- Email: [email protected]
Is a positive family history predictive for recurrent acute otitis media in children? An evidence-based case report
Otolaryngology–Head and Neck Surgery (2010) 142, 31-35
EVIDENCE–BASED CASE REPORT
Is a positive family history predictive for recurrent acute otitis media in children? An evidence-based case report Monique Albersen, MD,* Maja Bulatovic´, MD* Sanneke H. Lindner, MD, MSc,* Feikje van Stiphout, MD,* Geert J. M. G. van der Heijden, PhD, Anne G. M. Schilder, MD, PhD, and Maroeska M. Rovers, PhD, Utrecht, The Netherlands No sponsorships or competing interests have been disclosed for this article. ABSTRACT In this evidence-based case report, we studied the clinical question: Is a positive family history of acute otitis media (AOM) predictive for recurrent acute otitis media (rAOM) in children between zero and two years of age? The search yielded 3178 articles, of which only two were relevant and had a high validity regarding our clinical question. Neither of these two studies provided the final answer to our clinical question because they did not report stratified absolute risks for a positive family history. Fortunately, we were able to study the absolute risks in one of the two studies. The absolute risk of rAOM without distinguishing family history was 33 percent; the risk was 27 percent for children without a family history and 45 percent for children with a positive family history. Family history increases the absolute risk, but not in a way that it will help to predict rAOM accurately. © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
Clinical Case
D
uring consulting, a one-year-old boy, Sam, is seen with his father. The father states that Sam has been crying for two nights. Furthermore, Sam is grasping both his ears, and has been sniffing for a week and has had moderate fever for two days. If the parents provide analgesics to Sam, he sleeps for a couple of hours. The father assumes that Sam has an ear infection, which he wants treated. Furthermore, he states that both he and Sam’s older brother have frequently experienced acute otitis media (AOM). He asks
whether this has consequences for Sam’s risk—that is, whether the risk of getting recurrent AOM is higher for Sam compared with other children without a family history.
Searching for Evidence The first step was to formulate an answerable clinical question. Here the clinical question was one of differential prognosis: Is a positive family history of acute otitis media (AOM) predictive for recurrent acute otitis media (rAOM) in children between zero and two years of age? We designed a search filter using relevant synonyms for the domain, which is children with AOM, and the outcome, which is rAOM. We retrieved relevant publications in EMBASE, Cochrane, and MEDLINE using search terms in the title and abstract fields. We did not include the determinant—positive family history—in our search filter to guard against reporting and retrieval bias. Our search yielded 1203 records in MEDLINE, 1692 articles in EMBASE, and 273 in Cochrane (Table 1). The titles and abstracts of all retrieved records were screened according to the following inclusion criteria: “children between zero and two years of age not treated with antibiotics during their first AOM episode,” “positive family history,” defined as parents and/or siblings who had experienced one or more AOM episodes, and “rAOM.” These criteria were chosen because the highest incidence of AOM occurs between six and 24 months of age, parent history of rAOM is a prognostic risk factor for rAOM,1-4 and, in The Netherlands, antibiotics are not commonly used as first-line treatment in children with AOM. The exclusion criteria employed are shown in the flow chart (Fig 1). Upon screening, 28 publications remained for further analysis. The full text of the 28 selected publications was studied in more detail for their relevance in terms of our
Received July 22, 2009; revised October 7, 2009; accepted October 23, 2009. *All four authors contributed equally to the report.
0194-5998/$36.00 © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.10.036
32
Otolaryngology–Head and Neck Surgery, Vol 142, No 1, January 2010
Table 1 Search strategy for relevant studies Database
Search
Hits
Selection
MEDLINE
((baby OR babies OR babyhood OR brood OR child* OR descendant* OR heredity OR infancy OR infant* OR juvenile* OR kid* OR lineage OR offspring OR preteen* OR progeny OR sibling* OR sprout OR toddler* OR young OR young child* OR youngster* OR youth OR boy* OR girl* OR 0 2 OR 0 2 y OR 0 2 yr OR 0 2 years OR 0 2 y old OR 0 2 yr old OR 0 2 yrs old OR 0 2 years old OR 0 24 months OR 0 24 months old OR preschool) AND (otitis OR otitis’ OR otit OR otits OR otits media OR otitismedia OR otitis media OR otitus media OR otitis media acuta OR otitis media acute OR acute otitis media OR otitis media ear* OR otitis media episode* OR otitis media event* OR otitis media history OR otitis media occurrence OR otitis media prone OR otitis positive OR otitis proness OR otitis-prone OR otitis prone OR middle ear infection OR middle ear inflammation OR middle ear inflammatory disease OR middle ear inflammatory process OR middle ear involvement OR middle ear otitis OR middle ear problem* OR middle ear inflammatory diseases)) AND (recurrent OR recurrence* OR recurring OR recidivation OR relapse* OR recidivism OR recidivating OR relapsing OR recidive*) Idem Medline Idem Medline
1203
23
1692 273
31 3
EMBASE Cochrane
domain, determinant, and outcome. As a result, 24 publications were excluded. The quality of methods and reporting of results of the remaining four articles were critically appraised4-7 according to the criteria shown in Table 2. Two of these5,6 were subsequently excluded from further assessment. Stenström et al5 derived incidence rates instead of relative risks (RRs) of rAOM in children with siblings or parents who had experienced rAOM episodes; therefore, RRs could not be calculated owing to incomplete data. Teele et al6 did not report an estimated effect or any precision measures. The publications of Damoiseaux et al4 and Sipila et al7 were of sufficient quality and provided numerical data that were usable for answering our question. Data from these two studies were extracted and evaluated.
Results Damoiseaux et al4 performed a prospective cohort study to assess whether known determinants for rAOM apply to children under the age of two years. rAOM was described as at least one episode of AOM within six months after the first AOM episode. Children with siblings who had rAOM were found to have a slightly higher chance (odds ratio [OR] 1.1; 95% confidence interval [CI] 0.6-2.3) of developing rAOM in comparison with children whose siblings did not experience rAOM (Table 3). Sipila et al7 performed a prospective cohort study to assess the effects of postulated risk factors for rAOM. They defined rAOM as all subsequent AOM episodes after the first AOM episode, occurring more than 13 days apart. They showed that children whose siblings had a history of AOM
had a higher chance of developing rAOM (RR 3.0-3.3; P ⬍ 0.001) compared with children with siblings without a history of AOM, depending on the number of AOMs in their siblings (Table 3).
Translating Evidence into Practice The evidence regarding the influence of a positive family history on rAOM is scarce and inconsistent: Damoiseaux et al4 presented an OR of 1.1 (95% CI 0.6-2.3), and Sipila et al7 an RR of 3.0-3.3 (P ⬍ 0.001). Several important drawbacks are inherent in the critically appraised studies. First, the evidence presented in both articles pertains only to the influence of siblings with AOM on the development of rAOM, whereas parent history of AOM has not been investigated. Second, Damoiseaux et al and Sipila et al used distinct definitions for both rAOM4,7 and family history,4 which also differed from those established in the objective of our study. Although we excluded studies of children treated with antibiotics during their first AOM episode, we did include the study of Damoiseaux et al4 because they incorporated in their risk analysis for rAOM both the children treated with antibiotics during their initial AOM episode and those not treated with antibiotics. Sipila et al7 encountered a high percentage of patients lost to follow-up, 21 percent, which can distort the results and subsequently the conclusions of the study. Moreover, no CIs were reported, and we were unable to calculate them from the article owing to insufficient data. Neither did these two best articles provide the numbers to recalculate the absolute risks, which are needed for prognostic risk stratification—that is, to establish the influence of
Albersen et al
Is a positive family history predictive . . .
Figure 1
33
Flow chart showing retrieval results and exclusion criteria for screening literature.
positive family history on rAOM. Furthermore, the clinical relevance of an OR of 1.1 (95% CI 0.6-2.3, Damoiseaux et al4) and an RR of 3.0-3.3 (P ⬍ 0.001, Sipila et al7) in children with a positive family history of rAOM depends on the baseline risk of rAOM. Unfortunately, on the basis of both publications, it was not possible to retrieve information regarding this baseline risk from the studies at hand. In general, it is known that 30 percent of children develop rAOM before the age of one and a half years.7 Although this does not reflect the baseline risk of rAOM, one could state that the reported OR and RR are relevant in this population. Finally, to minimize reporting and retrieval bias, we did not include the determinant (i.e., a positive family history) in our search filter. When a determinant does not have an effect on the outcome, it is very unlikely to be included in the title or abstract. As a result, it is also very unlikely that it will be assigned as a key word or a MeSH
term. Still, full-text articles, in particular their tables, may include relevant information on the determinant outcome relationship. This type of reporting and publication bias is regularly seen and may, in the context of literature reviews, give rise to retrieval bias and thereby easily influence the results.
Conclusion Because none of the studies provided stratified absolute risks for a positive family history, the question from daily practice (i.e., whether to ask for family history to predict the risk of rAOM) could not be answered. However, given that one of the two relevant studies was performed at our department, we were able to look at the absolute risks. The absolute risk of rAOM was 33 percent without distinguishing family history, 27 percent for children without a positive
34
Otolaryngology–Head and Neck Surgery, Vol 142, No 1, January 2010
Table 2 Criteria for critical appraisal of relevant studies
Relevance Study design Damoiseaux et al (2006)
Prospective cohort
Stenström et al (1997) Sipila et al (1988)
Retrospective patientcontrol Prospective cohort
Teele et al (1980)
Prospective cohort
Domain
Determinant
Children 6-24 mo with an AOM episode in family practice Children 0-30 mo
Children 5-32 mo
Children 0-36 mo
Outcome
Follow-up (mo)
Missing data Lost to Drop-out follow-up (%) (%)
Standardization
Level of evidence
6.3
6.3
⫹
1b
na
C 5.3 P 0.0
na
⫾
2c
rAOM*
18
0.0
21
⫹
3
rAOM*
33-36
?
⫾
2c
Sibling history of rAOM
rAOM*
6
Father, mother, or siblings with AOM episodes Siblings with AOM attacks during follow-up and positive otitis history of the parents Siblings and parents with rAOM
Otitis proneness
?
⫹, good; ⫾, moderate; ?, unknown; AOM, acute otitis media; C, controls; na, not applicable; P, patients; rAOM, recurrent AOM. *Definitions of rAOM differ from each other and from the definition used in this evidence-based case report.
needed eight hours to scan the 2000 titles retrieved from the bibliographical databases. The subsequent procedures involved judgments that have been described as explicitly as we can. Some of these procedures related to what is included in the QUORUM (Quality of Reporting of Meta-analyses) statement.10 We explicitly and transparently present the standard procedures used (including judgments made) and results, to the extent that they should be reproducible. Thereby we give the readers the possibility to judge the quality and validity of this work. Eventually, only two articles remained. We, however, consider them to provide the current best evidence because they have been filtered on the basis of quality and relevance by applying these rather rigorous procedures. Still, they do not provide all the numbers needed to recalculate the absolute risks, which are needed for prognostic risk stratification. This highlights that reporting the absolute risks or the numbers is not yet state of the art in prognostic ENT research. In this particular case, however, we were lucky to have the possibility to derive baseline absolute risk from the original
family history, and 45 percent (risk difference 18%, 95% CI 1%-34%) for children with a positive family history. Family history increases the absolute risk, but not in a way that it will help to predict rAOM accurately. Next to family history, other factors should be taken into account; however, to date, a multivariate model for the prediction of the absolute risk of rAOM is lacking. Hence, accurate prediction of the risk of rAOM is not possible. Furthermore, our experience is that reporting the absolute risks or the numbers to recalculate these absolute risks is not yet state of the art in prognostic ENT research. Rigorously designed prognostic prediction research8,9 is needed to acquire knowledge about the risk of rAOM. Finally, the value of our approach can be questioned given that we answer our question on prognostic risk stratification on the basis of only two articles from about 2000 articles that we initially retrieved. Subsequently, we had to access the original data set from one study to answer our question. In our experience, it takes about an hour to scan 250 titles, implying that for this article we
Table 3 Influence of siblings with rAOM on occurrence of rAOM within the study population Effect
Precision
Study
Population (n)
OR
RR
95% CI
P value
Damoiseaux et al (2006) Sipila et al (1988)
210 1294
1.1 — — —
— 3.102 (2 AOM) 3.251 (3 AOM) 2.954 (4 AOM)
0.6-2.3 — — —
— ⬍0.001 ⬍0.001 ⬍0.001
AOM, acute otitis media; CI, confidence interval; OR, odds ratio; rAOM, recurrent AOM; RR, relative risk.
Albersen et al
Is a positive family history predictive . . .
data, and thereby were able to come up with an appropriate answer for our question.
Author Information From the Julius Centre for Health Sciences and Primary Care, Department of Otorhinolaryngology, University Medical Centre Utrecht, Utrecht, The Netherlands. Corresponding author: Maroeska M. Rovers, Julius Centre for Health Sciences and Primary Care, Department of Otolaryngology, University Medical Centre Utrecht, Str 6.131, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail address: [email protected].
Author Contributions Monique Albersen, writing of report; Maja Bulatovic´, writing of report; Sanneke H. Lindner, writing of report; Feikje van Stiphout, writing of report; Geert J. M. G. van der Heijden, supervision and revision; Anne G. M. Schilder, supervision and revision; Maroeska M. Rovers, supervision and revision.
Disclosures Competing interests: None. Sponsorships: None.
35
References 1. Bluestone CD, Stephenson JS, Martin LM. Ten-year review of otitis media pathogens. Pediatr Infect Dis J 1992;11:S7. 2. Paradise JL, Rockette HE, Colborn DK, et al. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics 1997;99:318. 3. Teele DW, Klein JO, Rosner BA, et al. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J Infect Dis 1989;160:83. 4. Damoiseaux RAMJ, Rovers MM, Van Balen FAM, et al. Long-term prognosis of acute otitis media in infancy: determinants of recurrent acute otitis media and persistent middle ear effusion. Family Practice 2006;23:40 –5. 5. Stenström C, Ingvarsson L. Otitis-prone children and controls: a study of possible predisposing factors. Heredity, family background and perinatal period. Acta Otolaryngol 1997;117:87–93. 6. Teele DW, Klein JO, Rosner BA. Epidemiology of otitis media in children. Ann Otol Rhinol Laryngol Suppl 1980;89:5– 6. 7. Sipila M, Karma P, Pukander J, et al. The Bayesian approach to the evaluation of risk factors in acute and recurrent acute otitis media. Acta Otolaryngol 1988;106:94 –101. 8. Moons KG, Royston P, Vergouwe Y, et al. Prognosis and prognostic research: what, why, and how? BMJ 2009;338:b375. 9. Moons KG, Altman DG, Vergouwe Y, et al. Prognosis and prognostic research: application and impact of prognostic models in clinical practice. BMJ 2009;338:606. 10. Clarke M. The QUORUM statement. Lancet 2000;355:756 –7.
EVIDENCE–BASED CASE REPORT
Is a positive family history predictive for recurrent acute otitis media in children? An evidence-based case report Monique Albersen, MD,* Maja Bulatovic´, MD* Sanneke H. Lindner, MD, MSc,* Feikje van Stiphout, MD,* Geert J. M. G. van der Heijden, PhD, Anne G. M. Schilder, MD, PhD, and Maroeska M. Rovers, PhD, Utrecht, The Netherlands No sponsorships or competing interests have been disclosed for this article. ABSTRACT In this evidence-based case report, we studied the clinical question: Is a positive family history of acute otitis media (AOM) predictive for recurrent acute otitis media (rAOM) in children between zero and two years of age? The search yielded 3178 articles, of which only two were relevant and had a high validity regarding our clinical question. Neither of these two studies provided the final answer to our clinical question because they did not report stratified absolute risks for a positive family history. Fortunately, we were able to study the absolute risks in one of the two studies. The absolute risk of rAOM without distinguishing family history was 33 percent; the risk was 27 percent for children without a family history and 45 percent for children with a positive family history. Family history increases the absolute risk, but not in a way that it will help to predict rAOM accurately. © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
Clinical Case
D
uring consulting, a one-year-old boy, Sam, is seen with his father. The father states that Sam has been crying for two nights. Furthermore, Sam is grasping both his ears, and has been sniffing for a week and has had moderate fever for two days. If the parents provide analgesics to Sam, he sleeps for a couple of hours. The father assumes that Sam has an ear infection, which he wants treated. Furthermore, he states that both he and Sam’s older brother have frequently experienced acute otitis media (AOM). He asks
whether this has consequences for Sam’s risk—that is, whether the risk of getting recurrent AOM is higher for Sam compared with other children without a family history.
Searching for Evidence The first step was to formulate an answerable clinical question. Here the clinical question was one of differential prognosis: Is a positive family history of acute otitis media (AOM) predictive for recurrent acute otitis media (rAOM) in children between zero and two years of age? We designed a search filter using relevant synonyms for the domain, which is children with AOM, and the outcome, which is rAOM. We retrieved relevant publications in EMBASE, Cochrane, and MEDLINE using search terms in the title and abstract fields. We did not include the determinant—positive family history—in our search filter to guard against reporting and retrieval bias. Our search yielded 1203 records in MEDLINE, 1692 articles in EMBASE, and 273 in Cochrane (Table 1). The titles and abstracts of all retrieved records were screened according to the following inclusion criteria: “children between zero and two years of age not treated with antibiotics during their first AOM episode,” “positive family history,” defined as parents and/or siblings who had experienced one or more AOM episodes, and “rAOM.” These criteria were chosen because the highest incidence of AOM occurs between six and 24 months of age, parent history of rAOM is a prognostic risk factor for rAOM,1-4 and, in The Netherlands, antibiotics are not commonly used as first-line treatment in children with AOM. The exclusion criteria employed are shown in the flow chart (Fig 1). Upon screening, 28 publications remained for further analysis. The full text of the 28 selected publications was studied in more detail for their relevance in terms of our
Received July 22, 2009; revised October 7, 2009; accepted October 23, 2009. *All four authors contributed equally to the report.
0194-5998/$36.00 © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.10.036
32
Otolaryngology–Head and Neck Surgery, Vol 142, No 1, January 2010
Table 1 Search strategy for relevant studies Database
Search
Hits
Selection
MEDLINE
((baby OR babies OR babyhood OR brood OR child* OR descendant* OR heredity OR infancy OR infant* OR juvenile* OR kid* OR lineage OR offspring OR preteen* OR progeny OR sibling* OR sprout OR toddler* OR young OR young child* OR youngster* OR youth OR boy* OR girl* OR 0 2 OR 0 2 y OR 0 2 yr OR 0 2 years OR 0 2 y old OR 0 2 yr old OR 0 2 yrs old OR 0 2 years old OR 0 24 months OR 0 24 months old OR preschool) AND (otitis OR otitis’ OR otit OR otits OR otits media OR otitismedia OR otitis media OR otitus media OR otitis media acuta OR otitis media acute OR acute otitis media OR otitis media ear* OR otitis media episode* OR otitis media event* OR otitis media history OR otitis media occurrence OR otitis media prone OR otitis positive OR otitis proness OR otitis-prone OR otitis prone OR middle ear infection OR middle ear inflammation OR middle ear inflammatory disease OR middle ear inflammatory process OR middle ear involvement OR middle ear otitis OR middle ear problem* OR middle ear inflammatory diseases)) AND (recurrent OR recurrence* OR recurring OR recidivation OR relapse* OR recidivism OR recidivating OR relapsing OR recidive*) Idem Medline Idem Medline
1203
23
1692 273
31 3
EMBASE Cochrane
domain, determinant, and outcome. As a result, 24 publications were excluded. The quality of methods and reporting of results of the remaining four articles were critically appraised4-7 according to the criteria shown in Table 2. Two of these5,6 were subsequently excluded from further assessment. Stenström et al5 derived incidence rates instead of relative risks (RRs) of rAOM in children with siblings or parents who had experienced rAOM episodes; therefore, RRs could not be calculated owing to incomplete data. Teele et al6 did not report an estimated effect or any precision measures. The publications of Damoiseaux et al4 and Sipila et al7 were of sufficient quality and provided numerical data that were usable for answering our question. Data from these two studies were extracted and evaluated.
Results Damoiseaux et al4 performed a prospective cohort study to assess whether known determinants for rAOM apply to children under the age of two years. rAOM was described as at least one episode of AOM within six months after the first AOM episode. Children with siblings who had rAOM were found to have a slightly higher chance (odds ratio [OR] 1.1; 95% confidence interval [CI] 0.6-2.3) of developing rAOM in comparison with children whose siblings did not experience rAOM (Table 3). Sipila et al7 performed a prospective cohort study to assess the effects of postulated risk factors for rAOM. They defined rAOM as all subsequent AOM episodes after the first AOM episode, occurring more than 13 days apart. They showed that children whose siblings had a history of AOM
had a higher chance of developing rAOM (RR 3.0-3.3; P ⬍ 0.001) compared with children with siblings without a history of AOM, depending on the number of AOMs in their siblings (Table 3).
Translating Evidence into Practice The evidence regarding the influence of a positive family history on rAOM is scarce and inconsistent: Damoiseaux et al4 presented an OR of 1.1 (95% CI 0.6-2.3), and Sipila et al7 an RR of 3.0-3.3 (P ⬍ 0.001). Several important drawbacks are inherent in the critically appraised studies. First, the evidence presented in both articles pertains only to the influence of siblings with AOM on the development of rAOM, whereas parent history of AOM has not been investigated. Second, Damoiseaux et al and Sipila et al used distinct definitions for both rAOM4,7 and family history,4 which also differed from those established in the objective of our study. Although we excluded studies of children treated with antibiotics during their first AOM episode, we did include the study of Damoiseaux et al4 because they incorporated in their risk analysis for rAOM both the children treated with antibiotics during their initial AOM episode and those not treated with antibiotics. Sipila et al7 encountered a high percentage of patients lost to follow-up, 21 percent, which can distort the results and subsequently the conclusions of the study. Moreover, no CIs were reported, and we were unable to calculate them from the article owing to insufficient data. Neither did these two best articles provide the numbers to recalculate the absolute risks, which are needed for prognostic risk stratification—that is, to establish the influence of
Albersen et al
Is a positive family history predictive . . .
Figure 1
33
Flow chart showing retrieval results and exclusion criteria for screening literature.
positive family history on rAOM. Furthermore, the clinical relevance of an OR of 1.1 (95% CI 0.6-2.3, Damoiseaux et al4) and an RR of 3.0-3.3 (P ⬍ 0.001, Sipila et al7) in children with a positive family history of rAOM depends on the baseline risk of rAOM. Unfortunately, on the basis of both publications, it was not possible to retrieve information regarding this baseline risk from the studies at hand. In general, it is known that 30 percent of children develop rAOM before the age of one and a half years.7 Although this does not reflect the baseline risk of rAOM, one could state that the reported OR and RR are relevant in this population. Finally, to minimize reporting and retrieval bias, we did not include the determinant (i.e., a positive family history) in our search filter. When a determinant does not have an effect on the outcome, it is very unlikely to be included in the title or abstract. As a result, it is also very unlikely that it will be assigned as a key word or a MeSH
term. Still, full-text articles, in particular their tables, may include relevant information on the determinant outcome relationship. This type of reporting and publication bias is regularly seen and may, in the context of literature reviews, give rise to retrieval bias and thereby easily influence the results.
Conclusion Because none of the studies provided stratified absolute risks for a positive family history, the question from daily practice (i.e., whether to ask for family history to predict the risk of rAOM) could not be answered. However, given that one of the two relevant studies was performed at our department, we were able to look at the absolute risks. The absolute risk of rAOM was 33 percent without distinguishing family history, 27 percent for children without a positive
34
Otolaryngology–Head and Neck Surgery, Vol 142, No 1, January 2010
Table 2 Criteria for critical appraisal of relevant studies
Relevance Study design Damoiseaux et al (2006)
Prospective cohort
Stenström et al (1997) Sipila et al (1988)
Retrospective patientcontrol Prospective cohort
Teele et al (1980)
Prospective cohort
Domain
Determinant
Children 6-24 mo with an AOM episode in family practice Children 0-30 mo
Children 5-32 mo
Children 0-36 mo
Outcome
Follow-up (mo)
Missing data Lost to Drop-out follow-up (%) (%)
Standardization
Level of evidence
6.3
6.3
⫹
1b
na
C 5.3 P 0.0
na
⫾
2c
rAOM*
18
0.0
21
⫹
3
rAOM*
33-36
?
⫾
2c
Sibling history of rAOM
rAOM*
6
Father, mother, or siblings with AOM episodes Siblings with AOM attacks during follow-up and positive otitis history of the parents Siblings and parents with rAOM
Otitis proneness
?
⫹, good; ⫾, moderate; ?, unknown; AOM, acute otitis media; C, controls; na, not applicable; P, patients; rAOM, recurrent AOM. *Definitions of rAOM differ from each other and from the definition used in this evidence-based case report.
needed eight hours to scan the 2000 titles retrieved from the bibliographical databases. The subsequent procedures involved judgments that have been described as explicitly as we can. Some of these procedures related to what is included in the QUORUM (Quality of Reporting of Meta-analyses) statement.10 We explicitly and transparently present the standard procedures used (including judgments made) and results, to the extent that they should be reproducible. Thereby we give the readers the possibility to judge the quality and validity of this work. Eventually, only two articles remained. We, however, consider them to provide the current best evidence because they have been filtered on the basis of quality and relevance by applying these rather rigorous procedures. Still, they do not provide all the numbers needed to recalculate the absolute risks, which are needed for prognostic risk stratification. This highlights that reporting the absolute risks or the numbers is not yet state of the art in prognostic ENT research. In this particular case, however, we were lucky to have the possibility to derive baseline absolute risk from the original
family history, and 45 percent (risk difference 18%, 95% CI 1%-34%) for children with a positive family history. Family history increases the absolute risk, but not in a way that it will help to predict rAOM accurately. Next to family history, other factors should be taken into account; however, to date, a multivariate model for the prediction of the absolute risk of rAOM is lacking. Hence, accurate prediction of the risk of rAOM is not possible. Furthermore, our experience is that reporting the absolute risks or the numbers to recalculate these absolute risks is not yet state of the art in prognostic ENT research. Rigorously designed prognostic prediction research8,9 is needed to acquire knowledge about the risk of rAOM. Finally, the value of our approach can be questioned given that we answer our question on prognostic risk stratification on the basis of only two articles from about 2000 articles that we initially retrieved. Subsequently, we had to access the original data set from one study to answer our question. In our experience, it takes about an hour to scan 250 titles, implying that for this article we
Table 3 Influence of siblings with rAOM on occurrence of rAOM within the study population Effect
Precision
Study
Population (n)
OR
RR
95% CI
P value
Damoiseaux et al (2006) Sipila et al (1988)
210 1294
1.1 — — —
— 3.102 (2 AOM) 3.251 (3 AOM) 2.954 (4 AOM)
0.6-2.3 — — —
— ⬍0.001 ⬍0.001 ⬍0.001
AOM, acute otitis media; CI, confidence interval; OR, odds ratio; rAOM, recurrent AOM; RR, relative risk.
Albersen et al
Is a positive family history predictive . . .
data, and thereby were able to come up with an appropriate answer for our question.
Author Information From the Julius Centre for Health Sciences and Primary Care, Department of Otorhinolaryngology, University Medical Centre Utrecht, Utrecht, The Netherlands. Corresponding author: Maroeska M. Rovers, Julius Centre for Health Sciences and Primary Care, Department of Otolaryngology, University Medical Centre Utrecht, Str 6.131, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail address: [email protected].
Author Contributions Monique Albersen, writing of report; Maja Bulatovic´, writing of report; Sanneke H. Lindner, writing of report; Feikje van Stiphout, writing of report; Geert J. M. G. van der Heijden, supervision and revision; Anne G. M. Schilder, supervision and revision; Maroeska M. Rovers, supervision and revision.
Disclosures Competing interests: None. Sponsorships: None.
35
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