> >>>> If your hospital administrators are like ours, they don't really care >>> about the best-practice guidelines...just the satisfaction scores. When >>> surveys come back giving the doctor a series of 1's because they doctor >>> "didn't do anything about my child's strep throat and I had to go to an >>> urgent care" they want to know what we are doing to improve our scores. >>> Telling them that strep only gets better a day earlier with treatment and >>> the child wasn't in an age range for rheumatic fever so it didn't matter >>> isn't something they care about. That's how one ends up with language >>> added to one's contract tying incentives and penalties to Press-Gainey >>> performance. >>>> >>>> 3. What's a day worth to a parent/child? >>>> >>>> When your child is sick, would you like him to be better a day >>> earlier? As a parent of four, I would have to say my answer is yes. >>> Most parents I see would say yes as well. That extra day could be two >>> extra days in some cases and we have no way of knowing for sure...it >>> could also be zero, but few parents would see that as an issue if there >>> is a good chance the illness could be one or two days shorter. For >>> parents who are working, sometimes in positions where taking more sick >>> days could mean not advancing or at the very least, being seen as >>> unreliable because they are always out with "kid issues," that extra day >>> might mean a lot. So when we say, "It's not worthwhile because they >>> only get better a day earlier at best," we are making a value judgement >>> about the worth of a day of wellness and the value of the parents' time. >>>> >>>> As I said, just playing devil's advocate. I tend to agree in principle >>> with what others have written in this thread. But we must always >>> remember that there are times when we still may be doing better care, >>> given the balance of all the issues at hand, when we give a little ground >>> on "best care." >>>> >>>> >>>> Dave Smith, MD >>>> >>>> >>>> >>>> >>>> For more information, send mail to [log in to unmask] with the >>> message: info PED-EM-L >>>> The URL for the PED-EM-L Web Page is: >>>> http://listserv.brown.edu/ped-em-l.html >>>> Confidentiality Notice: This e-mail message, including any attachments, >>> is for the sole use of the intended >>>> recipient(s) and may contain confidential and privileged information. >>> Any unauthorized review, use, disclosure or distribution is prohibited. >>>> If you are not the intended recipient, please contact the sender by >>> reply e-mail and destroy all copies of the original message. >>>> >>>> For more information, send mail to [log in to unmask] with the >>> message: info PED-EM-L >>>> The URL for the PED-EM-L Web Page is: >>>> http://listserv.brown.edu/ped-em-l.html >>> >>> >>> Fergus Thornton >>> read my blog @ http://docdownunder.wordpress.com >>> >>> For more information, send mail to [log in to unmask] with the >>> message: info PED-EM-L >>> The URL for the PED-EM-L Web Page is: >>> http://listserv.brown.edu/ped-em-l.html >> >> >> >> Amy Baxter MD >> Pediatric Emergency Medicine Associates >> 404 371-1190 >> >> >> For more information, send mail to [log in to unmask] with the message: info PED-EM-L >> The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html >> >> For more information, send mail to [log in to unmask] with the message: info PED-EM-L >> The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
I have strep about three times a year since I moved to Atlanta, about once per year before that. SEveral times I have been unable to get to be tested, and I am feverish and miserable and going to sleep at 0830PM until I get to employee health or the doctor to get the swab. I don't take amox unless I know for sure it's strep, but each time this has happened I feel much better within 12 hours of starting antibiotics and the fever goes away. I'm not saying other people get better that fast, although when I've been camp doctor I see similar resolution of strep with abx but not strep negative with no abx. My personal N is about 16. The longest I've been uncomfortable and feverish and miserable before getting the swab is about 4 days. The shortest time is about 5 hours, when I knew I had an exposure and started feeling the symptoms. And, of course, I do wear a mask when I swab now so it's been about 6 months! I'm doing well! How do you feel about treating UTIs in women? Let them fight the symptoms and wait it out since pyelo is uncommon? Thanks for your a priori assessment that I am evidence based! Take care, Amy William Gibson <[log in to unmask]> writes: >Dr. Baxter, > Thank you for your personal opinion, but what is the evidence to >support >your claim. No study has shown that people get better in 12 hours if you >treat strep with an antibiotic. I am glad placebo works for you, but I >don't think it's a solid foundation for the practice of medicine. I am >surprised that you do. > >Wm Gibson MD >----- Original Message ----- >From: "Amy Baxter" <[log in to unmask]> >To: <[log in to unmask]> >Sent: Thursday, June 03, 2010 9:19 AM >Subject: Re: Strep--Other Considerations > > >> OK, I've stayed out of this, in part because I agreed with Kevin >Powell's >> comments and didn't want to be redundant, but seriously? When I start >to >> feel streppy because some kid I did a strep test on coughs in my face, I >> am thrilled when the swab they do at employee health comes back >positive. >> Thanks to the wonders of post-1943 medicine, I know I'll be feeling >better >> in 12 hours and don't need to try to swap my shift the next day, know I >> will be productive again, know I can manage my own contagion. And of >> course I take antibiotics! >> >> I do lots of pain drops for viral otitis, and am scrupulously >parsimonious >> even when parents of adenoviral children wail and get in my face. I >swab >> children less than three years once or twice a year, I quote the red >book, >> and even when they have exudates and a positive family contact if the >> rapid is negative, too bad: no antibiotics for you. But in the face of >a >> positive bacterial contagion, the "high likelihood" of an adverse >reaction >> doesn't stop me from gratefully getting treatment myself; bacterial >> illness is what antibiotics are for. I fight the good fight against >> antibiotics for viral illnesses on a daily basis, but good heavens, if I >> have strep, DELUGE me, and that goes double for the patients who entrust >> their time, health, comfort, and money in me. >> >> Double penicillin latte for me, please. >> >> -Amy >> >> Fergus Thornton <[log in to unmask]> writes: >>>"Primum non nocere" >>> >>>Giving a course of Ab with a high likelihood of an adverse reaction for >>><24hr sooner relief >>>violates this. Many of you seem to be looking at this from the >>>perspective of one child (yours!) but multiply this by 10,000/day to get >>>a sense of the unnecessary antibiotics given in the US daily. This is >>>difficult to justify. I'm sorry your kid has one extra day of a sore >>>throat but really . . . . is it worth deluging the world with more >>>antibiotics? >>> >>>-----Original Message----- >>>>From: "Chamberlain, Jim" <[log in to unmask]> >>>>Sent: Jun 1, 2010 10:51 PM >>>>To: [log in to unmask] >>>>Subject: Re: Strep--Other Considerations >>>> >>>>I agree with you about shortening the course of disease. >>>> >>>>I disagree that we should lower ourselves so we are practicing at the >>>lowest common denominator. We need to educate our parents (and >>>administrators) about the risks and benefits of medications. Otherwise, >>>we should just put a large vat of amoxicillin in our waiting rooms and >>>let parents decide when they want antibiotics. >>>> >>>>James Chamberlain, MD >>>>Division Chief, Emergency Medicine >>>>Children's National Medical Center >>>>111 Michigan Avenue, NW >>>>Washington, DC 20010 >>>> >>>>202.476.3253 (O) >>>>202.476.3573 (F) >>>>202.476.5433 (Emergency Access) >>>> >>>>-----Original Message----- >>>>From: Pediatric Emergency Medicine Discussion List >>>[mailto:[log in to unmask]] On Behalf Of Dave Smith >>>>Sent: Tuesday, June 01, 2010 4:29 PM >>>>To: [log in to unmask] >>>>Subject: Strep--Other Considerations >>>> >>>>I want to play devil's advocate for a moment on another set of >>>perspectives: >>>> >>>>1. What is the impact of not treating in terms of outcomes not >>>considered by studies? >>>> >>>>What I mean by this is that it is all well and good to pound the table >>>and hold up the studies and say, "Best practice says I don't need to >>>test/treat your 2 year old son, Mrs. Smith," but then, how often does >>>Mrs. Smith go to the urgent care down the road where they invariably see >>>a febrile toddler, order blood, urine and a chest xray, and give >>>Rocephin? Even if she goes to her PMD the next day and they simply do a >>>strep and treat (which I think most PMD's would do despite our urgings >to >>>the contrary), she's now incurred another visit to another medical >>>provider, increasing overall costs in the process. In the former >>>case, the child undergoes a while slew of tests and a treatment we could >>>have prevented. As I like to say, Evidence-Based Medicine is the >>>beginning of wisdom, not the entirity of it. We also have to practice >>>"realistic medicine" ." Over-adherence to dogma may lead to >>>parents seeking other outlets that end up doing far worse >>>> than a script for PenVK. Writing that script in some (many?) cases >>>would thus be better practice than what the child ended up with even >>>though it may not have been "best practice." >>>> >>>>2. We live in a world of Press-Gainey >>>> >>>>If your hospital administrators are like ours, they don't really care >>>about the best-practice guidelines...just the satisfaction scores. When >>>surveys come back giving the doctor a series of 1's because they doctor >>>"didn't do anything about my child's strep throat and I had to go to an >>>urgent care" they want to know what we are doing to improve our scores. >>>Telling them that strep only gets better a day earlier with treatment >and >>>the child wasn't in an age range for rheumatic fever so it didn't matter >>>isn't something they care about. That's how one ends up with language >>>added to one's contract tying incentives and penalties to Press-Gainey >>>performance. >>>> >>>>3. What's a day worth to a parent/child? >>>> >>>>When your child is sick, would you like him to be better a day >>>earlier? As a parent of four, I would have to say my answer is yes. >>>Most parents I see would say yes as well. That extra day could be two >>>extra days in some cases and we have no way of knowing for sure...it >>>could also be zero, but few parents would see that as an issue if there >>>is a good chance the illness could be one or two days shorter. For >>>parents who are working, sometimes in positions where taking more sick >>>days could mean not advancing or at the very least, being seen as >>>unreliable because they are always out with "kid issues," that extra day >>>might mean a lot. So when we say, "It's not worthwhile because they >>>only get better a day earlier at best," we are making a value judgement >>>about the worth of a day of wellness and the value of the parents' time. >>>> >>>>As I said, just playing devil's advocate. I tend to agree in principle >>>with what others have written in this thread. But we must always >>>remember that there are times when we still may be doing better care, >>>given the balance of all the issues at hand, when we give a little >ground >>>on "best care." >>>> >>>> >>>>Dave Smith, MD >>>> >>>> >>>> >>>> >>>>For more information, send mail to [log in to unmask] with the >>>message: info PED-EM-L >>>>The URL for the PED-EM-L Web Page is: >>>> http://listserv.brown.edu/ped-em-l.html >>>>Confidentiality Notice: This e-mail message, including any attachments, >>>is for the sole use of the intended >>>>recipient(s) and may contain confidential and privileged information. >>>Any unauthorized review, use, disclosure or distribution is prohibited. >>>>If you are not the intended recipient, please contact the sender by >>>reply e-mail and destroy all copies of the original message. >>>> >>>>For more information, send mail to [log in to unmask] with the >>>message: info PED-EM-L >>>>The URL for the PED-EM-L Web Page is: >>>> http://listserv.brown.edu/ped-em-l.html >>> >>> >>>Fergus Thornton >>>read my blog @ http://docdownunder.wordpress.com >>> >>>For more information, send mail to [log in to unmask] with the >>>message: info PED-EM-L >>>The URL for the PED-EM-L Web Page is: >>> http://listserv.brown.edu/ped-em-l.html >> >> >> >> Amy Baxter MD >> Pediatric Emergency Medicine Associates >> 404 371-1190 >> >> >> For more information, send mail to [log in to unmask] with the >> message: info PED-EM-L >> The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html >> > >For more information, send mail to [log in to unmask] with the >message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Amy Baxter MD Pediatric Emergency Medicine Associates 404 371-1190 For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
 Please post to list. I am away from my home computer and can't do it. TO all, I think the Centor Criteria and the AAP Redbook reccomendations use 5-18 years of age to include the highest risk group. I have never believed that the remainder of the population coldn't get RF. ( look at David's post). How does the disease know when your birthday is? Does everyone rul eout febrile convulsion as a possible diagnosis in a 7 year old who present with a brief GTC, associated with fever? Just saying, Marty -----Original Message----- From: Scherzer, Daniel <[log in to unmask]> To: [log in to unmask] Sent: Tue, Jun 1, 2010 2:01 pm Subject: Re: Rapid Strep Test < 2 years old Dr. Smith, The GAS pharyngitis that you remember might not have been the one that sensitized you to have an autoimmune response - it might just have spurred it on. The antibiotics you took during your relatively recent illness didn't help because the antibodies were already primed. The sensitizing episode could have been subtle or remote. It's the GAS that goes undetected or untreated (and your own immuno-uniqueness) that sets you up. Your story is important and not just an isolated anecdote. Best of luck to you. D.J. Scherzer -----Original Message----- From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Dave Smith Sent: Sunday, May 30, 2010 10:21 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I am 41 and just recovered from Acute Rheumatic Fever that developed after an adequately treated GAS pharyngitis. (Without going into detail, diagnosis was arrived at by meeting Jones Criteria and having no other positives in my rheumatologic workup...rheumatology and infectious disease (Duke) evaluated me and concur) I am a white male, European descent, and never lived off the North American continent...shouldn't have happened. Try to incorporate that into this discussion....even I am not sure how it fits in or what one could learn from it. R. David Smith, MD Children's Acute Care Medical Director, Peds Emergency Christus Schumpert, Sutton Children's Hospital, Shreveport, LA Cape Fear Valley Medical Center, Fayetteville, NC ________________________________ From: "Mittal, Manoj K" <[log in to unmask]> To: [log in to unmask] Sent: Sun, May 30, 2010 10:18:20 AM Subject: Re: Rapid Strep Test < 2 years old How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). Manoj Manoj K. Mittal, MD, MRCP (UK) Division of Emergency Medicine The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia, PA ________________________________________ From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] Sent: Sunday, May 30, 2010 1:34 AM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old Antibiotics have not been shown to impact post-strep GN. The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur. Mike Falk Sent from my iPhone On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: You talk about treating the disease; are you equating a + strep with the disease? #2 is less than 24 hours; not worth a course of Ab's #3 the latest I've read is that there is no relationship. #4 What's the incidence of PSGN in this age group? #5 doesn't occur in this age group Nope, haven't convinced me yet to test or treat these kids with Ab's. -----Original Message----- From: Kevin Powell <[log in to unmask]> Sent: May 29, 2010 1:26 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I treat strep infections 1.. to reduce contagion 2.. to speed healing and reduce suffering 3.. to reduce suppurative sequelae 4.. to reduce other sequelae, such as glomerulonephritis 5.. to prevent rheumatic fever roughly in that order. I think the 1990 era teaching that treatment didn't reduce length of illness was supplanted by 2000 with data showing 1 day fewer of symptoms by treating typical strep pharyngitis in older children. No data in the toddlers. There are lots of places in ER medicine where I would like to reduce exposing kids to antibiotics. Disease with a proven bacterial pathogen is way down the list. {SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR findings would be high on my list. This past year I've been working as a hospitalist for pulmonology and I am frustrated with the number of consults weekly that involve telling parents their child with recurrent pneumonias doesn't have an immunodeficiency, he has undertreated asthma.} The risk/benefit of testing will be different in toddlers. As I said before, I don't routinely test for strep in toddlers with sore throats - far too many viral illnesses. But if a sib has strep or other factors raise the concern, it is appropriate to test toddlers and, unless shown an applicable Bayesian analysis, I would recommend treating the disease when it is found. If an institution has a protocol in place to do rapid streps in triage on all children with fevers or sore throats, I have minimal experience practicing that way and defer to others to cite references on that protocol applied to toddlers. Kevin Powell MD PhD FAAP SSM Cardinal Glennon Children's Medical Center Associate Professor of Pediatrics Saint Louis University -----Original Message----- From: Chamberlain, Jim [mailto:[log in to unmask]] Sent: Saturday, May 29, 2010 8:52 AM To: Kevin Powell; [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old But the reason we treat Strep is to prevent rheumatic fever. Children this age don't get RF. Data on symptom resolution suggests a minimally faster improvement if treated. So why expose all these kids to antibiotics? For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:               http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html ----------------------------------------- Confidentiality Notice: The following mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. The recipient is responsible to maintain the confidentiality of this information and to use the information only for authorized purposes. If you are not the intended recipient (or authorized to receive information for the intended recipient), you are hereby notified that any review, use, disclosure, distribution, copying, printing, or action taken in reliance on the contents of this e-mail is strictly prohibited. If you have received this communication in error, please notify us immediately by reply e-mail and destroy all copies of the original message. Thank you. For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
It seems to me that the original question has morphed into something entirely different. The issue is not who should be treated for a positive strep test...the issue is who should be tested. With carrier rates in asymptomatic school aged children being quoted up to 20-25% in the literature, we need to be aware of the increasing rate of false positives (where positive means the disease state is present, and not just the bacteria) when the prevalence of disease decreases (as in the youngest patients). Of course, there are cases of pathologic GAS in these very young patients, but if our pre-test probability is low (eg 1 yr old with one day of fever, runny nose, no rash, etc), the false positive rate is sky-high. For me, if I send the test and it's positive, I treat. But more often than not, I'm not sending the test in patients under 3 yrs old unless there is something that separates that patient from the numerous others with straightforward viral symptoms. Jeff Jeff Seiden, MD Pediatric Emergency Medicine The Children's Hospital of Philadelphia 215-590-7053 [log in to unmask] ________________________________________ From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of Pamela Ross, MD [[log in to unmask]] Sent: Thursday, June 03, 2010 6:45 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old  Please post to list. I am away from my home computer and can't do it. TO all, I think the Centor Criteria and the AAP Redbook reccomendations use 5-18 years of age to include the highest risk group. I have never believed that the remainder of the population coldn't get RF. ( look at David's post). How does the disease know when your birthday is? Does everyone rul eout febrile convulsion as a possible diagnosis in a 7 year old who present with a brief GTC, associated with fever? Just saying, Marty -----Original Message----- From: Scherzer, Daniel <[log in to unmask]> To: [log in to unmask] Sent: Tue, Jun 1, 2010 2:01 pm Subject: Re: Rapid Strep Test < 2 years old Dr. Smith, The GAS pharyngitis that you remember might not have been the one that sensitized you to have an autoimmune response - it might just have spurred it on. The antibiotics you took during your relatively recent illness didn't help because the antibodies were already primed. The sensitizing episode could have been subtle or remote. It's the GAS that goes undetected or untreated (and your own immuno-uniqueness) that sets you up. Your story is important and not just an isolated anecdote. Best of luck to you. D.J. Scherzer -----Original Message----- From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Dave Smith Sent: Sunday, May 30, 2010 10:21 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I am 41 and just recovered from Acute Rheumatic Fever that developed after an adequately treated GAS pharyngitis. (Without going into detail, diagnosis was arrived at by meeting Jones Criteria and having no other positives in my rheumatologic workup...rheumatology and infectious disease (Duke) evaluated me and concur) I am a white male, European descent, and never lived off the North American continent...shouldn't have happened. Try to incorporate that into this discussion....even I am not sure how it fits in or what one could learn from it. R. David Smith, MD Children's Acute Care Medical Director, Peds Emergency Christus Schumpert, Sutton Children's Hospital, Shreveport, LA Cape Fear Valley Medical Center, Fayetteville, NC ________________________________ From: "Mittal, Manoj K" <[log in to unmask]> To: [log in to unmask] Sent: Sun, May 30, 2010 10:18:20 AM Subject: Re: Rapid Strep Test < 2 years old How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs). Manoj Manoj K. Mittal, MD, MRCP (UK) Division of Emergency Medicine The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia, PA ________________________________________ From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]] Sent: Sunday, May 30, 2010 1:34 AM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old Antibiotics have not been shown to impact post-strep GN. The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur. Mike Falk Sent from my iPhone On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote: You talk about treating the disease; are you equating a + strep with the disease? #2 is less than 24 hours; not worth a course of Ab's #3 the latest I've read is that there is no relationship. #4 What's the incidence of PSGN in this age group? #5 doesn't occur in this age group Nope, haven't convinced me yet to test or treat these kids with Ab's. -----Original Message----- From: Kevin Powell <[log in to unmask]> Sent: May 29, 2010 1:26 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old I treat strep infections 1.. to reduce contagion 2.. to speed healing and reduce suffering 3.. to reduce suppurative sequelae 4.. to reduce other sequelae, such as glomerulonephritis 5.. to prevent rheumatic fever roughly in that order. I think the 1990 era teaching that treatment didn't reduce length of illness was supplanted by 2000 with data showing 1 day fewer of symptoms by treating typical strep pharyngitis in older children. No data in the toddlers. There are lots of places in ER medicine where I would like to reduce exposing kids to antibiotics. Disease with a proven bacterial pathogen is way down the list. {SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR findings would be high on my list. This past year I've been working as a hospitalist for pulmonology and I am frustrated with the number of consults weekly that involve telling parents their child with recurrent pneumonias doesn't have an immunodeficiency, he has undertreated asthma.} The risk/benefit of testing will be different in toddlers. As I said before, I don't routinely test for strep in toddlers with sore throats - far too many viral illnesses. But if a sib has strep or other factors raise the concern, it is appropriate to test toddlers and, unless shown an applicable Bayesian analysis, I would recommend treating the disease when it is found. If an institution has a protocol in place to do rapid streps in triage on all children with fevers or sore throats, I have minimal experience practicing that way and defer to others to cite references on that protocol applied to toddlers. Kevin Powell MD PhD FAAP SSM Cardinal Glennon Children's Medical Center Associate Professor of Pediatrics Saint Louis University -----Original Message----- From: Chamberlain, Jim [mailto:[log in to unmask]] Sent: Saturday, May 29, 2010 8:52 AM To: Kevin Powell; [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old But the reason we treat Strep is to prevent rheumatic fever. Children this age don't get RF. Data on symptom resolution suggests a minimally faster improvement if treated. So why expose all these kids to antibiotics? For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:               http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                 http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html ----------------------------------------- Confidentiality Notice: The following mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. The recipient is responsible to maintain the confidentiality of this information and to use the information only for authorized purposes. If you are not the intended recipient (or authorized to receive information for the intended recipient), you are hereby notified that any review, use, disclosure, distribution, copying, printing, or action taken in reliance on the contents of this e-mail is strictly prohibited. If you have received this communication in error, please notify us immediately by reply e-mail and destroy all copies of the original message. Thank you. For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
Jeff, Thanks for clarifying my original question. Should we even be testing the <2-3 yr old for strep? Thanks, Fred -----Original Message----- From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Seiden, Jeffrey A Sent: Thursday, June 03, 2010 4:19 PM To: [log in to unmask] Subject: Re: Rapid Strep Test < 2 years old It seems to me that the original question has morphed into something entirely different. The issue is not who should be treated for a positive strep test...the issue is who should be tested. With carrier rates in asymptomatic school aged children being quoted up to 20-25% in the literature, we need to be aware of the increasing rate of false positives (where positive means the disease state is present, and not just the bacteria) when the prevalence of disease decreases (as in the youngest patients). Of course, there are cases of pathologic GAS in these very young patients, but if our pre-test probability is low (eg 1 yr old with one day of fever, runny nose, no rash, etc), the false positive rate is sky-high. For me, if I send the test and it's positive, I treat. But more often than not, I'm not sending the test in patients under 3 yrs old unless there is something that separates that patient from the numerous others with straightforward viral symptoms. Jeff Jeff Seiden, MD Pediatric Emergency Medicine The Children's Hospital of Philadelphia 215-590-7053 [log in to unmask] ________________________________________ For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
While I appreciate your observations, we need to make decisions based on evidence. You also don't state how you make the diagnosis. Just the strep screen? -----Original Message----- >From: Scott Nau <[log in to unmask]> >Sent: Jun 2, 2010 9:01 PM >To: [log in to unmask] >Subject: Rapid Strep Tests > >I am a general pediatrician with nearly 30 years of experience. Pardon me, but I bristle at some of the discussion relating to treating and testing for streptococcal infections in children. GAS pharyngitis is not necessarily the benign self-limited illness that some seem to feel it is. Go back and review pediatric texts from the 19th century and death rates of up to 30% were described in scarlet fever epidemics. Death could occur due to exsanguination as soft tissue infection of the anterior neck eroded into great vessels. My crystal ball has never worked well and I seem never to be able to predict who will get a peritonsillar abscess and who will not. >Say what you may, antibiotics work for GAS. Children can be significantly ill for several days and are better in a day and normal in two days with a few doses of an inexpensive antibiotic. Perhaps we are not preventing many cases of rhemumatic heart disease, but our patients get better more quickly. They return to school more quickly and their parents get back to work. The societal savings are no doubt significant. >Does symptomatic GAS pharyngitis occur in children less than age two? Without a doubt. I see it infrequently but blindly asserting that it doesn't because somebody said it doesn't will lead to errors, unavoidably. I have seen GAS in one year old's and even in an infant in the first two weeks of life who was significantly ill and whose mother had GAS pharyngitis. Choose your victims carefully for testing but if you never look, you will never know. I concede that blanket testing of febrile toddlers by midlevel providers will lead to overdiagnosis but that is an entirely separate issue. >Too many times it seems that we are prejudiced against our smallest patients. Some are suggesting not treating children with GAS pharyngitis because of a lack of risk of rheumatic fever and its usual benign course. More suggest not treating ear infections in children. What would you do if you were ill, took time off work, had a painful ear or GAS and your provider suggested observation with treatment in a few days if things didn't improve spontaneously? I am betting you would be looking for a new physician. Yet that is what the current trend seems to be. This is not an issue of overuse of antibiotics. If we could prevent the use of antibiotics for colds and "tonsilitis" and "bronchitis" and eliminate the inaccurate diagnosis of otitis in a febrile child with a "pink ear" the problem would be solved. How many subscribers of this list use pneumatic otoscopy routinely? The vast majority of the time when I evaluate children with "otitis" for their persistent high fevers, they !  h! > ave clean ears. Those children seen in emergency rooms previously were not appropriately examined and many times have huge amounts of cerumen that someone has miraculously looked right through. >Part of what I pledged to do as a physician was try to help people. Over the years I have learned that s__t does happen. Withholding treatment for GAS is an invitation to get your shoes dirty and is a disservice to your patients. >Scott Nau, MD >Cedar Rapids, IA > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
UTI's lead to pyelo in a certain % of cases. There is no evidence that not treating leads to PTA. -----Original Message----- >From: Amy Baxter <[log in to unmask]> >Sent: Jun 3, 2010 4:17 PM >To: [log in to unmask] >Subject: Re: Strep--Other Considerations > >I have strep about three times a year since I moved to Atlanta, about once >per year before that. SEveral times I have been unable to get to be >tested, and I am feverish and miserable and going to sleep at 0830PM until >I get to employee health or the doctor to get the swab. I don't take amox >unless I know for sure it's strep, but each time this has happened I feel >much better within 12 hours of starting antibiotics and the fever goes >away. I'm not saying other people get better that fast, although when >I've been camp doctor I see similar resolution of strep with abx but not >strep negative with no abx. My personal N is about 16. The longest I've >been uncomfortable and feverish and miserable before getting the swab is >about 4 days. The shortest time is about 5 hours, when I knew I had an >exposure and started feeling the symptoms. And, of course, I do wear a >mask when I swab now so it's been about 6 months! I'm doing well! > >How do you feel about treating UTIs in women? Let them fight the symptoms >and wait it out since pyelo is uncommon? > >Thanks for your a priori assessment that I am evidence based! > >Take care, >Amy > > > >William Gibson <[log in to unmask]> writes: >>Dr. Baxter, >> Thank you for your personal opinion, but what is the evidence to >>support >>your claim. No study has shown that people get better in 12 hours if you >>treat strep with an antibiotic. I am glad placebo works for you, but I >>don't think it's a solid foundation for the practice of medicine. I am >>surprised that you do. >> >>Wm Gibson MD >>----- Original Message ----- >>From: "Amy Baxter" <[log in to unmask]> >>To: <[log in to unmask]> >>Sent: Thursday, June 03, 2010 9:19 AM >>Subject: Re: Strep--Other Considerations >> >> >>> OK, I've stayed out of this, in part because I agreed with Kevin >>Powell's >>> comments and didn't want to be redundant, but seriously? When I start >>to >>> feel streppy because some kid I did a strep test on coughs in my face, I >>> am thrilled when the swab they do at employee health comes back >>positive. >>> Thanks to the wonders of post-1943 medicine, I know I'll be feeling >>better >>> in 12 hours and don't need to try to swap my shift the next day, know I >>> will be productive again, know I can manage my own contagion. And of >>> course I take antibiotics! >>> >>> I do lots of pain drops for viral otitis, and am scrupulously >>parsimonious >>> even when parents of adenoviral children wail and get in my face. I >>swab >>> children less than three years once or twice a year, I quote the red >>book, >>> and even when they have exudates and a positive family contact if the >>> rapid is negative, too bad: no antibiotics for you. But in the face of >>a >>> positive bacterial contagion, the "high likelihood" of an adverse >>reaction >>> doesn't stop me from gratefully getting treatment myself; bacterial >>> illness is what antibiotics are for. I fight the good fight against >>> antibiotics for viral illnesses on a daily basis, but good heavens, if I >>> have strep, DELUGE me, and that goes double for the patients who entrust >>> their time, health, comfort, and money in me. >>> >>> Double penicillin latte for me, please. >>> >>> -Amy >>> >>> Fergus Thornton <[log in to unmask]> writes: >>>>"Primum non nocere" >>>> >>>>Giving a course of Ab with a high likelihood of an adverse reaction for >>>><24hr sooner relief >>>>violates this. Many of you seem to be looking at this from the >>>>perspective of one child (yours!) but multiply this by 10,000/day to get >>>>a sense of the unnecessary antibiotics given in the US daily. This is >>>>difficult to justify. I'm sorry your kid has one extra day of a sore >>>>throat but really . . . . is it worth deluging the world with more >>>>antibiotics? >>>> >>>>-----Original Message----- >>>>>From: "Chamberlain, Jim" <[log in to unmask]> >>>>>Sent: Jun 1, 2010 10:51 PM >>>>>To: [log in to unmask] >>>>>Subject: Re: Strep--Other Considerations >>>>> >>>>>I agree with you about shortening the course of disease. >>>>> >>>>>I disagree that we should lower ourselves so we are practicing at the >>>>lowest common denominator. We need to educate our parents (and >>>>administrators) about the risks and benefits of medications. Otherwise, >>>>we should just put a large vat of amoxicillin in our waiting rooms and >>>>let parents decide when they want antibiotics. >>>>> >>>>>James Chamberlain, MD >>>>>Division Chief, Emergency Medicine >>>>>Children's National Medical Center >>>>>111 Michigan Avenue, NW >>>>>Washington, DC 20010 >>>>> >>>>>202.476.3253 (O) >>>>>202.476.3573 (F) >>>>>202.476.5433 (Emergency Access) >>>>> >>>>>-----Original Message----- >>>>>From: Pediatric Emergency Medicine Discussion List >>>>[mailto:[log in to unmask]] On Behalf Of Dave Smith >>>>>Sent: Tuesday, June 01, 2010 4:29 PM >>>>>To: [log in to unmask] >>>>>Subject: Strep--Other Considerations >>>>> >>>>>I want to play devil's advocate for a moment on another set of >>>>perspectives: >>>>> >>>>>1. What is the impact of not treating in terms of outcomes not >>>>considered by studies? >>>>> >>>>>What I mean by this is that it is all well and good to pound the table >>>>and hold up the studies and say, "Best practice says I don't need to >>>>test/treat your 2 year old son, Mrs. Smith," but then, how often does >>>>Mrs. Smith go to the urgent care down the road where they invariably see >>>>a febrile toddler, order blood, urine and a chest xray, and give >>>>Rocephin? Even if she goes to her PMD the next day and they simply do a >>>>strep and treat (which I think most PMD's would do despite our urgings >>to >>>>the contrary), she's now incurred another visit to another medical >>>>provider, increasing overall costs in the process. In the former >>>>case, the child undergoes a while slew of tests and a treatment we could >>>>have prevented. As I like to say, Evidence-Based Medicine is the >>>>beginning of wisdom, not the entirity of it. We also have to practice >>>>"realistic medicine" ." Over-adherence to dogma may lead to >>>>parents seeking other outlets that end up doing far worse >>>>> than a script for PenVK. Writing that script in some (many?) cases >>>>would thus be better practice than what the child ended up with even >>>>though it may not have been "best practice." >>>>> >>>>>2. We live in a world of Press-Gainey >>>>> >>>>>If your hospital administrators are like ours, they don't really care >>>>about the best-practice guidelines...just the satisfaction scores. When >>>>surveys come back giving the doctor a series of 1's because they doctor >>>>"didn't do anything about my child's strep throat and I had to go to an >>>>urgent care" they want to know what we are doing to improve our scores. >>>>Telling them that strep only gets better a day earlier with treatment >>and >>>>the child wasn't in an age range for rheumatic fever so it didn't matter >>>>isn't something they care about. That's how one ends up with language >>>>added to one's contract tying incentives and penalties to Press-Gainey >>>>performance. >>>>> >>>>>3. What's a day worth to a parent/child? >>>>> >>>>>When your child is sick, would you like him to be better a day >>>>earlier? As a parent of four, I would have to say my answer is yes. >>>>Most parents I see would say yes as well. That extra day could be two >>>>extra days in some cases and we have no way of knowing for sure...it >>>>could also be zero, but few parents would see that as an issue if there >>>>is a good chance the illness could be one or two days shorter. For >>>>parents who are working, sometimes in positions where taking more sick >>>>days could mean not advancing or at the very least, being seen as >>>>unreliable because they are always out with "kid issues," that extra day >>>>might mean a lot. So when we say, "It's not worthwhile because they >>>>only get better a day earlier at best," we are making a value judgement >>>>about the worth of a day of wellness and the value of the parents' time. >>>>> >>>>>As I said, just playing devil's advocate. I tend to agree in principle >>>>with what others have written in this thread. But we must always >>>>remember that there are times when we still may be doing better care, >>>>given the balance of all the issues at hand, when we give a little >>ground >>>>on "best care." >>>>> >>>>> >>>>>Dave Smith, MD >>>>> >>>>> >>>>> >>>>> >>>>>For more information, send mail to [log in to unmask] with the >>>>message: info PED-EM-L >>>>>The URL for the PED-EM-L Web Page is: >>>>> http://listserv.brown.edu/ped-em-l.html >>>>>Confidentiality Notice: This e-mail message, including any attachments, >>>>is for the sole use of the intended >>>>>recipient(s) and may contain confidential and privileged information. >>>>Any unauthorized review, use, disclosure or distribution is prohibited. >>>>>If you are not the intended recipient, please contact the sender by >>>>reply e-mail and destroy all copies of the original message. >>>>> >>>>>For more information, send mail to [log in to unmask] with the >>>>message: info PED-EM-L >>>>>The URL for the PED-EM-L Web Page is: >>>>> http://listserv.brown.edu/ped-em-l.html >>>> >>>> >>>>Fergus Thornton >>>>read my blog @ http://docdownunder.wordpress.com >>>> >>>>For more information, send mail to [log in to unmask] with the >>>>message: info PED-EM-L >>>>The URL for the PED-EM-L Web Page is: >>>> http://listserv.brown.edu/ped-em-l.html >>> >>> >>> >>> Amy Baxter MD >>> Pediatric Emergency Medicine Associates >>> 404 371-1190 >>> >>> >>> For more information, send mail to [log in to unmask] with the >>> message: info PED-EM-L >>> The URL for the PED-EM-L Web Page is: >>> http://listserv.brown.edu/ped-em-l.html >>> >> >>For more information, send mail to [log in to unmask] with the >>message: info PED-EM-L >>The URL for the PED-EM-L Web Page is: >> http://listserv.brown.edu/ped-em-l.html > > > >Amy Baxter MD >Pediatric Emergency Medicine Associates >404 371-1190 > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L >The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html Fergus Thornton read my blog @ http://docdownunder.wordpress.com For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html
I'm just speaking for myself but I think we've hit the main points in this debate, perhaps we could move on. James > Date: Mon, 7 Jun 2010 14:17:15 -0400 > From: [log in to unmask] > Subject: Re: Strep--Other Considerations > To: [log in to unmask] > > UTI's lead to pyelo in a certain % of cases. There is no evidence that not treating leads to PTA. > > > -----Original Message----- > >From: Amy Baxter <[log in to unmask]> > >Sent: Jun 3, 2010 4:17 PM > >To: [log in to unmask] > >Subject: Re: Strep--Other Considerations > > > >I have strep about three times a year since I moved to Atlanta, about once > >per year before that. SEveral times I have been unable to get to be > >tested, and I am feverish and miserable and going to sleep at 0830PM until > >I get to employee health or the doctor to get the swab. I don't take amox > >unless I know for sure it's strep, but each time this has happened I feel > >much better within 12 hours of starting antibiotics and the fever goes > >away. I'm not saying other people get better that fast, although when > >I've been camp doctor I see similar resolution of strep with abx but not > >strep negative with no abx. My personal N is about 16. The longest I've > >been uncomfortable and feverish and miserable before getting the swab is > >about 4 days. The shortest time is about 5 hours, when I knew I had an > >exposure and started feeling the symptoms. And, of course, I do wear a > >mask when I swab now so it's been about 6 months! I'm doing well! > > > >How do you feel about treating UTIs in women? Let them fight the symptoms > >and wait it out since pyelo is uncommon? > > > >Thanks for your a priori assessment that I am evidence based! > > > >Take care, > >Amy > > > > > > > >William Gibson <[log in to unmask]> writes: > >>Dr. Baxter, > >> Thank you for your personal opinion, but what is the evidence to > >>support > >>your claim. No study has shown that people get better in 12 hours if you > >>treat strep with an antibiotic. I am glad placebo works for you, but I > >>don't think it's a solid foundation for the practice of medicine. I am > >>surprised that you do. > >> > >>Wm Gibson MD > >>----- Original Message ----- > >>From: "Amy Baxter" <[log in to unmask]> > >>To: <[log in to unmask]> > >>Sent: Thursday, June 03, 2010 9:19 AM > >>Subject: Re: Strep--Other Considerations > >> > >> > >>> OK, I've stayed out of this, in part because I agreed with Kevin > >>Powell's > >>> comments and didn't want to be redundant, but seriously? When I start > >>to > >>> feel streppy because some kid I did a strep test on coughs in my face, I > >>> am thrilled when the swab they do at employee health comes back > >>positive. > >>> Thanks to the wonders of post-1943 medicine, I know I'll be feeling > >>better > >>> in 12 hours and don't need to try to swap my shift the next day, know I > >>> will be productive again, know I can manage my own contagion. And of > >>> course I take antibiotics! > >>> > >>> I do lots of pain drops for viral otitis, and am scrupulously > >>parsimonious > >>> even when parents of adenoviral children wail and get in my face. I > >>swab > >>> children less than three years once or twice a year, I quote the red > >>book, > >>> and even when they have exudates and a positive family contact if the > >>> rapid is negative, too bad: no antibiotics for you. But in the face of > >>a > >>> positive bacterial contagion, the "high likelihood" of an adverse > >>reaction > >>> doesn't stop me from gratefully getting treatment myself; bacterial > >>> illness is what antibiotics are for. I fight the good fight against > >>> antibiotics for viral illnesses on a daily basis, but good heavens, if I > >>> have strep, DELUGE me, and that goes double for the patients who entrust > >>> their time, health, comfort, and money in me. > >>> > >>> Double penicillin latte for me, please. > >>> > >>> -Amy > >>> > >>> Fergus Thornton <[log in to unmask]> writes: > >>>>"Primum non nocere" > >>>> > >>>>Giving a course of Ab with a high likelihood of an adverse reaction for > >>>><24hr sooner relief > >>>>violates this. Many of you seem to be looking at this from the > >>>>perspective of one child (yours!) but multiply this by 10,000/day to get > >>>>a sense of the unnecessary antibiotics given in the US daily. This is > >>>>difficult to justify. I'm sorry your kid has one extra day of a sore > >>>>throat but really . . . . is it worth deluging the world with more > >>>>antibiotics? > >>>> > >>>>-----Original Message----- > >>>>>From: "Chamberlain, Jim" <[log in to unmask]> > >>>>>Sent: Jun 1, 2010 10:51 PM > >>>>>To: [log in to unmask] > >>>>>Subject: Re: Strep--Other Considerations > >>>>> > >>>>>I agree with you about shortening the course of disease. > >>>>> > >>>>>I disagree that we should lower ourselves so we are practicing at the > >>>>lowest common denominator. We need to educate our parents (and > >>>>administrators) about the risks and benefits of medications. Otherwise, > >>>>we should just put a large vat of amoxicillin in our waiting rooms and > >>>>let parents decide when they want antibiotics. > >>>>> > >>>>>James Chamberlain, MD > >>>>>Division Chief, Emergency Medicine > >>>>>Children's National Medical Center > >>>>>111 Michigan Avenue, NW > >>>>>Washington, DC 20010 > >>>>> > >>>>>202.476.3253 (O) > >>>>>202.476.3573 (F) > >>>>>202.476.5433 (Emergency Access) > >>>>> > >>>>>-----Original Message----- > >>>>>From: Pediatric Emergency Medicine Discussion List > >>>>[mailto:[log in to unmask]] On Behalf Of Dave Smith > >>>>>Sent: Tuesday, June 01, 2010 4:29 PM > >>>>>To: [log in to unmask] > >>>>>Subject: Strep--Other Considerations > >>>>> > >>>>>I want to play devil's advocate for a moment on another set of > >>>>perspectives: > >>>>> > >>>>>1. What is the impact of not treating in terms of outcomes not > >>>>considered by studies? > >>>>> > >>>>>What I mean by this is that it is all well and good to pound the table > >>>>and hold up the studies and say, "Best practice says I don't need to > >>>>test/treat your 2 year old son, Mrs. Smith," but then, how often does > >>>>Mrs. Smith go to the urgent care down the road where they invariably see > >>>>a febrile toddler, order blood, urine and a chest xray, and give > >>>>Rocephin? Even if she goes to her PMD the next day and they simply do a > >>>>strep and treat (which I think most PMD's would do despite our urgings > >>to > >>>>the contrary), she's now incurred another visit to another medical > >>>>provider, increasing overall costs in the process. In the former > >>>>case, the child undergoes a while slew of tests and a treatment we could > >>>>have prevented. As I like to say, Evidence-Based Medicine is the > >>>>beginning of wisdom, not the entirity of it. We also have to practice > >>>>"realistic medicine" ." Over-adherence to dogma may lead to > >>>>parents seeking other outlets that end up doing far worse > >>>>> than a script for PenVK. Writing that script in some (many?) cases > >>>>would thus be better practice than what the child ended up with even > >>>>though it may not have been "best practice." > >>>>> > >>>>>2. We live in a world of Press-Gainey > >>>>> > >>>>>If your hospital administrators are like ours, they don't really care > >>>>about the best-practice guidelines...just the satisfaction scores. When > >>>>surveys come back giving the doctor a series of 1's because they doctor > >>>>"didn't do anything about my child's strep throat and I had to go to an > >>>>urgent care" they want to know what we are doing to improve our scores. > >>>>Telling them that strep only gets better a day earlier with treatment > >>and > >>>>the child wasn't in an age range for rheumatic fever so it didn't matter > >>>>isn't something they care about. That's how one ends up with language > >>>>added to one's contract tying incentives and penalties to Press-Gainey > >>>>performance. > >>>>> > >>>>>3. What's a day worth to a parent/child? > >>>>> > >>>>>When your child is sick, would you like him to be better a day > >>>>earlier? As a parent of four, I would have to say my answer is yes. > >>>>Most parents I see would say yes as well. That extra day could be two > >>>>extra days in some cases and we have no way of knowing for sure...it > >>>>could also be zero, but few parents would see that as an issue if there > >>>>is a good chance the illness could be one or two days shorter. For > >>>>parents who are working, sometimes in positions where taking more sick > >>>>days could mean not advancing or at the very least, being seen as > >>>>unreliable because they are always out with "kid issues," that extra day > >>>>might mean a lot. So when we say, "It's not worthwhile because they > >>>>only get better a day earlier at best," we are making a value judgement > >>>>about the worth of a day of wellness and the value of the parents' time. > >>>>> > >>>>>As I said, just playing devil's advocate. I tend to agree in principle > >>>>with what others have written in this thread. But we must always > >>>>remember that there are times when we still may be doing better care, > >>>>given the balance of all the issues at hand, when we give a little > >>ground > >>>>on "best care." > >>>>> > >>>>> > >>>>>Dave Smith, MD > >>>>> > >>>>> > >>>>> > >>>>> > >>>>>For more information, send mail to [log in to unmask] with the > >>>>message: info PED-EM-L > >>>>>The URL for the PED-EM-L Web Page is: > >>>>> http://listserv.brown.edu/ped-em-l.html > >>>>>Confidentiality Notice: This e-mail message, including any attachments, > >>>>is for the sole use of the intended > >>>>>recipient(s) and may contain confidential and privileged information. > >>>>Any unauthorized review, use, disclosure or distribution is prohibited. > >>>>>If you are not the intended recipient, please contact the sender by > >>>>reply e-mail and destroy all copies of the original message. > >>>>> > >>>>>For more information, send mail to [log in to unmask] with the > >>>>message: info PED-EM-L > >>>>>The URL for the PED-EM-L Web Page is: > >>>>> http://listserv.brown.edu/ped-em-l.html > >>>> > >>>> > >>>>Fergus Thornton > >>>>read my blog @ http://docdownunder.wordpress.com > >>>> > >>>>For more information, send mail to [log in to unmask] with the > >>>>message: info PED-EM-L > >>>>The URL for the PED-EM-L Web Page is: > >>>> http://listserv.brown.edu/ped-em-l.html > >>> > >>> > >>> > >>> Amy Baxter MD > >>> Pediatric Emergency Medicine Associates > >>> 404 371-1190 > >>> > >>> > >>> For more information, send mail to [log in to unmask] with the > >>> message: info PED-EM-L > >>> The URL for the PED-EM-L Web Page is: > >>> http://listserv.brown.edu/ped-em-l.html > >>> > >> > >>For more information, send mail to [log in to unmask] with the > >>message: info PED-EM-L > >>The URL for the PED-EM-L Web Page is: > >> http://listserv.brown.edu/ped-em-l.html > > > > > > > >Amy Baxter MD > >Pediatric Emergency Medicine Associates > >404 371-1190 > > > > > >For more information, send mail to [log in to unmask] with the message: info PED-EM-L > >The URL for the PED-EM-L Web Page is: > > http://listserv.brown.edu/ped-em-l.html > > > Fergus Thornton > read my blog @ http://docdownunder.wordpress.com > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L > The URL for the PED-EM-L Web Page is: > http://listserv.brown.edu/ped-em-l.html _________________________________________________________________ Hotmail has tools for the New Busy. Search, chat and e-mail from your inbox. http://www.windowslive.com/campaign/thenewbusy?ocid=PID28326::T:WLMTAGL:ON:W L:en-US:WM_HMP:042010_1 For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html For more information, send mail to [log in to unmask] with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:                  http://listserv.brown.edu/ped-em-l.html

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