William Feldman

How serious are the adverse effects of screening

The adverse effects of screening are not commonly studied. False-positive tests lead to discomfort, costs, and risks from additional diagnostic and therapeutic procedures. False-negative tests lead to a sense of security and delays in seeking medical help when symptoms develop. Labeling an individual with a false-positive test, or with a true-positive test for which there is no evidence that intervention makes a difference, e.g., intervention on an 80-year-old asymptomatic woman with hypercholesterolemia, can have a markedly negative impact on the quality of life. Interpreting statistical abnormalities out of clinical context, e.g., lending importance to a multiphasic blood screen showing “high” alkaline phosphatase in a teenager, leads to unnecessary costs and anxiety. The cost of screening programs that may not have been shown to do more good than harm is already having an impact on the resources available to diagnose and treatment symptomatic persons. Premature implementation of unproved screening programs will continue to decrease physician and public confidence in prevention.

Methodologic limitations in the literature on vesicoureteral reflux: A critical review

We analyzed studies concerned with four important aspects of vesicoureteral reflux in infancy and childhood: the imaging procedures for the evaluation of vesicoureteral reflux, the treatment of reflux, and the correlation between reflux and later development of hypertension and end-stage kidney disease. The objectives of the study were to evaluate the validity and reliability of the current literature, to draw conclusions, and to recommend future studies for unresolved issues. We reached the following conclusions: (1) Retrograde cystography should be the gold standard for diagnosing vesicoureteral reflux. When ultrasonography and cystography are performed together, all clinically important abnormalities in the urinary system are detected. Intravenous pyelography is needed only when either or both of these studies are abnormal. (2) Other than abolishing reflux, surgery offers no short-term advantages (in terms of preventing breakthrough urinary tract infections, improving renal function, or preventing the development of new scars, hypertension, or end-stage kidney disease) over medical management. (3) The short periods of follow-up and methodologic flaws encountered in the reviewed studies make determination of the incidence of hypertension in children with vesicoureteral reflux impossible. (4) Although indications for an association between vesicoureteral reflux and end-stage kidney disease exist, the strength of this association has not been determined.

Methodologic Guides for the Evaluation of Community Developmental Screening Programs

A screening program is an organized effort to detect, among presumably developmentally normal children in the community, disabilities that were previously undetected. Such a program also includes all the events that must occur after screening if it is to benefit a community’s children. These include diagnostic confirmation, therapeutic and preventive intervention, and follow-up.