137. Antibiotics in Children, TSH, Hip Osteoarthritis, Mammograms

https://www.youtube.com/watch?v=EBhEjYhVoZk

Goggin K et al. Reductions in parent interest in receiving antibiotics following a 90-second video intervention in outpatient pediatric clinics. J Pediatr 2020 Jun 15; [e-pub]. (https://doi.org/10.1016/j.jpeds.2020.06.027)

acute respiratory tract illnesses (ARTIs; cough, congestion, sore throat, and earache) is a PROBLEM with a capital P. or maybe I should say its a pain in the A with a capital A and that A of course is referring to antibiotics-- parents want antibiotics, sometimes demand antibiotics and no matter what you say, its hard to say no time and time and time again and eventually EVERYONE and yes I mean everyone will eventually give an antibiotic when they in their heart of heart knows it is likely not indicated. BUT what if we could educate our pts before we walked in the room.

In this study they surveyed 1051 parents about their knowledge of and interest in receiving antibiotics for their children. Surveys were conducted before and after parents watched a professionally created 90-second cartoon-- I dont have access to the cartoon but I didnt find a two minute cartoon on youtube and it is the in the show notes-- just go to details of this podcast! how do you get to the details??
if you are listening to this podcast on apple you click the little dots in the lower right hand corner, click go to show, then it goes to this show and click on details and BAM its magic all the information about this show. and ths me there is a listener named paul and I wont give the last name but you emailed me about an article and for the life of me I can’t find that article back so please re email me andrewbuelt@gmail.com
back to the study
in this survey
Parents rated their interest in receiving an antibiotic using a visual analogue scale ranging from 0-100, with 0 being “I definitely do not want an antibiotic,” 50 “Neutral,” and 100 “I absolutely want an antibiotic.”

at baseline average score was 57 and it reduced down to 47 BUT if you were one of the parents that scored much higher say a mean around 83 which is geting close to the 100 “I absolutely want an antibiotic.” your score dropped down to 63 which is much closer to neutral!! This gives you a chance to not write antibiotics if not needed- i dont take care of kids 1-5 but if I did EVERY parent would be watching this video or it would be on repeat for the education videos.


last episode I talked about breast cancer screening and the age old saying is when it rains it pours which is clearly seen in this paper

Le Blanc JM et al. Association of Medicaid expansion under the Affordable Care Act with breast cancer stage at diagnosis. JAMA Surg 2020 Jul 1; [e-pub]. (https://doi.org/10.1001/jamasurg.2020.1495)

Affordable Care Act (ACA) went into full effect in early 2014.
luckily for us as of 2018, 37 states, including the District of Columbia had adopted Medicaid expansion and 14 had not.
this is prime time to look to see what happens when all of a sudden these women have insurance and can get mammograms! Ideally we should see a burst of new early cancers that then prevent all these really aggressive late cancers!! riiiiiight??
in this retrospective cohort analysis they looked at Stage at diagnosis was compared between patients who were uninsured, had Medicaid or Medicare, or were privately covered during the preexpansion years (2012-2013) and postexpansion years (2015-2016)
Stage at diagnosis (early [stage 0 or 1] vs. late [stage 3 or 4]) was assessed by state and insurance status for pre-expansion years (2012–2013) compared with postexpansion years (2015–2016).

“Between 2007 and 2012, the percentage of late-stage cancer was around 12% for those that were insurance or had medicaid”- this makes sense if you have insurance all things being equal all states should have pretty equal rates of breast cancer
BUT
Patients with late-stage cancer who were uninsured in nonexpansion states exhibited a 1 percentage–point non significant decline from 24.2% to 23.5% (P = .14), whereas patients with late-stage cancer who were uninsured or had Medicaid in the expansion states saw a significant decrease from 21.8% to 19.3% (P 
What they are trying to say is look at this if you are in a state that has insurance expansion then you yes you are more likely to see a decrease in late or advance breast cancer BUT the devel is in the detail. First they gave you a decrease in percentage points which is always a red flag, do you not think I as an educated individual reading your paper can tell the difference between hard numbers?? If you go to the actually hard core numbers it tells a different story!
If you look at the hard numbers you will find that all of a sudden the numbers are not so clear- infact those states that expanded medicaid and took on the ACA actually had a 7% decrease in their rates of advance cancer while those who did not expand medicaid or take on medicaid had almost a 15% decrease in their rates of advance breast cancer. maybe the final results should be -- if you want to lower your rates of advance breast cancer then dont advance medicaid and give mammograms for everyone cause it didnt do the job-- or at least that would be the finals results if I was writing the paper---



Yamamoto JM et al. Thyroid function testing and management during and after pregnancy among women without thyroid disease before pregnancy. CMAJ 2020 Jun 1; 192:E596. (https://doi.org/10.1503/cmaj.191664)
retrospective cohort study of 111 522 (59.2%) women who had at least 1 TSH measurement
in total 4% or 4417 women had “subclinical hypothyroid which was defined as a range between 4.01 and 9.99 mIU/L. about half were started on treatment synthroid and half were not. of the almost 2000 with subclinical hypothryoid that were not started on therapy and got another TSH test- 68% had a repeat TSH wnl. and if you thought o good the tsh went back to normal, that women is fine, you would be wrong because despite the numbers going back to normal for 68% of the women, roughly 40% of the women WERE STILL STARTED ON synthroid or thyroid medication!! The frustration with TSH exceeds my words and the logic is exactly the opposite, purely illogical.

At baseline almost 1400k women had normal TSH and were still started on treatment- with a normal TSH!
AND of the women with TSH value of 10.00 mIU/L or higher, the women that you would think need to be started on TSH or at least may benefit from being on thyroid hormone therapy only had initiated during only 300 (17.6%) of the pregnancies. LESS than 1 in 5 women were started on thyroid therapy with TSH > 10 and roughly 1 in 10 were started on thyroid therapy with TSH in normal range. Sometimes I really get worried


how do you know that hip pain is osteoarthritis and not a strangulated inguinal hernia

Does this patient have hip osteoarthritis?: The rational clinical examination systematic review Metcalfe D, Perry DC, Claireaux HA, et al. JAMA. 2019;322(23):2323-2333. doi: 10.1001/jama.2019.19413.
Let’s say your patient has hip or groin pain. How do you know if it’s osteoarthritis (OA)?

results
in the end Six studies with 1,110 patients; 509 (38%) had radiographic hip OA.
The following features were found to be useful:
Squat causing posterior pain (likelihood ratio [LR] +6.1)
Groin pain on passive adduction or abduction (LR +5.7)
to rule out OA is normal passive hip adduction (LR –0.25)
while these are not high LR ratios over 10 that we would hope for, if you combine a couple of them together they can work synergistically to give you a higher likelihood ratio and more secure diagnosis.