Data from the Updated Cochrane review on Antibiotics for Acute Otitis Media.

Chris Cates has updated his excellent "NNT" digrams for the management of acute otitis media.  He's got these cool charts that help explain the concept of an NNT.  I use these in the office .. pulling up his site on the internet and walking parents through these concepts.  WHile 1st year medical students seem to have a problem with "NNT" — mom and dad seem to "get it" without too much trouble.

Coordinating Government Roles in Improving Healthcare Quality

Today, the IOM released another report on the state of medical care and medical errors.

"We strived to view the health system from the perspective of patients, especially those with chronic conditions, where a premium is placed on care that is coordinated over time, across settings, and across multiple payers. Such a coordinated focus requires government programs and health care providers to unify and standardize their quality-improvement efforts. Our report encourages the federal government to take full advantage of its influential position to set the quality standard for the entire health care sector"

It's compelling stuff, and deserves a careful read at the very least.  Their take-home message is a valuable one:  if we are going to have significant, coordinated progress in reducing medical errors, and improving efficiency, there needs to be clear, agressive federal leadership.

I think that this is another suggestion that the "free market" doesn't apply to healthcare.  While it may very well work for widgets and alkaline batteries and perhaps even corn meal .. healthcare .. and the enormous economies that are woven together around healthcare … is different.  I agree that we need to develop strong leadership to coordinate such an effort .. but .. as my former boss used to say .. "it's like herding cats."

Perianal strep – “strep butt” in an adult

 One of the joys of being a physician is treating family members over the phone.  For the past two weeks, I've done my best to help a family member 3000 miles away with rectal itching.   Amid phone calls about "my hiney hole" … we've run through the list of disorders that could be causing the problem.  The note home from the kids' school about pinworm turned out to be a red herring .. as the course of mebendazole didn't help much, and the stool was negative for parasites.  

And so this went on-and-on.  Her physician (an internist) diagnosed hemorrhoids .. but treatment didn't help at all.  ?A fungal infection?  The physician tried antifungals. No change … it even seemed a bit worse.

Weeks pass .. and still no resolution.  I start to try to learn about the physical signs.  The husband gets involved.. he reports a bright red area around the anus. 

She's got two kids – 6 and 4.  Hmmm … the only thing I can think of that hasn't been considered is GABHS.  I haven't seen "strep butt" in an adult .. but kids do get it .. and I see a few cases of it every year.  Could this 36 year old mother-of-two-likely-strep-vectors get it?  I don't see why not.  I suggest this .. and suggest that she get a strep culture (or even a rapid test) from her physician.

End of long story:  after working (very) hard to convince her physician (who had never heard of perianal strep) that this was a reasonable diagnostic test .. my relative received a phone call today from her very surprised physician – "very heavy GABHS." 

While reasonably common in children, now we all know GABHS can be seen in adults too.