Paul T. Dick

Routine diagnostic imaging for childhood urinary tract infections: a systematic overview.

OBJECTIVE To assess the quality of the evidence on which current recommendations for routine diagnostic imaging for childhood urinary tract infection are based. METHODS A systematic overview of the literature using the MEDLINE database (1966 to October 1994), article bibliographies, and a manual search of current publications using Current Contents, was undertaken. Preset criteria were used to categorize study sample and design, and interrater reliability was assessed with a random sample. RESULTS A total of 434 publications were evaluated, and 63 studies met the criteria for inclusion. There was 100% interrater agreement on inclusion eligibility and design classification. No controlled trials or analytic studies evaluating routine diagnostic imaging were found. All 63 studies were descriptive, and only 10 were prospective. None of the studies provided evidence of the impact of routine imaging on the development of renal scars and clinical outcomes in children with their first urinary tract infection. CONCLUSION Methodologically sound, prospective studies are needed to assess whether children with their first urinary tract infection who have routine diagnostic imaging are better off than children who have imaging for specific indications. We conclude that the current recommendations are not based on firm evidence.

Case verification of children with asthma in Ontario.

Asthma is an important chronic childhood illness. A population‐based surveillance program could measure the burden of illness, but first, the validity of an administrative diagnosis of asthma must be confirmed. The objective was to evaluate the accuracy of population‐based outpatient administrative data in identifying children with asthma for the purpose of on‐going asthma surveillance and research. Twenty‐one primary care physician (PCP) clinics in Ontario participated. Patients under 18 yr old were categorized into three diagnosis categories according to administrative data diagnosis codes: asthma, asthma‐related, and non‐asthma. In each PCP clinic, for each diagnosis category, 10 charts were randomly selected for abstraction. A panel of experts (blind to the code) reviewed the abstracted charts and identified them as asthma or non‐asthma. The reviewers’ diagnosis was considered the gold standard. The accuracy of the administrative data diagnosis coding was analyzed using the concepts of diagnostic test evaluation. Six hundred and thirty patient charts were abstracted and reviewed. Overall agreement between the diagnosis provided by expert chart review and the administrative data diagnosis code was 84.8% (p < 0.001), and was 60.2%, 94.8% and 99.5% for the asthma, asthma‐related, and non‐asthma categories, respectively. Additionally, the sensitivity and specificity were 91.4% and 82.9%, respectively. Agreement between the administrative data diagnosis code and the PCP chart diagnosis was 99.4% (p < 0.001). An administrative data diagnosis code of asthma is sensitive and specific for identifying asthma. By using the results of this study as a starting point, future research will create a cohort of children with asthma to be used for population‐based surveillance and research.

Evaluation of the Utility of Radiography in Acute Bronchiolitis

Objectives To determine the proportion of radiographs inconsistent with bronchiolitis in children with typical presentation of bronchiolitis and to compare rates of intended antibiotic therapy before radiography versus those given antibiotics after radiography. Study design We conducted a prospective cohort study in a pediatric emergency department of 265 infants aged 2 to 23 months with radiographs showing either airway disease only (simple bronchiolitis), airway and airspace disease (complex bronchiolitis), and inconsistent diagnoses (eg, lobar consolidation). Results The rate of inconsistent radiographs was 2 of 265 cases (0.75%; 95% CI 0-1.8). A total of 246 children (92.8%) had simple radiographs, and 17 radiographs (6.9%) were complex. To identify 1 inconsistent and 1 complex radiograph requires imaging 133 and 15 children, respectively. Of 148 infants with oxygen saturation >92% and a respiratory disease assessment score <10 of 17 points, 143 (96.6%) had a simple radiograph, compared with 102 of 117 infants (87.2%) with higher scores or lower saturation (odds ratio, 3.9; 95% CI, 1.3-14.3). Seven infants (2.6%) were identified for antibiotics pre-radiography; 39 infants (14.7%) received antibiotics post-radiography (95% CI, 8-16). Conclusions Infants with typical bronchiolitis do not need imaging because it is almost always consistent with bronchiolitis. Risk of airspace disease appears particularly low in children with saturation higher than 92% and mild to moderate distress.

Neonatal arterial ischemic stroke and cerebral sinovenous thrombosis are more commonly diagnosed in boys

The risk factors for arterial ischemic stroke and cerebral sinovenous thrombosis in neonates are not well understood. We looked at gender, birthweight, and gestational age in neonates with arterial ischemic stroke and cerebral sinovenous thrombosis to see if there were trends suggesting that these were risk factors. We identified neonates with a gestational age at birth ≥ 36 weeks and a diagnosis of arterial ischemic stroke or cerebral sinovenous thrombosis made by computed tomography or magnetic resonance imaging during the neonatal period from a consecutive cohort study of children with arterial ischemic stroke and cerebral sinovenous thrombosis in Ontario. Data on gender, birthweight, and gestational age were obtained by health record review. Sixty-six children with neonatal arterial ischemic stroke were identified. Forty-one (62.1%; 95% CI 49.3—73.8%) were male. Thirty-two children with neonatal cerebral sinovenous thrombosis were identified. Twenty-five (78.1%; 95% CI 60.0—90.7%) were male. One male child was identified with both arterial ischemic stroke and cerebral sinovenous thrombosis. There was a trend toward higher than average birthweights among neonates with arterial ischemic stroke and a trend toward older gestational age in female neonates with arterial ischemic stroke. Our data suggest that neonatal arterial ischemic stroke and cerebral sinovenous thrombosis are more commonly diagnosed in boys. The slightly larger size of male neonates may be contributory in arterial ischemic stroke. It is not known whether boys are at higher risk of developing arterial ischemic stroke and cerebral sinovenous thrombosis or are simply more likely to present with symptoms resulting in diagnosis. These issues need further study. (J Child Neurol 2004;19:493—497).

Participant satisfaction and comfort with multidisciplinary pediatric telemedicine consultations

PURPOSE The aim of this study was to measure both satisfaction and comfort levels and estimates of cost savings of families with children receiving health care services from a distant pediatric tertiary care center by readily available telecommunications technologies. METHODS From February 1996 to September 1997, 140 children at a site 840 miles from the tertiary care center were seen during an evaluative trial of telemedicine consultations (TMC). The TMC visit was the initial encounter with the tertiary care specialist for 31 children. After consultation, each family was asked to complete an anonymous quality management survey that asked for estimates of cost savings and assessed their level of comfort and satisfaction with 13 other aspects of the TMC encounter. A 3- or 5-point Likert scale was used for each question. Comfort scores before and after each consultation were compared by chi2 analysis. Logistic regression was used to determine the independent predictors of satisfaction. RESULTS 104 of the 140 (74%) families responded. Mean patient estimated cost savings was

Canadian Acute Respiratory Illness and Flu Scale (CARIFS): Development of a valid measure for childhood respiratory infections

1,318+/-677. The highest level of comfort was noted by 58% of respondents before TMC and by 77% after (P = .005). On a 5-point scale, 71% scored 5 (completely satisfied). None scored less than 3. The independent statistically significant predictors of satisfaction were concerns about privacy, comfort with the camera, and perceived specialist comfort. CONCLUSIONS In addition to providing financial savings, TMC is well accepted by families and children. Those using this new technology must give special attention to issues of patient privacy, camera comfort, and specialist comfort.

High-Dose Inhaled Fluticasone Does Not Replace Oral Prednisolone in Children With Mild to Moderate Acute Asthma

Although acute respiratory infection (ARI) is the most frequent clinical syndrome in childhood, there is no validated measure of its severity. Therefore a parental questionnaire was developed: the Canadian Acute Respiratory Illness Flu Scale (CARIFS). A process of item generation, item reduction, and scale construction resulted in a scale composed of 18 items covering three domains; symptoms (e.g., cough); function (e.g., play), and parental impact (e.g., clinginess). The validity of the scale was evaluated in a study of 220 children with ARI. Construct validity was assessed by comparing the CARIFS score with physician, nurse, and parental assessment of the childs health. Data were available from 206 children (94%). The CARIFS correlated well with measures of the construct (Spearmans correlations between 0.36 and 0.52). Responsiveness was shown, with 90% of children having a CARIFS score less than a quarter of its initial value, by the tenth day.

Cranial ultrasonography has a low sensitivity for detecting arterial ischemic stroke in term neonates.

BACKGROUND. Inhaled corticosteroids are not as effective as oral corticosteroids in school-aged children with severe acute asthma. It is uncertain how inhaled corticosteroids compare with oral corticosteroids in mild to moderate exacerbations. PRIMARY OBJECTIVE. The purpose of this work was to determine whether there is a significant difference in the percentage of predicted forced expiratory volume in 1 second in children with mild to moderate acute asthma treated with either inhaled fluticasone or oral prednisolone. METHODS. This was a randomized, double-blind controlled trial conducted between 2001 and 2004 in a tertiary care pediatric emergency department. We studied a convenience sample of 69 previously healthy children 5 to 17 years of age with acute asthma and forced expiratory volume in 1 second at 50% to 79% predicted value; 41 families refused participation. Albuterol was given in the emergency department and salmeterol was given after discharge to all patients, as well as either 2 mg of fluticasone via metered dose inhaler and valved holding chamber in the emergency department plus 500 μg twice daily via Diskus for 10 doses after discharge (fluticasone group, N = 35) or 2 mg/kg of oral prednisolone in the emergency department plus 5 daily doses of 1 mg/kg of prednisolone after discharge (prednisolone group, N = 34). We measured a priori defined absolute change in percent predicted forced expiratory volume in 1 second from baseline to 4 and 48 hours in the 2 groups. RESULTS. At 240 minutes, the forced expiratory volume in 1 second increased by 19.1% ± 12.7% in the fluticasone group and 29.8% ± 15.5% in the prednisolone group. At 48 hours, this difference was no longer significant (estimated difference: 4.0 ± 3.4; P = .14). The relapse rates by 48 hours were 12.5% and 0% in the fluticasone group and prednisolone group, respectively. CONCLUSION. Airway obstruction in children with mild to moderate acute asthma in the emergency department improves faster on oral than inhaled corticosteroids.

Volume Matters: Physician Practice Characteristics and Immunization Coverage Among Young Children Insured Through a Universal Health Plan

The aim of this study was to investigate the sensitivity of cranial ultrasonography for detecting acute arterial ischemic stroke in term neonates. Thirty-six neonates with gestational age 36 weeks who had cranial ultrasonography followed by computed tomography (CT) or magnetic resonance imaging (MRI) confirming arterial ischemic stroke were identified from a consecutive cohort study of all children diagnosed with arterial ischemic stroke by CT or MRI and seen at Chedoke McMaster Hospital between January 1992 and December 1998 or at The Hospital for Sick Children between January 1992 and December 2000. Cranial ultrasonography demonstrated focal abnormalities in 11 patients, giving the initial cranial ultrasonography a sensitivity of 30.5% for identifying neonates with infarction (95% CI 15.5—45.5%). The sensitivity of cranial ultrasonography performed in the two pediatric referral centers (Chedoke McMaster Hospital and Hospital for Sick Children; n = 19) was higher than that in community hospitals (n = 17) (47.3% versus 11.7%; P =.031). Neonates with suspected infarction should be evaluated with CT or MRI. (J Child Neurol 2003; 18: 98—103).

Independent walking after neonatal arterial ischemic stroke and sinovenous thrombosis

OBJECTIVES. We studied the association between immunization coverage for a cohort of 2-year-old children covered by a universal health insurance plan and pediatric provider and other health services characteristics. METHODS. We assembled a cohort of 101570 infants born in urban areas in Ontario, Canada, between July 1, 1997, and June 31, 1998. Children were considered to have up-to-date (UTD) immunization coverage if they had ≥5 immunizations by 2 years of age, ie, the recommended 3 doses and 1 booster of diphtheria-polio-tetanus-pertussis/Haemophilus influenzae type b vaccine and 1 dose of measles-mumps-rubella vaccine. Provider practice characteristics were derived from outpatient billing records, and 1996 census data were used to derive neighborhood income quintiles. The association between UTD immunization status and provider characteristics was assessed with multilevel regression models, controlling for patient characteristics. RESULTS. Overall, the rate of complete UTD immunization coverage was low (66.3%) despite a large number of primary care visits (median: 19 visits). Children whose usual provider had a low volume of pediatric primary care were less than one half as likely to be UTD. Other factors associated with not being UTD included very low continuity of care, low continuity of care, and usual provider in practice for <5 years. With adjustment for patient and provider characteristics, there was no difference in immunization coverage for general practitioners versus pediatricians. Children from low-income neighborhoods were less likely to be UTD. CONCLUSIONS. Despite universal access to primary care services, rates of complete immunization coverage among 2-year-old children in Ontario are low. Because visit rates are high, primary care reform should include interventions directed at provider immunization practices to reduce missed opportunities.