Looking back, Looking forward

One of the nice things about living in Australia is being amongst the first to welcome in the new year.  As 2016 draws to a close and 2017 creeps out from under duvet, it is time to take a look back at the last year on DFTB.

Since the beginning of the year we have published 126 posts by 19 different authors. Here are some of our highlights of the year.

 

“This year has been a great one at DFTB as I finally got to meet someone else on the team in the flesh.  People seem to think that Tessa, Ben, Henry and myself knew each other before the website and hang out all the time but it wasn’t until I went to SMACCDub that I finally got to meet another quarter of the team. It’s been a great year for making new friends in the FOAMed community and strengthening relationships with old ones. On a more personal level little Rosie was born and spluttered into my world bringing a helpless little human into the house.” Andy

 

“Andy has touched on a really lovely thing about DFTB & FOAMed in general – something that’s certainly been a highlight for me this year – the matching of warm faces and handshakes to kindred names and voices from across the globe. This year I’ve relished coordinating the Sweet Spot interview series; the opportunity to seek explicit, practical advice from a group of professional superiors is one of the great strengths of our community. More personally, I’ve been afforded the chance to work part-time for half of 2016 and appreciate the (family) benefits and (professional) challenges this brings. Finally, I’m coming to the end of a posting in Adolescent Psychiatry, which has certainly given me some fresh perspectives on Medicine, Paediatrics and Psychiatry, the latter of which I hope to share into the new year.” Henry

 

“2016 has afforded me the opportunity to talk with several people whose work I really admire including Adam Cheng, Walter Eppich, Nate Kupperman and of course, Tessa Davis (who I met for the first time in April). What struck me about all these, in my mind incomprehensibly productive, people is that they seem to very much enjoy what they do.  Reflecting on my own practice the things that I tend to get better feedback about tend to be the things that I enjoy the most. Therefore in the spirit of making the world a better place I am going to spend 2017 trying to do as much of what I enjoy as possible. I am really looking forward to meeting more inspirational people at DFTB17, first up will be a coffee with Andy Tagg who I have still yet to meet IRL”.  Ben

 

“2016 has been fabulous for DFTB. In this, our third year as a blog, we have broadened our collaboration – this includes with EMA Journal (we are section editors), APLS (distributing their conference videos), PERUKI (our new series Bubbling Up) and others. I hope that over the coming year DFTB continues to involve and collaborate. And of course our conference (DFTB17) is coming up in 2017 which is a new adventure for all of us. Working with the DFTB team is an absolute joy – even though we have not all met in person, it really doesn’t matter. We communicate constantly and work together so well. Over the years, the most successful projects I have been involved with are the ones with the best teams. Andy, Ben, and Henry – you are an awesome team to work with.”. Tessa

We all hope you continue to join us as we forge new ground with the inaugural Don’t Forget the Bubbles conference in Brisbane (August 28th -30th) as well as producing our usual quality material.

Mandible x-rays

An orthopantomogram (OPG) is a good view to demonstrate most mandibular fractures.

 

A PA mandible shows the displacement of fractures. It also demonstrates symphysis menti fractures which can be missed on the OPG.

pa-anatomy

Image from WikiRadiography

If an OPG cannot be obtained, a lateral view can be helpful. The body and ramus can be viewed along with the TMJ articulation.

lateral-anatomy

Image from WikiRadiography

 

Know your anatomy

mandible-anatomy

Image from WikiRadiography

 

 

Follow the line of the mandible.

  • Remember that the air-filled oesophagus often means that black lines cross the mandible near the angle of the mandible (see image above).

 

Look at the condylar and coronoid process, rami and body, submental symphysis, and alveolar ridge for fractures

  • Condylar process fractures can occur at the base so look carefully as they are easily missed.
  • In general, if you see one mandibular fracture then look for another one as it is common to have more than one, or TMJ dislocation.

 

A Guardsman’s fracture is where there is a fracture of the symphysis and both condyles. This is due to a fall with impact on the midpoint of the chin.


Management

  • Favourable fractures are held in alignment.
  • Unfavourable fracture are displaced by the muscles pulling them.
  • Mandibular fractures of the body or angle of the mandible can be managed conservatively, unless they are displaced, in which case reduction and internal fixation may be required.
  • Condylar fractures are usually managed conservatively, unless there is occlusion of normal movement due to dislocation of the condylar head.

If you want to test yourself then Norwich Image Interpretation Course has a great online facial x-ray quiz.

Ears looking at you, kid

Earache is a leading cause of grumpiness in children.  A recent paper in the New England Journal of Medicine has suggested that a 10 day course of antibiotics is more effective than a 5 day course in treating acute otitis media and, as such, should be considered in infants under 2 years with otitis media. But is this right?

Before we dive into the nitty gritty it is worth taking a look at the paper and forming your own impressions.

Hoberman A, Paradise JL, Rockette HE, et al. Shortened antimicrobial treatment for acute otitis media in young children. N Engl J Med 2016;375:2446-2456

Let’s start with the basics first.  Here is their PICO…

Population – Children between 6 to 23 months of age, who had received at least two doses of conjugate pneumococcal vaccine and who were diagnosed with acute otitis media.

Intervention – 10 day course of amoxicillin-clavulanate

Comparitor – 5 days of amoxicillin-clavulanate followed by 5 days of placebo.

Outcome – rates of clinical response based on signs and symptoms

At first glance this seems pretty reasonable but the premise of this study is all about treatment of acute otitis media (AOM).  Most guidelines would suggest that the antibiotic of choice is a weight based regime of amoxicillin (15mg/kg/dose tds) with co-amoxiclav for rescue therapy, not first line.

 

How do they diagnose AOM?

The investigators made the diagnosis on the basis of three criteria:-

  • Less than 48 hours of symptoms that received a parental score greater than 3 on the Acute Otitis Media – Severity Of Symptoms (AOM-SOS) scale
  • Presence of a middle ear effusion
  • Moderate or marked bulging of the tympanic membrane OR slight bulging accompanied by apparent otalagia or marked tympanic membrane erythema

I see children with earache almost every day in the emergency department but I very rarely make the diagnosis of acute otitis media and had never heard of the AOM-SOS.

 

What is on the AOM-SOS?

The seven item scale is rated by the parents and consists of the following:

  • tugging of ears
  • crying
  • irritability
  • difficulty sleeping
  • diminished activity
  • diminished appetite
  • fever

Each item is rated as none (0), “a little” (1) or “a lot” (2), giving a score ranging from 0 to 14. The average score, prior to treatment, was around 8±3. Fever, earache and crying was seen in 90% of children with AOM but also 72% of kids without it in one prospective survey. A Costa Rican trial (primarily looking at efficacy of an antibiotic) found no correlation between AOM-SOS and bacterial persistence as determined by tympanocentesis.

 

How did they determine the presence of a middle ear effusion?

All of the doctors underwent an otoscopic validation program prior to beginning the study.

But I had more quibbles about the final diagnostic criteria. Whilst moderate or marked bulging may be clinically obvious slight bulging and earache or slight bulging with a red TM will occur in practically any crying child.  The AAP suggest that the diagnosis of AOM should be confirmed with pneumatic otoscopy ± tympanometry. The suggestion of tympanocentesis in the presence of an effusion seems a little too hardcore. Just looking at a tympanic membrane in a grizzly 18 month old can be challenge.

 

Skip over the next section if it is a bit too nerdy for you…

Appraising this randomized control trial

Was the PICO clearly stated? – YES (See above)

Was the assignment to treatments randomized? – YES – Children were stratified according to age then block randomized.

Was the randomization concealed? – UNKNOWN – No mention is made of the method of randomization.

Were all the subjects enrolled accounted for? – YES

Were they analysed in the groups to which they were randomized? – YES – the trial was set up as a non-inferiority trial and data examined using the intention-to-treat principle.

Were the subjects and clinicians adequately blinded? – YES

Aside from the treatment were the groups treated equally? – YES 

Were the groups similar at the start of the trial? – YES

How large was the treatment effect? – The investigators observed greater failure of treatment in children who underwent the 5 day course than underwent the 10 day course of antibiotics with an Number Needed to prevent failure of 6.

Do these results apply to my patients? – And that’s the crux, isn’t it?

Parents were contacted by phone on day 4, 5, or 6 and were seen at an end of treatment visit at day 12,13 or 14. The parents also recorded daily  AOM-SOS scores. Clinical failure (what we really care about) was defined as either:

  • Worsening of symptoms
  • Otoscopic signs of worsening infection
  • Incomplete resolution of symptoms at end of treatment

 

And the results? Drum roll please……..

Clinical failure of treatment was seen in 77 of 229 (33%) children treated with the 5 day course and 39 of 238 (16%) those treated with the 10 day course. This works out as a number needed to treat of 6 to prevent treatment failure. The largest treatment effect was seen with those children who were more unwell at the outset and this was on the basis of fever and perceived pain.  In the authors own words, “…we did not find interactions between treatment and other indexes of severity, namely AOM-SOS scores, infection in both ears versus one ear, and degrees of tympanic membrane bulging.” There was no significant difference in symptom scores between the two groups from day 6 to day 14. There then seems, to me at least, to be a degree of data dredging to show a statistically significant (P=0.003) reduction in symptom scores between the two groups.

There was no significant difference in the rates of adverse events or recurrence of disease.

With the increased uptake of vaccination against pneumococcus and H. Influenza there has been a decreased incidence of bacterial causes of otitis. The organisms commonly implicated are S. pneumonia, H. influenza and M. Catarrhalis. Here’s how often these are recovered from middle ear fluid.

It can be much harder to assess young children and so parental impressions are often used as surrogate markers of treatment success or failure. A number of studies have suggested that antibiotics may reduce persistent symptoms but seem to have little effect on fever or duration of crying. I’ll save my opinions on treating fevers for another time.

The key point for me is mentioned in the opening line of the paper…

“Limiting the duration of antimicrobial treatment constitutes a potential strategy to reduce the risk of antimicrobial resistance among children with acute otitis media”

I don’t routinely prescribe antibiotics for acute otitis media though occasionally will use a ‘watchful waiting’ approach and this seems to be pretty commonplace in Europe. The AAP suggests that this is an option in children under two years of age with non-severe illness or an equivocal diagnosis. Here is the summary of the 2015 Cochrane data.

The 2013 update to the AAP guidelines is a little more prescriptive suggesting that antibiotics should be prescribed in cases of severe AOM or bilateral AOM, as it is here where the evidence is strongest for benefit. If the AOM is unlateral and not severe then the watchful waiting approach is appropriate.

 

Are antibiotics a benign treatment?

Diarrhoea occurred in 30% of children in each group of the study and dermatitis occurred in 34%.

 

What about the economic burden of treatment?

The American Academy of Pediatrics estimated that the direct cost of treating AOM (in 1995) was $1.96 billion dollars with indirect costs adding a further $1.02 billion dollars. The cost to the individual can range from between $10 and $100 dollars. The 2015 Cochrane review stated that a whopping 95% cases in the US are treated with antibiotics. An article in press in the Journal of Paediatrics by Youngster et al looking at trends in antibiotic use in children across a number of industrialized countries reveals wide practice variation with a 7.5 times difference in prescribing rates between some countries, with the US not being the worst offender.

When clinicians utilized a ‘wait-and-see’ approach 63% of parents didn’t even fill their scripts and there was no difference in fever, otalgia or unscheduled visits.

 

Were there any potential conflicts of interest?

It’s always worth looking at the fine print. The lead author holds a patent related to the development of a version of co-amoxiclav.  Would it be unfair of me to state that this might be perceived as a major COI?

 

Bottom line

I would have loved to see a third arm in this study – the ten day placebo arm. The lead author has done a study comparing 10 days of antibiotics versus placebo and found no statistically significant difference between the two groups in terms of symptom resolution. With almost 1 in 3 children suffering from at least one adverse effect from antibiotics there was a great opportunity to look at the effectiveness of the antibiotics. If we take the results at face value the authors suggest we would have to treat six children with a 10 day course of co-amoxiclav to lessen clinical failure but that two of these six will suffer from diarrhoea and dermatitis.

In treating with antibiotics we really need to consider what our goal is. There seems to be no difference in long term adverse events if a child receives antibiotics or not and only marginal benefit if they do (perhaps a day less of ear related symptoms) but quite a high risk of the systemic effects of the antibiotics. I use a shared decision making approach with the parents in these cases…

“We can prescribe antibiotics for little Timmy’s earache. If it is a bacterial infection there is a one in six chance, the roll of a die, that he will have one day less of symptoms such as pain, but there is also almost a one in three chance we will give him diarrhoea and a nappy rash.”

If you want to be a probablestician then the chance of Timmy having a bacterial infection and being made symptomatically better by antibiotics is 1 in 24 (by my rusty A level statistics).

All of this is on the proviso that I am dealing with a routine patient. Certain subgroups such as the indigenous population are much more at risk from serious adverse events and need to be considered differently. Up to 73% of indigenous children under 12 months of age have suffered from AOM and its complications.

References

Damoiseaux RA, van Balen FA, Hoes AW, Verheij TJ, De Melker RA. Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years. Bmj. 2000 Feb 5;320(7231):350-4

American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004 May;113(5):1451

Niemela M, Uhari M, JOUNIO-ERVASTI KA, Luotonen J, Alho OP, Vierimaa E. Lack of specific symptomatology in children with acute otitis media. The Pediatric infectious disease journal. 1994 Sep 1;13(9):765-8.

Venekamp RP, Sanders S, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. The Cochrane Library. 2013 Jan 1

Hoberman A, Paradise JL, Rockette HE, Shaikh N, Wald ER, Kearney DH, Colborn DK, Kurs-Lasky M, Bhatnagar S, Haralam MA, Zoffel LM. Treatment of acute otitis media in children under 2 years of age. New England Journal of Medicine. 2011 Jan 13;364(2):105-15.
Gunasekera H, O’Connor TE, Vijayasekaran S, Del Mar CB. Primary care management of otitis media among Australian children. Medical journal of Australia. 2009 Nov 2;191(9):S55.
Kong K, Coates HL. Natural history, definitions, risk factors and burden of otitis media. Medical Journal of Australia. 2009 Nov 2;191(9):S39.
Shaikh N, Wang EE, Arguedas A, Dagan R, Soley C, Song J, Echols R. Acute otitis media severity of symptom score in a tympanocentesis study. The Pediatric infectious disease journal. 2011 Mar 1;30(3):253-5.

Laine MK, Tähtinen PA, Ruuskanen O, Huovinen P, Ruohola A. Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age. Pediatrics. 2010 May 1;125(5):e1154-61.

Spiro DM, Tay KY, Arnold DH, Dziura JD, Baker MD, Shapiro ED. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. Jama. 2006 Sep 13;296(10):1235-41

Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, Joffe MD, Miller DT, Rosenfeld RM, Sevilla XD, Schwartz RH. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar 1;131(3):e964-99.

Monasta L, Ronfani L, Marchetti F, Montico M, Brumatti LV, Bavcar A, Grasso D, Barbiero C, Tamburlini G. Burden of disease caused by otitis media: systematic review and global estimates. PLoS One. 2012 Apr 30;7(4):e36226.

Paradise JL, Hoberman A, Rockette HE, Shaikh N. Treating acute otitis media in young children: what constitutes success?. The Pediatric infectious disease journal. 2013 Jul;32(7):745.

Happy Holidays!

The team at Don’t Forget The Bubbles would like to wish all of those who come and visit us online a happy holiday season.

To make sure it is a good one we’ll leave you with this paper from the aptly named Journal of Happiness Studies…

Kasser T, Sheldon KM. What makes for a merry Christmas?. Journal of Happiness Studies. 2002 Dec 1;3(4):313-29.

This qualitative study involved information gleaned from interviews with 117 individuals, aged between 18 and 80, regarding their experiences of the Christmas season.  The bottom line is something that we, in our hearts, already knew -we are happier when they involve family or faith and less happy when spending money and receiving gifts is the overwhelming aim. This is something Charles Dickens well knew 180 years ago…

“There are many things from which I might have derived good, by which I have not profited, I dare say,’ returned the nephew. ‘Christmas among the rest. But I am sure I have always thought of Christmas time, when it has come round—apart from the veneration due to its sacred name and origin, if anything belonging to it can be apart from that—as a good time; a kind, forgiving, charitable, pleasant time; the only time I know of, in the long calendar of the year, when men and women seem by one consent to open their shut-up hearts freely, and to think of people below them as if they really were fellow-passengers to the grave, and not another race of creatures bound on other journeys. And therefore, uncle, though it has never put a scrap of gold or silver in my pocket, I believe that it has done me good, and will do me good; and I say, God bless it!”

Charles Dickens – A Christmas Carol

Our Friends in the North

As Christmas approaches I still cannot get used to it in the southern hemisphere. Coming from England I am used to a cold, dark, and often wet, festive season, with its attendant medical problems. I was reminded of this whilst listening to the latest podcast from Ken Milne and the Skeptics Guide to Emergency Medicine.

Ken and his guest skeptic, Chris Bond,  took a critical look at this paper, and were joined in discussion  by the author Amy Plint.

Plint, A.C., Taljaard, M., McGahern, C., Scott, S.D., Grimshaw, J.M., Klassen, T.P. and Johnson, D.W. (2016) ‘Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohorhttps://www.aap.org/en-us/Documents/quality_bqip_pediatrics.pdft Study’, CJEM, 18(6), pp. 443–452. doi: 10.1017/cem.2016.7.
Take a read of the paper before reading on…
This observational study of 28 community hospitals provided some interesting results.  It’s not the primary outcome of admission rates that I want to consider but some of the secondary outcome measures.
Key secondary outcomes
  • 80% of children received bronchodilators in the ED and 45% received them on discharge
  • 31% of children received steroids in the ED and 24% on discharge
  • 5% received antibiotics in the ED and 13% on discharge
  • 55% of children received a chest x-ray
  • 23% had a nasopharyngeal swab
  • 7% had blood tests

Bronchiolitis is one of the most common causes of presentation to the emergency department and accounts for around 2% of all paediatric admissions.  But I don’t want to concentrate on the management of bronchiolitis here – take a look at Henry’s post here or listen to the smooth Tim Horeczko for the latest – I want to consider why there is such a deviation between what we would consider standard practice and actual practice.

The study was carried out in mixed community emergency departments, staffed by generalists rather than trained paediatric emergency practitioners. Some of the sites only recruited 2 patients and so it is understandable that they might not be up to date with current recommendations. The major factor that lessens the external validity of this study is the that the data was based on presentations between the 2005 and 2007 bronchiolitis seasons. Hopefully there has been an increased uptake of clinical guidelines since then.

Cabana et al. identified a number of factors affecting adherence to clinical practice guidelines. They break down to those related to either physician attitudes, physician knowledge or behaviours.

Attitudes

  • Not agreeing with specific guidelines e.g. interpretation of the evidence
  • Not agreeing with guidelines in general
  • Lack of motivation

Knowledge

  • Lack of familiarity perhaps due to amount of knowledge available or lack of access
  • Lack of awareness associated with time needed to stay up to date

Behaviours

  • Patient factors such as problems reconciling patient preferences with guidelines
  • Guideline factors such as the presence of contradictory guidelines
  • Environmental factors such as a lack of time or resources

We covered the role FOAM can play in cutting down the knowledge translation window before and it is initiatives like the SGEM ‘Hot off the Press‘ that can help this happen.

References

Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines?: A framework for improvement. Jama. 1999 Oct 20;282(15):1458-65.

Lenzer J. Why we can’t trust clinical guidelines. BMJ. 2013 Jun 14;346(58):f3830.

Fryar C. Doctors can depart from guidelines in patients’ best interests. BMJ. 2015 Feb 18;350:h841.

Lenzer J, Hoffman JR, Furberg CD, Ioannidis JP, Guideline Panel Review Working Group. Ensuring the integrity of clinical practice guidelines: a tool for protecting patients. BMJ. 2013 Sep 17;347:f5535.

Jenco M. QI project decreases unnecessary care for bronchiolitis.

Korppi M. What are evidence‐based guidelines and what are they not?. Acta Paediatrica. 2016 Jan 1;105(1):11-2.

Ralston SL, Garber MD, Rice-Conboy E, Mussman GM, Shadman KA, Walley SC, Nichols E. A multicenter collaborative to reduce unnecessary care in inpatient bronchiolitis. Pediatrics. 2016 Jan 1;137(1):e20150851.