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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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>>>>
>>>>
>>>>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