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CMAJ : Canadian Medical Association... Jan 2015Several clinical prediction rules for diagnosing group A streptococcal infection in children with pharyngitis are available. We aimed to compare the diagnostic accuracy... (Review)
Review
Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective multicentre external validation study.
BACKGROUND
Several clinical prediction rules for diagnosing group A streptococcal infection in children with pharyngitis are available. We aimed to compare the diagnostic accuracy of rules-based selective testing strategies in a prospective cohort of children with pharyngitis.
METHODS
We identified clinical prediction rules through a systematic search of MEDLINE and Embase (1975-2014), which we then validated in a prospective cohort involving French children who presented with pharyngitis during a 1-year period (2010-2011). We diagnosed infection with group A streptococcus using two throat swabs: one obtained for a rapid antigen detection test (StreptAtest, Dectrapharm) and one obtained for culture (reference standard). We validated rules-based selective testing strategies as follows: low risk of group A streptococcal infection, no further testing or antibiotic therapy needed; intermediate risk of infection, rapid antigen detection for all patients and antibiotic therapy for those with a positive test result; and high risk of infection, empiric antibiotic treatment.
RESULTS
We identified 8 clinical prediction rules, 6 of which could be prospectively validated. Sensitivity and specificity of rules-based selective testing strategies ranged from 66% (95% confidence interval [CI] 61-72) to 94% (95% CI 92-97) and from 40% (95% CI 35-45) to 88% (95% CI 85-91), respectively. Use of rapid antigen detection testing following the clinical prediction rule ranged from 24% (95% CI 21-27) to 86% (95% CI 84-89). None of the rules-based selective testing strategies achieved our diagnostic accuracy target (sensitivity and specificity>85%).
INTERPRETATION
Rules-based selective testing strategies did not show sufficient diagnostic accuracy in this study population. The relevance of clinical prediction rules for determining which children with pharyngitis should undergo a rapid antigen detection test remains questionable.
Topics: Bacteriological Techniques; Child; Diagnosis, Differential; Humans; Multicenter Studies as Topic; Pharyngitis; Practice Guidelines as Topic; Predictive Value of Tests; Prospective Studies; Streptococcal Infections; Streptococcus pyogenes; Validation Studies as Topic
PubMed: 25487666
DOI: 10.1503/cmaj.140772 -
The Cochrane Database of Systematic... Nov 2014Surgical removal of the tonsils, with or without adenoidectomy (adeno-/tonsillectomy), is a common ENT operation, but the indications for surgery are controversial. This... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical removal of the tonsils, with or without adenoidectomy (adeno-/tonsillectomy), is a common ENT operation, but the indications for surgery are controversial. This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 1999 and previously updated in 2009.
OBJECTIVES
To assess the effectiveness of tonsillectomy (with and without adenoidectomy) in children and adults with chronic/recurrent acute tonsillitis in reducing the number and severity of episodes of tonsillitis or sore throat.
SEARCH METHODS
We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 30 June 2014.
SELECTION CRITERIA
Randomised controlled trials comparing tonsillectomy (with or without adenoidectomy) with non-surgical treatment in adults and children with chronic/recurrent acute tonsillitis.
DATA COLLECTION AND ANALYSIS
We used the standard methodological procedures expected by The Cochrane Collaboration.
MAIN RESULTS
This review includes seven trials with low to moderate risk of bias: five undertaken in children (987 participants) and two in adults (156 participants). An eighth trial in adults (40 participants) was at high risk of bias and did not provide any data for analysis. Good information about the effectiveness of adeno-/tonsillectomy is only available for the first year following surgery in children and for a shorter period (five to six months) in adults.We combined data from five trials in children; these trials included children who were 'severely affected' (based on the specific 'Paradise' criteria) and less severely affected. Children who had an adeno-/tonsillectomy had an average of three episodes of sore throats (of any severity) in the first postoperative year, compared to 3.6 episodes in the control group; a difference of 0.6 episodes (95% confidence interval (CI) -1 to -0.1; moderate quality evidence). One of the three episodes in the surgical group was the 'predictable' one that occurred in the immediate postoperative period.When we analysed only episodes of moderate/severe sore throat, children who had been more severely affected and had adeno-/tonsillectomy had on average 1.1 episodes of sore throat in the first postoperative year, compared with 1.2 episodes in the control group (low quality evidence). This is not a significant difference but one episode in the surgical group was that occurring immediately after surgery.Less severely affected children had more episodes of moderate/severe sore throat after surgery (1.2 episodes) than in the control group (0.4 episodes: difference 0.8, 95% CI 0.7 to 0.9), but again one episode was the predictable postoperative episode (moderate quality evidence).Data on the number of sore throat days is only available for moderately affected children and is consistent with the data on episodes. In the first year after surgery children undergoing surgery had an average of 18 days of sore throat (of which some - between five and seven on average - will be in the immediate postoperative period), compared with 23 days in the control group (difference 5.1 days, 95% CI 2.2 to 8.1; moderate quality evidence).When we pooled the data from two studies in adults (156 participants), there were 3.6 fewer episodes (95% CI 7.9 fewer to 0.70 more; low quality evidence) in the group receiving surgery within six months post-surgery. However, statistical heterogeneity was significant. The pooled mean difference for number of days with sore throat in a follow-up period of about six months was 10.6 days fewer in favour of the group receiving surgery (95% CI 5.8 fewer to 15.8 fewer; low quality evidence). However, there was also significant statistical heterogeneity in this analysis and the number of days with postoperative pain (which appeared to be on average 13 to 17 days in the two trials) was not included. Given the short duration of follow-up and the differences between studies, we considered the evidence for adults to be of low quality.Two studies in children reported that there was "no statistically significant difference" in quality of life outcomes, but the data could not be pooled. One study reported no difference in analgesics consumption. We found no evidence for prescription of antibiotics.Limited data are available from the included studies to quantify the important risks of primary and secondary haemorrhage.
AUTHORS' CONCLUSIONS
Adeno-/tonsillectomy leads to a reduction in the number of episodes of sore throat and days with sore throat in children in the first year after surgery compared to (initial) non-surgical treatment. Children who were more severely affected were more likely to benefit as they had a small reduction in moderate/severe sore throat episodes. The size of the effect is very modest, but there may be a benefit to knowing the precise timing of one episode of pain lasting several days - it occurs immediately after surgery as a direct consequence of the procedure. It is clear that some children get better without any surgery, and that whilst removing the tonsils will always prevent 'tonsillitis', the impact of the procedure on 'sore throats' due to pharyngitis is much less predictable.Insufficient information is available on the effectiveness of adeno-/tonsillectomy versus non-surgical treatment in adults to draw a firm conclusion.The impact of surgery, as demonstrated in the included studies, is modest. Many participants in the non-surgical group improve spontaneously (although some people randomised to this group do in fact undergo surgery). The potential 'benefit' of surgery must be weighed against the risks of the procedure as adeno-/tonsillectomy is associated with a small but significant degree of morbidity in the form of primary and secondary haemorrhage and, even with good analgesia, is particularly uncomfortable for adults.
Topics: Acute Disease; Adenoidectomy; Adult; Child; Chronic Disease; Humans; Pharyngitis; Randomized Controlled Trials as Topic; Recurrence; Tonsillectomy; Tonsillitis
PubMed: 25407135
DOI: 10.1002/14651858.CD001802.pub3 -
PloS One 2014Pharyngitis management guidelines include estimates of the test characteristics of rapid antigen streptococcus tests (RAST) using a non-systematic approach. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pharyngitis management guidelines include estimates of the test characteristics of rapid antigen streptococcus tests (RAST) using a non-systematic approach.
OBJECTIVE
To examine the sensitivity and specificity, and sources of variability, of RAST for diagnosing group A streptococcal (GAS) pharyngitis.
DATA SOURCES
MEDLINE, Cochrane Reviews, Centre for Reviews and Dissemination, Scopus, SciELO, CINAHL, guidelines, 2000-2012.
STUDY SELECTION
Culture as reference standard, all languages.
DATA EXTRACTION AND SYNTHESIS
Study characteristics, quality.
MAIN OUTCOME(S) AND MEASURE(S)
Sensitivity, specificity.
RESULTS
We included 59 studies encompassing 55,766 patients. Forty three studies (18,464 patients) fulfilled the higher quality definition (at least 50 patients, prospective data collection, and no significant biases) and 16 (35,634 patients) did not. For the higher quality immunochromatographic methods in children (10,325 patients), heterogeneity was high for sensitivity (inconsistency [I(2)] 88%) and specificity (I(2) 86%). For enzyme immunoassay in children (342 patients), the pooled sensitivity was 86% (95% CI, 79-92%) and the pooled specificity was 92% (95% CI, 88-95%). For the higher quality immunochromatographic methods in the adult population (1,216 patients), the pooled sensitivity was 91% (95% CI, 87 to 94%) and the pooled specificity was 93% (95% CI, 92 to 95%); however, heterogeneity was modest for sensitivity (I(2) 61%) and specificity (I(2) 72%). For enzyme immunoassay in the adult population (333 patients), the pooled sensitivity was 86% (95% CI, 81-91%) and the pooled specificity was 97% (95% CI, 96 to 99%); however, heterogeneity was high for sensitivity and specificity (both, I(2) 88%).
CONCLUSIONS
RAST immunochromatographic methods appear to be very sensitive and highly specific to diagnose group A streptococcal pharyngitis among adults but not in children. We could not identify sources of variability among higher quality studies. The present systematic review provides the best evidence for the wide range of sensitivity included in current guidelines.
Topics: Chromatography, Affinity; Humans; Immunoenzyme Techniques; Pharyngitis; Sensitivity and Specificity; Streptococcal Infections; Streptococcus pyogenes
PubMed: 25369170
DOI: 10.1371/journal.pone.0111727 -
BMJ Clinical Evidence Jul 2014The definition of severe recurrent throat infections is arbitrary, but recent criteria have defined severe tonsillitis as: five or more episodes of true tonsillitis a... (Review)
Review
INTRODUCTION
The definition of severe recurrent throat infections is arbitrary, but recent criteria have defined severe tonsillitis as: five or more episodes of true tonsillitis a year; symptoms for at least 1 year; and episodes that are disabling and prevent normal functioning. Diagnosis of acute tonsillitis is clinical, and it can be difficult to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis, but more accurate tests take longer to deliver results. Bacteria are cultured from few people with tonsillitis. Other causes include infectious mononucleosis from Epstein-Barr virus infection, cytomegalovirus, toxoplasmosis, HIV, hepatitis A, and rubella.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of tonsillectomy in children and adults with acute recurrent or chronic throat infections? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 15 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: cold-steel tonsillectomy and diathermy tonsillectomy.
Topics: Electrocoagulation; Humans; Tonsillectomy; Tonsillitis
PubMed: 25051184
DOI: No ID Found -
Anaesthesia Oct 2014We systematically reviewed 31 adult randomised clinical trials of the i-gel(®) vs laryngeal mask airway. The mean (95% CI) leak pressure difference and relative risk... (Comparative Study)
Comparative Study Meta-Analysis Review
We systematically reviewed 31 adult randomised clinical trials of the i-gel(®) vs laryngeal mask airway. The mean (95% CI) leak pressure difference and relative risk (95% CI) of insertion on the first attempt were similar: 0.40 (-1.23 to 2.02) cmH2 O and 0.98 (0.95-1.01), respectively. The mean (95% CI) insertion time and the relative risk (95% CI) of sore throat were less with the i-gel: by 1.46 (0.33-2.60) s, p = 0.01, and 0.59 (0.38-0.90), p = 0.02, respectively. The relative risk of poor fibreoptic view through the i-gel was 0.29 (0.16-0.54), p < 0.0001. All outcomes displayed substantial heterogeneity, I(2) ≥ 75%. Subgroup analyses did not decrease heterogeneity, but suggested that insertion of the i-gel was faster than for first-generation laryngeal mask airways and that the i-gel leak pressure was higher than first generation, but lower than second-generation, laryngeal mask airways. A less frequent sore throat was the main clinical advantage of the i-gel.
Topics: Adult; Humans; Laryngeal Masks; Pharyngitis; Randomized Controlled Trials as Topic
PubMed: 25040063
DOI: 10.1111/anae.12772 -
Anaesthesia Sep 2014Previous comparisons between the Ambu(®) AuraOnce(™) and other laryngeal mask airways have revealed different results across various clinical studies. We aimed to... (Comparative Study)
Comparative Study Meta-Analysis Review
Previous comparisons between the Ambu(®) AuraOnce(™) and other laryngeal mask airways have revealed different results across various clinical studies. We aimed to perform a systematic review with meta-analysis on the efficacy and safety of the AuraOnce compared with other laryngeal mask airways for airway maintenance in adults undergoing general anaesthesia. Our search of PubMed, PubMed Central, Scopus and the Central Register of Clinical Trials of the Cochrane Collaboration yielded nine randomised controlled trials eligible for inclusion. Comparator laryngeal mask airways were the LMA Unique(™) (four trials), the LMA Classic(®) (five trials) and the Portex(®) Soft Seal(®) (three trials). The AuraOnce provided an oropharyngeal leak pressure higher than the LMA Unique (304 participants, mean (95% CI) difference 3.1 (1.6-4.7) cmH2 O, p < 0.0001) and equivalent to the LMA Classic. The Soft Seal provided a higher leak pressure than the AuraOnce (229 participants, mean (95% CI) difference 3.5 (0.4-6.7) cmH2 O, p = 0.03). Insertion was significantly faster with the AuraOnce than the LMA Unique (304 participants, mean (95% CI) difference 5.4 (2.1-8.71) s, p = 0.001) and Soft Seal (229 participants, mean (95% CI) difference 9.5 (3.0-15.9) s, p = 0.004), but similar to the LMA Classic. The first-insertion success rate of the AuraOnce was equivalent to the LMA Unique, LMA Classic and Soft Seal. We found a higher likelihood of bloodstaining on the cuff with the Soft Seal and a higher incidence of sore throat with the LMA Classic. We conclude that the AuraOnce is an effective alternative to the LMA Classic and LMA Unique, and easier to insert than all three other devices studied.
Topics: Adolescent; Adult; Aged; Air Pressure; Anesthesia, General; Female; Humans; Laryngeal Masks; Larynx; Male; Middle Aged; Odds Ratio; Patient Safety; Pharyngitis; Postoperative Complications; Prospective Studies; Randomized Controlled Trials as Topic; Treatment Outcome; Young Adult
PubMed: 24801012
DOI: 10.1111/anae.12682 -
BMC Family Practice Mar 2014Ambroxol has a local anaesthetic action and is marketed for pain relief for sore throat. The objective is to examine the efficacy and safety of ambroxol for the relief... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Ambroxol has a local anaesthetic action and is marketed for pain relief for sore throat. The objective is to examine the efficacy and safety of ambroxol for the relief of pain associated with acute uncomplicated sore throat.
METHODS
A systematic review of the literature and meta-analysis. Selection criteria consisted of randomized controlled trials which compared ambroxol to placebo or any other treatment for sore throat. Two reviewers independently assessed for relevance, inclusion, and risk of bias. Weighted mean differences (WMDs) were calculated and are reported with corresponding 95% confidence intervals (CIs).
RESULTS AND CONCLUSION
From 14 potentially relevant citations, five trials reported in three publications met the inclusion criteria, three of them were published twice. Ambroxol lozenges were compared in different dosages (5-30 mg) with mint flavoured lozenges and once with benzocaine. Main outcome was a ratio of pain reduction measured repeatedly over 3 h compared to baseline on 6-item verbal rating scale. A total of 1.772 adult patients participated in the trials. Pain intensity decreased in both study arms. A meta-analysis of the 5 controlled trials resulted in a difference in pain reduction compared to placebo of -0.11 (95% CI [-0.15, -0.07]; p < 0.0001) favouring ambroxol 20 mg. Quality of reporting of the studies was low. Ambroxol is slightly more effective in relieving pain in acute sore throat than mint flavoured lozenges over a period of 3 h. However, the additional benefits of ambroxol beyond three hours, remain unclear given that more than 50% of patients using mint flavoured lozenges for pain relief reported good or very good efficacy after 1 day compared to 69% with ambroxol. Ambroxol is a safe option for individual patients with mainly local symptoms asking for treatment.
Topics: Ambroxol; Dosage Forms; Humans; Pain; Pharyngitis
PubMed: 24621446
DOI: 10.1186/1471-2296-15-45 -
BMJ Clinical Evidence Mar 2014About 10% of people present to primary healthcare services with sore throat each year. The causative organisms of sore throat may be bacteria (most commonly... (Review)
Review
INTRODUCTION
About 10% of people present to primary healthcare services with sore throat each year. The causative organisms of sore throat may be bacteria (most commonly Streptococcus) or viruses (typically rhinovirus), although it is difficult to distinguish bacterial from viral infections clinically.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of interventions to reduce symptoms of acute infective sore throat? We searched Medline, Embase, The Cochrane Library, and other important databases up to September 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 6 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: antibiotics, corticosteroids, non-steroidal anti-inflammatory drugs, and paracetamol.
Topics: Acetaminophen; Adrenal Cortex Hormones; Anti-Bacterial Agents; Anti-Inflammatory Agents, Non-Steroidal; Humans; Pharyngitis; Treatment Outcome
PubMed: 24589314
DOI: No ID Found -
PloS One 2014To summarize recommendations of existing guidelines on the treatment of upper respiratory tract infections (URTIs) in children, and to assess the methodological quality... (Review)
Review
OBJECTIVES
To summarize recommendations of existing guidelines on the treatment of upper respiratory tract infections (URTIs) in children, and to assess the methodological quality of these guidelines.
METHODS
We searched seven databases and web sites of relevant academic agencies. Evidence-based guidelines on pediatric URTIs were included. AGREE II was used to assess the quality of these guidelines. Two researchers selected guidelines independently and extracted information on publication years, institutions, target populations, recommendations, quality of evidence, and strength of recommendations. We compared the similarities and differences of recommendations and their strength. We also analyzed the reasons for variation.
RESULTS
Thirteen guidelines meeting our inclusion criteria were included. Huge differences existed among these 13 guidelines concerning the categorization of evidence and recommendations. Nearly all of these guidelines lacked the sufficient involvement of stake holders. Further, the applicability of these guidelines still needs to be improved. In terms of recommendations, penicillin and amoxicillin were suggested for group A streptococcal pharyngitis. Amoxicillin and amoxicillin-clavulanate were recommended for acute bacterial rhinosinusitis (ABRS). An observation of 2-3 days prior to antibiotic therapy initiation for mild acute otitis media (AOM) was recommended with amoxicillin as the suggested first choice agent. Direct evidence to support strong recommendations on the therapy for influenza is still lacking. In addition, the antimicrobial durations for pharyngitis and ABRS were still controversial. No consensus was reached for the onset of antibiotics for ABRS in children.
CONCLUSIONS
Future guidelines should use a consistent grading system for the quality of evidence and strength of recommendations. More effort needs to be paid to seek the preference of stake holders and to improve the applicability of guidelines. Further, there are still areas in pediatric URTIs that need more research.
Topics: Anti-Bacterial Agents; Child; Evidence-Based Medicine; Humans; Practice Guidelines as Topic; Respiratory Tract Infections
PubMed: 24586287
DOI: 10.1371/journal.pone.0087711 -
Journal of Infection in Developing... Jan 2014Zoonoses are infections transmitted from animal to man, either directly (through direct contact or contact with animal products) or indirectly (through an intermediate... (Review)
Review
INTRODUCTION
Zoonoses are infections transmitted from animal to man, either directly (through direct contact or contact with animal products) or indirectly (through an intermediate vector, such as an arthropod). The causative agents include bacteria, parasites, viruses, and fungi. The purpose of this review is to make an accurate examination of all zoonotic diseases that can be responsible of ear, nose, and throat (ENT) involvement.
METHODOLOGY
A PubMed search was performed combining the terms (otorhinolaryngology OR rhinology OR laryngology OR otology OR mastoiditis OR otitis OR sinusitis OR laryngitis OR rhinitis OR pharyngitis OR epiglottitis OR dysphonia OR ear OR larynx OR nose OR pharynx) with each one of the etiological agents of zoonoses for the period between January 1997 and August 2012 without language restrictions.
RESULTS
A total of 164 articles were selected and examined. Larynx was the most commonly involved ENT organ, followed by oral cavity, pharynx, and neck. Bacteria were the most representative microorganisms involved. Nose and major salivary glands were affected most frequently by protozoa; paranasal sinus, oral cavity, ear, neck, nerves and upper airway by bacteria; and larynx by fungi.
CONCLUSIONS
ENT symptoms and signs may be present in many zoonotic diseases, some of which are also present in industrialized countries. Most zoonotic diseases are not commonly encountered by ENT specialists. Appreciation of the possible occurrence of these diseases is important for a correct microbiological approach, which often requires special culture media and diagnostic techniques.
Topics: Animals; Ear Diseases; Humans; Nose Diseases; Pharyngeal Diseases; Zoonoses
PubMed: 24423708
DOI: 10.3855/jidc.4206