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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
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> >>>>>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
 		 	   		  
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