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JOURNAL READING Silvia Gita Aditama
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JOURNAL IDENTITY Title Management of recurrent tonsillitis in children Writer Diaa El Din El Hennawi , Ahmed Geneid , Salah Zaher, Mohamed Rifaat Ahmed Publisher American Journal of Otolaryngology–Head and Neck Medicine and Surgery/2017 Your Date Here YOUR FOOTER HERE ABSTRACT Objective: To compare azithromycin (AZT) and benzathine penicillin (BP) in the treatment of recurrent tonsillitis in children.
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METODE Definition Recurrent tonsillitis was defined as four or more episodes of ton- sillitis per year (for children of either gender) with two of the episodes confirmed to be group A streptococcal infection
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METHODS A randomized controlled clinical trial study created in the otolaryn- gology department - Suez Canal University Hospital – Ismailia – Egypt and Alexandria University Children Hospital – Egypt from March 2005 to May 2012 The study comprised of 350 children with recurrent streptococcal tonsillitis, 284 of whom completed the study and 162 children received conventional surgical treatment. The rest of the children, 122, were divided randomly into two equal main groups. Your Date Here YOUR FOOTER HERE 5 METHODS Group A children received a single intramuscular BP (600,000 IU for children ≤ 27 kg and 1,200,000 IU for ≥27 kg) every two weeks for six months. Group B children received single oral AZT (250 mg for children ≤ 25 kg and 500 mg for ≥25 kg) once weekly for six months.
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METHODS The enrolled children were aged from five to 12. The 350 children enrolled fulfilled the inclu- sion criteria and did not have any significant co- morbidities Significant co morbidities included: rheumatic heart disease, rheumatic fever, marked anesthetic risk, sensitivity to AZT or BP, the intake of drugs that might interfere with AZT or BP, hepatic impairment, or long QT syndrome
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METHODS Randomization was performed prior to study commencement as fol- lows: Opaque envelopes were numbered sequentially from 1 to 350. A computer-generated table of random numbers was used for group assignment; if the last digit of the random number was from 0 to 4, assignment was to group 1 (received conventional tonsillectomy), and if the last digit was from 5 to 9, assignment was to group 2 (re- ceived BP or AZT) Group 2 was randomized again in similar manner in group A and group B. Your Date Here YOUR FOOTER HERE 8 POPULATION
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METHODS
• Data collected included complete medical histories with an empha- sis on
recurrent tonsillitis. Symptoms' severity was assessed using a vi- sual analog scale for symptoms' severity (with 0 indicating no symptoms and 10 indicating the most severe symptoms). • CBC, ASOT, and ESR data were collected from all children at the beginning of the study and after six months. • CBC: Complete blood count • ASOT: A Streptococcus Test • ESR: Eritrosit Sedimentasion test (non specific test for infections or autoimmune disease)
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METHODS • The outcomes were assessed through the following measures: 1. Medical history and clinical evaluation by the end of the trial. 2. ASOT and ESR levels were taken before the start of the study and six months after it. 3. Symptoms' severity was assessed using the vi- sual analog scale for symptoms severity as described above. 4. The safety of drugs were assessed by the detection of adverse effects, which were classified as minor and accepted adverse effects (GIT upset, dizziness) or major, necessitating the exclusion of the child from the study (anaphylaxis, jaundice, a prolonged QT interval).
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METHODS 5. Satisfaction assessment was made by asking direct questions to the patients, their parents, and the medical staff. Patients' satisfac- tion was classified as a) the patient is comfortable and accepts the regimen; b) the patient is not comfortable but accepts and continues the regimen; c) the patient is not comfortable and does not accept the regimen and discontinues it (whereupon they were excluded from the study).
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METHODS Data collected were processed using SPSS version 18 (SPSS Inc., Chicago, IL, USA). Quantitative data were expressed as means ± SD while qualitative data were expressed as numbers and percentages. The Student's t-test was used to compare the significance of difference for the quantitative variables that followed a normal distribution.
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RESULT Your Date Here YOUR FOOTER HERE 14 AFTER TREATMENT RESULT
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ASOT AND ESR LEVELS • The tonsillectomy group had a mean ESR level of 70.3 ± 13.1 ml/h during the last episode of tonsillitis before tonsillectomy. Six months after the operation this level dropped to 8.7 ± 1.9 ml/h (P = 0.005). • The mean ASOT for the tonsillectomy group was 436 IU/ml before sur- gery and declined to 115 IU/ml after six months with statistically signif- icant improvement (P = 0.006). • The mean ASOT before treatment in group A was 476 IU/ml and 491 IU/ml in group B. After six-months follow-up a statistically signifi- cant reduction in the ASOT in both groups occurred as group A became 126 IU/ml while group B became 141 IU/ml (Table 1). There was no sta- tistically significant difference between the two groups.
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SEVERITY OF SYMPTOMS Before Treatment After Treatment • symptoms Group Mean SD Mean SD
Dysphagia A 8,1 1,5 5,3 1,8
B 8,7 1,1 4,9 1,4
Fever A 9,3 1,1 4,3 0,9
B 8,9 2,3 4,1 1,2
arthralgia A 7,2 0,9 3,9 1,8
B 7,9 1,4 3,6 0,9
Body ache A 8,7 1,4 3,7 1,1
B 8,1 0,8 3,2 1,7
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ADVERSE EFFECT • adverse effects encountered in the AZT group, three patients had minor adverse reactions e.g. nausea, vomiting, and abdom- inal cramps with diarrhea. • liver enzymes did not show a sig- nificant rise from before treatment to after treatment, nor was there a difference between group A and group B. • No serious adverse reactions were reported in either group. • No patients developed rheumatic activity during the study and follow-up period.
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COMFORTABILTY • Group A had a lower level of 36 (59.1%) comfortable patients, versus 25 who reported discomfort (40.9%). However, the uncomfortable group continued the treatment till the end of the year. • Satisfaction among group B patients was significantly higher among 58 patients (95.61%). Only three reported to be uncomfortable (4.9%) but they also continued the treatment. • It is evident that the AZT patients were more comfortable with the drug than the BP patients, with a statically significant difference between both groups regarding satisfaction
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COMPLIANCE • N 90% of both groups were taking the drug regularly. There was no statically significant difference between the groups regarding compliance.
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DISCUSSION Your Date Here YOUR FOOTER HERE 21 DISCUSSION Recurrent tonsillitis is considered to be one of the common reasons for primary care visits to physicians. Recurrent tonsillitis among chil- dren has a considerable impact on the quality of life, not only due to the effects on children but also the burden on the parents when their child is suffering. Tonsillectomy remains a common procedure. However, a number of immunological stud- ies on the effects of tonsillectomy point to the importance of a conservative attitude from an immunological point of view towards adenotonsillectomy
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DISCUSSION The aim of this study has been to look into alternatives to tonsillectomy, especially when the tonsillectomy criteria are not fully fulfilled, resources are not available or the parents opt for medical treatment. The two alternatives were BP and AZT. The present study showed that there is no significant difference be- tween the group A (BP) and B (AZT) in regard to recurrent tonsillitis after six- months follow-up. The ASOT and ESR levels were also reduced to nor- mal and there was no statistically significant difference between the groups.
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DISCUSSION The main concern for using AZT in long treatment has been its pos- sible association with increased cardiovascular risk and may lead to cardiovascular-related death in high-risk patients. A meta-analysis of randomized controlled trials by Almalki and Guo, reported AZT safety in patients studied in 12 trials included in the meta-analysis from 1990 to 2013. Nevertheless, its safety and effectiveness is comparable to Penicillin V
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DISCUSSION The results of this study show the efficacy of AZT in preventing re- current tonsillitis and reducing ASOT and ESR levels to a range compa- rable to those of BP and tonsillectomy. The children were more comfortable with an AZT regimen rather than a BP regimen. Minor ad- verse reactions were reported with AZT. The message of this study is that treatment options other than ton- sillectomy exist for treating recurrent tonsillitis. AZT, which is one of the treatments, proved to be safe and effective in our study. Further studies should look into the possibility of having shorter regimens of AZT when treating recurrent tonsillitis.
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CONCLUSION The treatment of recurrent tonsillitis is equally effective by treat- ment with AZT or BP in comparison to tonsillectomy. AZT was as effec- tive as BP and tonsillectomy against recurrent tonsillitis after six months of treatment.