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Association between chiropractic and pediatric classroom hours of microbiology with patterns of diagnosis of children with otitis media, upper respiratory or ear infection between 1995 and 2015.

Abstract: In 2010 a systematic review of 135 citations concluded that acute otitis media microbiology has changed with the use of pneumococcal conjugate vaccine (PCV7) and antibiotics are modestly more effective than no treatment but cause adverse effects in 4% to 10% of children.

Objective: The purpose of this study is to compare the classroom hours of microbiology between chiropractors and pediatricians in relation to patterns of diagnosis for children with otitis media, upper respiratory or ear infection.

Methods: A search of the available database to track down practice patterns for pediatricians was performed using the key words: diagnostic, accuracy, otitis and pediatrician. For chiropractic pattern of diagnosis data from the Job Analysis of Chiropractic for the years 2000 2005 and 2015 were used.

Only studies between 1995 and 2015 were included. Classroom hours of microbiology were calculated by performing a search of the chiropractic school catalogs using the keywords: microbiology 1 and microbiology 2. Postgraduate hours were not accounted for in this study. For allopathic training, data from one published study was used.

Results: Chiropractors receive a similar amount of classroom hours of microbiology compared to pediatricians upon finishing medical school (141/120). 51 % of chiropractors made an initial diagnosis to children with upper respiratory or ear infection compared to 50% of children with otitis media that were given an accurate diagnosis of otitis media by a pediatrician.

Conclusion: In this study, classroom hours of microbiology had a positive correlation with patterns of diagnosis for children with otitis media or ear infections for both chiropractic physicians and pediatricians. Perhaps the hours dedicated to pathogens causing ear infections in the microbiology syllabus should include image identification of infected ears and pneumatic video otoendoscopies. Since this is an observational study causal inference isn't claimed. Further studies confirming these studies are warranted.

Keywords: diagnostic, accuracy, otitis, pediatrician and chiropractic

Introduction

Otitis media is a complex and multifactorial condition with four defined stages: myringitis, acute otitis media, secretory (serous) otitis media, and chronic otitis media. In acute otitis media, the major organisms present are haemophilus influenzae, streptococcus pneumoniae, and moraxella catarrhalis. In chronic otitis media, these organisms, plus Staphylococcus aureus, escherichia coli, klebsiella pneumoniae, Pseudomonas aeruginosa and anaerobic bacteria are all prevalent. The microbiological flora of the middle ear in secretory otitis media is almost identical with that in acute otitis media. In cases of failure, in the immunocompromised and in instances of chronic otitis media, establishing the individual microbiology of the inflamed middle ear is very helpful. (1)

In 2010, a cross-sectional survey conducted in France, Germany, Spain, Poland, Argentina, Mexico, South Korea, Thailand and Saudi Arabia were made. Face-to-face interviews conducted with 1800 physicians (95% pediatricians) found that there was high awareness of streptococcus pneumoniae and haemophilus influenzae as causative bacterial pathogens: 77% and 74% respectively, but less recognition of non-typeable H. influenzae (NTHi); 59%. Although concern over antimicrobial resistance was widespread, empirical treatment with antibiotics was the most common first-line treatment. (2)

The condition of otitis media was selected because of the evidence of chiropractic treatment efficiency for children with otitis media. In 2012, Pohlman, et al, conducted a literature review of 49 articles: 17 commentaries, 15 case reports, 5 case series, 8 reviews, and 4 clinical trials where no serious adverse events were found. This literature review concluded that it is possible that some children with otitis media may benefit from spinal manipulative therapy or combined with other therapies. (3)

One survey of 586 chiropractors in 2003 conducted by McDonald, et al, found that 77% of chiropractors had good clinical outcomes when performing spinal manipulative therapy to patients with otitis media. (4) Another survey of 548 chiropractors in 2010, conducted by Alcantara, et al, found that ear, nose, and throat was the second most common pediatric condition addressed by chiropractors in practice. (5)

A few studies have evaluated the diagnosis practice patterns among general practitioners and pediatric residents. In 1990, Froom, et al, conducted a study involving general practices in Australia, Belgium, Great Britain, Israel, the Netherlands, New Zealand, Canada, Switzerland, and the United States with a total of 3660 children divided into the three age groups 0-12 months, 13-30 months, and greater or equal to 31 months. This study found that the diagnostic certainty in patients aged 0-12 months was 58%. This increased to 66% in those aged 13-30 months and 73.3% in those aged, greater or equal than 31 months. (6)

In 2002, Pichichero, conducted a study of 383 pediatric residents from various programs in the United States and found that the average standard deviation correct diagnosis on the otoscopic video examination was 41%. This study concluded that pediatric residents misdiagnose otitis media with effusion frequently. (7)

The purpose of this study is to compare the classroom hours of microbiology between chiropractors and pediatricians upon finishing medical school in relation to patterns of diagnosis for children with otitis media, upper respiratory or ear infection.

Methods

A search of the available database to track down diagnosis practice patterns for pediatricians was performed with a search of the pubmed and google scholar electronic database using the key words: diagnostic, accuracy, otitis and pediatrician. An inclusion and exclusion criteria was performed. Only studies between 1995 and 2015 measuring the diagnosis accuracy of pediatricians for children with otitis media were included.

For chiropractic pattern of diagnosis for children with upper respiratory or ear infection, an inclusion and exclusion criteria was performed. Only data from the Job Analysis of Chiropractic between 1995 and 2015 measuring the percent of chiropractors who made a diagnosis of an upper respiratory or ear infection were included.

Classroom hours of microbiology were calculated by performing a search of the chiropractic school catalogs using the keywords: microbiology 1 and microbiology 2 and course titles not matching the keywords were excluded. Postgraduate hours were not accounted for in this study. For allopathic microbiology hours, data from one published study was used.

Results

For chiropractic hours of microbiology, three Chiropractic colleges: Cleveland, Logan and Sherman met the search criteria with 135, 180 and 108 classroom hours of microbiology respectively. Chiropractors receive a similar amount of classroom hours of microbiology compared to pediatricians upon finishing medical school (141/120).

For chiropractic diagnosis practice patterns, 3 survey analysis measuring the percent of chiropractors who made an initial diagnosis for upper respiratory or ear infection were evaluated. The Job Analysis of Chiropractic conducted by the National Board of Chiropractic Examiners for the years 2000, 2005, and 2015 was included since they met the inclusion criteria. The three surveys for the years 2000, 2005 and 2015 had sample populations of 3,177; 2,167; and 1,540 respectively. The three surveys had a total of 6,884 chiropractors. According to the three surveys, 51 % of Chiropractors made an initial diagnosis of childhood upper respiratory or ear infection.

For allopathic diagnosis practice patterns, 3 studies measuring pediatric diagnosis accuracy were found. Two studies were conducted in 2001 and one study in 2003 with sample populations of 514; 1,271; and 2,190. The three studies had a total of 3,975 pediatricians. According to the three studies, the pediatricians had a 50% diagnosis accuracy for children with otitis media.

Discussion

The plausibility of a correlation between classroom hours of microbiology and diagnosis practice patterns was discussed in the introduction. Another plausible explanation is the positive correlation between pneumatic video-otoendoscopic (VOE) examination and diagnosis accuracy

In 2010, Al-Khatib, et al, conducted a study of 29 pediatric residents: 15 in the intervention group and 14 in the control group. The control group viewed a set of 25 still VOE images of the tympanic membranes of both normal and OME ears. The intervention group viewed the same still images but with the addition of pneumatic VOE assessments. The study found that the overall diagnostic accuracy was 91% for the intervention group versus 78% for the control group. (8) Another study in 2012, conducted by Rosenkranz, et al, of 23 general practitioners found that a multimodal, interactive workshop can significantly increase the confidence of general practitioners for diagnosis of otitis media with effusion and also for using pneumatic otoscopy and tympanometry. (9)

A topic not mentioned in this study is the treatment protocol and treatment options for otitis media. In 2004, the American Academy of Pediatrics and the American Academy of Family Physicians released a clinical practice guideline on the management of acute otitis media that included endorsement of an observation option for selected cases and recommendations of specific antibiotics. In 2005, Finkelstein, et al, conducted a study of 160 physicians and found that 38% of physicians treating children older or equal than 2 years old never or almost never reported using initial observation, 39% reported use occasionally, 17% sometimes, and 6% most of the time. (10)

In 2007, Vernachio, et al, conducted a study of 299 primary care physicians the observation option was considered reasonable by 83.3%, compared with 88.0% in 2004, and was used in a median of 15% of acute otitis media cases over the previous 3 months. (11)

In 2010, Coco, et al, conducted a study of 1114 physicians and found that the rate of acute otitis media encounters at which no antibiotic-prescribing was reported did not change after guideline publication. Furthermore, after guideline publication, the rate of amoxicillin-prescribing increased, the rate of amoxicillin/clavulanate-prescribing decreased, the rate of cefdinir-prescribing increased and the rate of analgesic-prescribing increased. (12)

This study poses a very important question in regards to the adherence to the treatment guidelines stipulated in 2001 for acute otitis media: Can chiropractic be a treatment option during watchful waiting in children with acute otitis in order to decrease antibiotic resistance and adverse effects?

In 1996, Froehle, conducted a retrospective study of 46 children aged 5 years and under and found that 93% of all episodes improved, 75% in 10 days or fewer and 43% with only one or two treatments. Young age, no history on antibiotic use, initial episode (vs. recurrent) and designation of an episode as discomfort rather than ear infection were factors associated with improvement with the fewest treatments. (13)

A possible adjunct to chiropractic treatment is propolis and zinc suspension. In 2009, Elemraid, et al, conducted a systematic review and concluded that supplementation studies using single micronutrients and vitamins to determine efficacy in reducing acute or chronic otitis media provided some evidence for an association of middle-ear pathology with deficiencies of zinc or vitamin A. (14) In 2010, Marchisio, et al, conducted a study of 122 children aged 1-5 years with a documented history of recurrent acute otitis media and found that the administration of a propolis and zinc suspension to children with a history of recurrent acute otitis media can significantly reduce the risk of new acute otitis media episodes and acute otitis media-related antibiotic courses, with no problem of safety or tolerability, and with a very good degree of parental satisfaction. (15)

Antibiotic therapy remains the treatment of choice for otitis media in most countries despite persuasive evidence that antibiotic therapy provides limited clinical benefit and promotes bacterial resistance. Meta-analysis of randomized, placebo-controlled trials demonstrated that antibiotics increased resolution at 1 week by only 13%. Amoxicillin remains as effective as any other antibiotic, despite increasing resistance to amoxicillin among the major bacterial pathogens. Immediate antibiotic treatment has been shown to reduce the duration of symptoms by 1 day but not until after the first 24 hours when symptoms were already improving.

Yearly administration of the influenza vaccine and/or treatment of influenza with an antiviral (oseltamivir) can significantly decrease the incidence of acute otitis media during influenza season. Although pneumococcal vaccination effectively reduces the incidence of acute otitis media due to vaccine-related serotypes, there is a significant increase in the number of episodes of acute otitis media due to other serotypes of S. pneumoniae such that the overall incidence of acute otitis media is reduced only minimally by pneumoccocal vaccine. The careful use of strict diagnostic criteria coupled with judicious use of antibiotic therapy will direct antibiotic treatment to only those patients likely to benefit. (16)

In 2004, Glasziou, et al, conducted a review of 8 randomized controlled trials with a total of 2,287 children and concluded that antibiotics provide a small benefit for acute otitis media in children. As most cases will resolve spontaneously, this benefit must be weighed against the possible adverse reactions. (17) In 2006, Rovers, et al, conducted a meta-analysis of data from 6 randomized trials of the effects of antibiotics in children with acute otitis media. Individual patient data from 1643 children aged from 6 months to 12 years were validated and reanalyzed.

This study concluded that antibiotics seem to be most beneficial in children younger than 2 years of age with bilateral acute otitis media, and in children with both acute otitis media and otorrhoea. For most other children with mild disease, an observational policy seems justified. (18) In 2010, Coker, et al, conducted a meta-analysis of 135 citations and concluded that otoscopic findings are critical to accurate acute otitis media diagnosis. Acute otitis media microbiology has changed with use of PCV7. Antibiotics are modestly more effective than no treatment but cause adverse effects in 4% to 10% of children. (19)

CONCLUSION

In this study, classroom hours of microbiology had a positive correlation with patterns of diagnosis for children with otitis media or ear infections for both chiropractic physicians and pediatricians. Perhaps the hours dedicated to pathogens causing ear infections in the microbiology syllabus should include image identification of infected ears and pneumatic video otoendoscopies. Since this is an observational study causal inference isn't claimed. Further studies confirming these studies are warranted.

[FIGURE 1 OMITTED]

References

(1.) Brook I, Van de heyning PH. Microbiology and management of otitis media. Scand J Infect Dis Suppl. 1994;93:20-32.

(2.) Arguedas A, Kvaerner K, Liese J, Schilder AG, Pelton SI. Otitis media across nine countries: disease burden and management. Int J Pediatr Otorhinolaryngol. 2010;74(12):1419-24.

(3.) Pohlman KA, Holton-brown MS. Otitis media and spinal manipulative therapy: a literature review. J Chiropr Med. 2012; 11(3):160-9.

(4.) William P. McDonald (Other Contributor). How Chiropractors Think and Practice, The Survey of North American Chiropractors. Institute for Social Research Ohio Northern University; 2003

(5.) Alcantara J, Ohm J, Kunz D. The chiropractic care of children. J Altern Complement Med. 2010;16(6):621-6.

(6.) Froom J, Culpepper L, Grob P, et al. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network. BMJ. 1990;300(6724):582-6.

(7.) Pichichero ME. Diagnostic accuracy, tympanocentesis training performance, and antibiotic selection by pediatric residents in management of otitis media. Pediatrics. 2002; 110(6): 1064-70.

(8.) Al-khatib T, Fanous A, Al-saab F, Sewitch M, Razack S, Nguyen LH. Pneumatic video-otoscopy teaching improves the diagnostic accuracy of otitis media with effusion: results of a randomized controlled trial. J Otolaryngol Head Neck Surg. 2010;39(6):631-4

(9.) Rosenkranz S, Abbott P, Reath J, Gunasekera H, Hu W. Promoting diagnostic accuracy in general practitioner management of otitis media in children: findings from a multimodal, interactive workshop on tympanometry and pneumatic otoscopy. Qual Prim Care. 2012;20(4):275-85.

(10.) Finkelstein JA, Stille CJ, Rifas-shiman SL, Goldmann D. Watchful waiting for acute otitis media: are parents and physicians ready?. Pediatrics. 2005; 115(6): 1466-73.

(11.) Vernacchio L, Vezina RM, Mitchell AA. Management of acute otitis media by primary care physicians: trends since the release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians clinical practice guideline. Pediatrics. 2007; 120(2):281-7

(12.) Coco A, Vernacchio L, Horst M, Anderson A. Management of acute otitis media after publication of the 2004 AAP and AAFP clinical practice guideline. Pediatrics. 2010;125(2):214-20.

(13.) Froehle RM. Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors. J Manipulative Physiol Ther. 1996;19(3):169-77.

(14.) Elemraid MA, Mackenzie IJ, Fraser WD, Brabin BJ. Nutritional factors in the pathogenesis of ear disease in children: a systematic review. Ann Trop Paediatr. 2009;29(2):85-99.

(15.) Marchisio P, Esposito S, Bianchini S, et al. Effectiveness of a propolis and zinc solution in preventing acute otitis media in children with a history of recurrent acute otitis media. Int J Immunopathol Pharmacol. 2010;23(2):567-75.

(16.) Pappas DE, Owen hendley J. Otitis media. A scholarly review of the evidence. Minerva Pediatr. 2003;55(5):407-14.

(17.) Glasziou PP, Del mar CB, Sanders SL, Hayem M. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2004;(1):CD000219.

(18.) Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet. 2006;368(9545): 1429-35.

(19.) Coker TR, Chan LS, Newberry SJ, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA. 2010;304(19):2161-9.

(20.) Cleveland Chiropractic College. Kansas City 2012-2013 Cataloghttp://www.cleveland.edu/media/cms_page_media/128/catalog2012.pdf

(21.) Logan College of Chiropractic University programs. Academic catalog 2012-2013 http://www.logan.edu/mm/files/Academics/Academic-Catalog-2012.pdf

(22.) Sherman College of Chiropractic. Catalog 2013 http://www.shermancollege.net/intranet/ACADEM/college-catalog/Catalog-current.pdf?_ga=1.227948443.70780240 4.1408562641

(23.) Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education. Altern Ther Health Med. 1998;4(5):64-75.

(24.) Mark G. Christensen. Job Analysis of Chiropractic 2000, A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic Within the United States. NATIONAL BOARD OF CHIROPRACTIC EXAMINERS; 2000

(25.) Examiners NB, Rollasch MW. Job Analysis of Chiropractic 2005, A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic Within the United States. NATIONAL BOARD OF CHIROPRACTIC EXAMINERS; 2005.

(26.) Job analysis 2015

(27.) Sorrento A, Pichichero ME. Assessing diagnostic accuracy and tympanocentesis skills by nurse practitioners in management of otitis media. J Am Acad Nurse Pract. 2001;13(11):524-9.

(28.) Pichichero ME, Poole MD. Assessing diagnostic accuracy and tympanocentesis skills in the management of otitis media. Arch Pediatr Adolesc Med. 2001; 155(10): 1137-42.

(29.) Pichichero ME. Diagnostic accuracy of otitis media and tympanocentesis skills assessment among pediatricians. Eur J Clin Microbiol Infect Dis. 2003;22(9):519-24.

by: Adrian Isaza, DC, DACBN, CCAP
TABLE 1
Classroom Hours of Microbiology for Chiropractors in the US

Chiropractic Schools (3 out      Microbiology Hours
of 18 schools represented)
Cleveland Chiropractic           Microbioloay 1= 75 Microbiology
College. Kansas (20)             2=60 Total: 135
Logan College of                 Microbiology 1=75 Microbiology
Chiropractic (21)                2=105 Total: 180
Sherman College (22)             Microbiology 1=48 Microbiology
                                 2=60 Total: 108
AVERAGE                          141

TABLE 2
Comparison of Classroom Hours of Microbiology

Classroom Hours of                 Classroom Hours of Microbiology
Microbiology for Chiropractic      for Allopathic
Schools (Table 1)                  Schools (23)
141                                120

TABLE 3
Percent of Chiropractors who Made an Initial Diagnosis or a
Non-Sublucation Diagnosis of Childhood Upper Respiratory Ear Infection

Study                    Condition         Percent of Chiropractors
                                           Initial Diagnosis

National board of        Childhood upper   57%
Chiropractic examiners.  respiratory
Job analysis of          or ear infection
chiropractic 2000 (24)

Study                            SAMPLE SIZE

National board of                3,177 Chiropractors
Chiropractic examiners.
Job analysis of
chiropractic 2000 (24)
examiners. Job analysis of      or ear infection
chiropractic 2005 (25)
National board of Chiropractic  Childhood upper respiratory  47%
examiners. Job analysis of      or ear infection
chiropractic 2015 (26)
TOTAL/AVERAGE                                                51%

National board of Chiropractic   2,167 Chiropractors
examiners. Job analysis of
chiropractic 2005 (25)
National board of Chiropractic   1,540 Chiropractors
examiners. Job analysis of
chiropractic 2015 (26)
TOTAL/AVERAGE                    6,884 Chiropractors

TABLE 4
Diagnostic Accuracy of Otitis Media Among Pediatricians

Study          Condition     Percent of          Sample Size
                             Children Diagnosed
                             with Otitis Media
Sorrento,
2001 (27)      Otitis media  50%                 1,271 Pediatricians
Pichichero,
2001 (28)      Otitis media  50%                 514 Pediatricians
Pichichero,
2003 (29)      Otitis media  51%                 2,190 Pediatricians
TOTAL/AVERAGE                50%                 3,975
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Date:Sep 1, 2016
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