PEM Fellow, wrote
" Wether it is history and clinical appearence only , rigorous algorithims
or unforgiving practice standards, the purpose is the same. Why do we
bother with all
We spend millions to hospitalize the R/O MI for 24-72
hrs to find the real MI's---why should we do less for children when the r/o
can be done quicker and cheaper???"
If I understand you correctly, are you then suggesting that we ignore all
algorithms, and stick a needle in the back of ALL kids with febrile
seizures, as an excuse for being less experienced, regardless of their age
or clinical presentation, because it is "cheaper and quicker"?
As a PEM fellow and future PED attending, I would rather have you and all
of us who deal with this scenario on a frequent basis offer our experience,
be available for consultation/referrals and be involved in teaching the
"nuances" to folks in our community (as you beautifully articulated) than
advocating "MASS" LP's. It ain't fun when it is your child getting an
unnecesssary LP just
because it is "quicker and cheaper than a workup for MI!!"
Switching if I may, to the issue of GABHS, I would like to thank Jon
Bennett for pointing out this recent reference on a cost-effective analysis
approach to its management. I enjoyed reading it and basically goes through
all (and some more) of the mental gyrations that Mike Newdow went through!!
Essentially, they do NOT recommend the "treat all" strategy because of the
issue of allergic reactions, both minor and major, to PCN resulting from
overtreatment. Their assumed estimate (from the literature) is
approximately 6:1000. Antibiotic resistance is the other issue. Given the
lower rates of ARF in the US in the last 2 decades (assumed to be 0.025%,
no current data available), a selective treatment strategy is recommended
with reliance on the OIA method of rapid detection. Sequential TC is
recommended only if there is a local epidemic of ARF in the area. The thing
I liked with this recommendation, was the inclusion in the sensitivity
analysis of a $$ value added to work/school days lost by delaying treatment
(by relying only on TC's). It is not possible to go through all their
cost/probability assumptions here, but overall they all seemed reasonable.
Thanks for listening
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