Urinary tract infections in girls: the cost-effectiveness of currently recommended investigative routines

Current recommendations for the universal investigation of urinary tract infection (UTI) in children by ultrasonography, voiding cystourethrography, and dimercaptosuccinic acid renal scan (and sometimes intravenous pyelography as well) are not based on any convincing evidence as to the necessity or effectiveness of such a routine. Over 8% of all girls will have a UTI during childhood. About 87 individuals in a million will develop end-stage renal disease (ESRD) by the age of 60 years, caused in about 9% by pyelonephritis (PN) or reflux nephropathy. From these statistics, the maximal risk of a first diagnosed UTI progressing to ESRD is approximately 1:10,000. The risk of developing hypertension following a first UTI in childhood, without eventual evolution to ESRD, appears to be very small. The cost of the widely recommended routine imaging procedures ranges from U.S. $355 in Britain to U.S. $1,090 in the United States. The minimal cost of preventing a single progression to ESRD by early diagnosis of underlying pathology-if this were possible in all cases-would range between U.S. $5 million in Britain and U.S. $15 million in the United States. Since in many instances progressive renal damage can not be prevented, the true cost is considerably higher. Lower UTI in girls is a very common and, in most cases, benign finding in primary-care practice. It is suggested that girls with afebrile UTI, presenting with lower urinary tract symptoms alone, need not undergo any imaging procedures, but should be followed with urine examinations and cultures at the time of febrile illness. The recommended investigative routines should be reserved for UTI in infants and in girls with fever or other symptoms suggesting PN, and for proven recurrent UTI. Such a regimen will allow a marked saving in terms of costs and in terms of unnecessary radiation, psychological stress to children, and stress, inconvenience, and time loss to parents. There is no evidence that this approach will compromise the course or final outcome of this very common condition.     

Refined microscopic urinalysis for red blood cell morphology in the evaluation of asymptomatic microscopic hematuria in a pediatric population

PURPOSE: The use of refined microscopic urinalysis for the presence of dysmorphic red blood cells (RBCs) has been evaluated in children and adults with a known source of hematuria. We examined the clinical usefulness of this study in a pediatric population with an unknown source of hematuria. MATERIALS AND METHODS: Children 12 years old or younger referred for evaluation of asymptomatic microscopic hematuria exhibiting 4 or more RBCs per high power field were enrolled in this study. Patients provided a first morning urine sample subjected to refined urinalysis for RBC morphology. Standard evaluation of patients was performed until a final diagnosis of the hematuria source was identified. RESULTS: A total of 44 patients completed the study. Refined urinalysis revealed pure dysmorphic RBCs in 22 patients, pure isomorphic RBCs in 8 and mixed isomorphic/dysmorphic RBCs in 14. The presence of dysmorphic RBCs correctly predicted a glomerulotubular source of hematuria in 29 of 36 patients (sensitivity 83%, specificity 81%), while the presence of isomorphic RBCs predicted a uroepithelial source of hematuria in 2 of 8 patients (sensitivity 25%, specificity 22%). Hematuria and 2+ proteinuria (100 mg./dl.) were more sensitive (100%) and specific (83%) than the presence of dysmorphic RBCs in predicting glomerulotubular hematuria. CONCLUSIONS: We believe that this is a costly test offering little additional information to the evaluation of microscopic hematuria in children. A thoughtful history and physical examination with microscopic urinalysis and dipstick for proteinuria provide an equal amount of diagnostic information. We do not recommend its routine use in the evaluation of microscopic hematuria in children.     

Lead''s toxic legacy for human reproduction: new studies establish significant bone lead release during pregnancy and nursing

We retrospectively evaluated the frequency of renal scintigraphic abnormalities in children over 5 years admitted with a first symptomatic urinary tract infection (UTI). Among 261 children investigated, we found only 23 over 5 years having had technetium-99m-dimercaptosuccinic acid scintigraphy during the acute phase of a first UTI. Obvious scintigraphic abnormalities were detected in 14 children (15 kidneys): 12 kidneys showed focal cortical defects and 3 were small and deformed. Ultrasound was normal in 7 of the 15 kidneys with abnormal scintigraphy and in all the kidneys with normal scintigraphy. Among the 12 kidneys with focal cortical lesions, 8 kidneys returned to normal or improved considerably 2-12 months after initial work-up. In conclusion, in children over 5 years admitted with a first symptomatic UTI, the frequency of scintigraphic abnormalities is high and a strategy based only on ultrasound data would miss about 50% of the abnormal kidneys.     

Risk factors and length of stay attributable to hospital infections of the urinary tract in general surgery patients

BACKGROUND: Urinary tract infection (UTI) is the second frequent site of infection in surgical patients; nevertheless, its study has been frequently neglected. The main objective of this report is the analysis of risk factors for ITU in general surgery. METHODS: A prospective study on 1,483 patients admitted at a service of general surgery for a 20-month study period has been carried out. The criteria used for diagnosing nosocomial were those of the CDC. Crude and adjusted for by logistic regression relative risks and its 95% confidence interval were estimated. To assess the length of stay attributable to UTI, infected patients were 1:1 matched with non-infected patients for surgical procedure, ASA score, age (+/- 10 years), emergency surgery, pre-operative stay, and urinary catheter. RESULTS: 33 patients (2.2%) developed UTI. In crude analysis, UTI risk was significantly associated with urethral catheter (and its duration), advanced age, severity of illness (McCabe-Jackson scale, ASA score, number of diagnoses), type of surgical wound, intrinsic risk of infection (measured by the SENIC and NNIS indices). Stepwise logistic regression analysis selected three independent predictors: urethral catheter, age and pre-operative stay. All urinary drain-ages were open. UTI prolonged hospital stay 4.7 days (95% Cl 3.4-6.2). The use of closed drain-age systems would eliminate 6 UTIs. Assuming a cost per day of hospital stay of $250 the use of closed systems would save $7,000 (IC 95%, 5300-9300). CONCLUSION: The use of closed systems for urethral catheters is cost-saving.     

Diurnal enuresis

Daytime wetting is a common problem in childhood; in most cases, it is an intermittent or self-limited problem with a benign and easily identifiable cause. The history is the most important aspect of the assessment. A urinalysis is helpful to look for UTI, and ultrasonography of both the kidney and the bladder is an excellent noninvasive screening study. More invasive diagnostic imaging studies are necessary only if the patient has symptoms or signs suggestive of urethral obstruction, neurogenic bladder, Hinman syndrome, or ectopic ureter. With time and appropriate treatment, the prognosis is excellent for the majority of patients.     

The cost of caring for end-stage kidney disease patients: an analysis based on hospital financial transaction records

The costs of care for end-stage renal disease patients continue to rise because of increased numbers of patients. Efforts to contain these costs have focused on the development of capitated payment schemes, in which all costs for the care of these patients are covered in a single payment. To determine the effect of a capitated reimbursement scheme on care of dialysis patients (both hemodialysis [HD] and peritoneal dialysis [PD]), complete financial records (all reimbursements for inpatient and outpatient care, as well as physician collections) of dialysis patients at a single medical center over 1 year were analyzed. For the period from July 1994 to July 1995, annualized cost per dialysis patient-year averaged $63,340, or 9.8% higher than the corrected estimate from the U.S. Renal Data Service (USRDS; $57,660). The "most expensive" 25% of patients engendered 44 to 48% of the total costs, and inpatient costs accounted for 37 to 40% of total costs. Nearly half of the inpatient costs resulted from only two categories (room charges and inpatient dialysis), whereas other categories each made up a small fraction of the inpatient costs. PD patients were far less expensive to care for than HD patients, due to reduced hospital days and lower cost of outpatient dialysis. Care for a university-based dialysis population was only slightly more expensive than estimates predicted from the USRDS. These results validate the USRDS spending data and suggest that they can be used effectively for setting capitated rates. Efforts to control costs without sacrificing quality of care must center on reducing inpatient costs, particularly room charges and the cost of inpatient dialysis.     

Eradication of urinary tract infection following spinal cord injury

A prospective study to evaluate the microbiological efficacy of antimicrobial treatment for urinary tract infection (UTI) was performed in 64 catheter-free spinal cord injured (SCI) patients who were visited monthly by a public health nurse who collected urine for culture and urinalysis. Patients also mailed urine dip slides for weekly bacterial counts. UTI was defined as a culture yielding > or = 100,000 colonies/ml. Treatment was given to asymptomatic patients only if pyuria (> or = 10 urinary leukocytes/high powered microscopic field) was present. Initial treatment was for 7-14 days (group 1). When it became apparent during the study that eradication was difficult and relapse or reinfection frequently occurred within a short time after cessation of antibiotic, a second treatment course of > or = 28 days (group 2) was given. By the end of the study, in which all patients were followed for a minimum of 30 days post treatment, 39/42 (93%) cases in group 1 and 11/13 (85%) in group 2 who had initial eradication, had relapsed or become reinfected. The median number of days and standard error for group 1 to relapse or become reinfected was 16 +/- 2.5, and for group 2 it was 27 +/- 6. Development of drug resistance was documented when bacteria isolated prior to any treatment were compared with strains isolated after > or = 28 days of antibiotics. In this study, urine sterility was achieved in a minority of treated UTIs and was relatively short lived.(ABSTRACT TRUNCATED AT 250 WORDS)     

Estimating the costs of occupational injury in the United States

This article estimates workplace injury costs in the U.S. These costs have been studied in less detail than most injury costs. Our methods, which mostly use regularly published data, produce order-of-magnitude estimates. Overall, workplace injuries cost the U.S. an estimated $140 billion annually. This estimate includes $17 billion in medical and emergency services, $60 billion in lost productivity, $5 billion in insurance costs, and $62 billion in lost quality of life. One sixth of the societal costs result from the 3% of workplace injuries in motor vehicle crashes. Motor vehicle costs per injury are almost 6 times the workplace injury average.     

Urinary trypsin inhibitor efficiently inhibits urokinase production in tumor necrosis factor-stimulated cells

We demonstrated that urinary trypsin inhibitor (UTI) efficiently inhibits soluble and tumor cell-associated plasmin activity and subsequently inhibits tumor cell invasion and metastasis. The effect of UTI on tumor necrosis factor-alpha (TNF)-induced stimulation of urokinase-type plasminogen activator (uPA) in cultured human umbilical vein endothelial cells (HUVEC) and in the promyeloid leukemia U937 cells was studied. uPA antigen was evaluated in the cell lysate and in the conditioned media by enzyme-linked immunosorbent assay, sodium dodecyl sulfate polyacrylamide gel electrophoresis, and Western blot. TNF can promote the production of uPA in HUVEC and in U937 cells. The PKC inhibitors (H7, calphostin C, and staurosporine) inhibited TNF-induced uPA expression and secretion in a dose-dependent manner. Analysis of the expression of cell surface receptor-bound uPA by flow cytometry using uPA-specific MAb indicates that induction of uPA expression by TNF was inhibited when these cells were incubated with UTI. On the other hand, treatment of the cells with UTI alone failed to alter uPA production. UTI also reduced the secretion of uPA in TNF-treated cells. UTI was as effective as PKC inhibitors in inhibiting uPA expression by TNF. Incubation of the cells with UTI, however, had no effect on the ability of PMA to stimulate cell-associated uPA expression. These data suggest that UTI may influence the PKC-dependent protein kinase pathway in uPA expression. The study on intracellular pathways involved in UTI modulation of uPA will enhance our understanding of the role that UTI plays in uPA-mediated cellular invasion.     

What are cancer patients willing to pay for prophylactic epoetin alfa? A cost-benefit analysis

BACKGROUND: Anemia, one of the most common complications of cancer chemotherapy, has been managed with red blood cell (RBC) transfusions. As an alternative, the agent epoetin alfa has the potential to reduce the transfusion requirements of patients receiving cancer chemotherapy. To estimate the value that cancer patients place on the drug, an economic analysis using the concept of willingness to pay (WTP) was conducted. METHODS: The method of WTP was used within the framework of a classical cost-benefit analysis to estimate the net cost or benefit of administering prophylactic epoetin alfa to cancer patients. This estimate included the direct cost of epoetin alfa administration and savings secondary to reduced RBC transfusions. A cohort of 100 cancer patients who received or were scheduled to receive cisplatin or noncisplatin chemotherapy (50 per group) were then interviewed to measure the maximum WTP (net benefit) that they experienced with epoetin alfa. RESULTS: Regarding the benefits they would experience after 3 months of epoetin alfa administration, patients receiving cisplatin and noncisplatin therapy stated that they would be willing to pay an average of 587 U.S. dollars (U.S.$587) (95%CI: $300-$875) and U.S.$613 (95%CI: $324-$902), respectively. These benefits were then subtracted from the total cost of the drug when administered to patients receiving cisplatin (U.S.$3530) and noncisplatin (U.S.$3653) therapy. This produced a net incremental treatment cost of U.S.$2943 (95%CI: $2655-$3230) and U.S.$3039 (95%CI: $2750-$3328) for the respective treatment groups. CONCLUSIONS: The results of the current study suggest that the routine administration of epoetin alfa to cancer patients receiving myelosuppressive chemotherapy is a highly resource-intensive treatment policy with modest benefit to patients. Additional research is required to identify high risk patient subgroups who would benefit most from the drug. [See editorial on pages 2427-9, this issue.]     

Anesthesia of wild red howler monkeys (Alouatta seniculus) with medetomidine/ketamine and reversal by atipamezole

The cost-effectiveness of two different methods of prevention of morbidity and mortality due to Plasmodium falciparum malaria, vaccination and impregnation of mosquito nets with permethrin, was compared. The analysis was performed with reference to the cohort of all children born in The Gambia in 1990 and protected for 5 years, using estimates of costs from studies in The Gambia. The vaccine was assumed to be given in three doses before the age of 6 months, through the Expanded Programme of Immunization, and to remain effective up to the age of 5 years. The bednets were assumed to be impregnated at 6-monthly intervals over the 5-year period. The expected number of deaths and attacks due to P. falciparum in the first 5 years of the 1990 cohort's lives were estimated from published literature. The numbers of deaths and attacks averted by the two strategies were then estimated by decision analysis, using the best estimates of effectiveness available in the literature. The vaccine strategy would have averted an estimated 743 deaths and 50,502 malaria attacks, whereas the net impregnation would have averted 1537 deaths and 69,415 attacks. The estimated cost per death averted was U.S. $252 for the vaccine and U.S. $711 for net impregnation. The estimated cost per P. falciparum attack averted was U.S. $3.71 for the vaccine and U.S. $15.75 for net impregnation. Sensitivity analysis, examining the effect of varying the vaccine cost or insecticide cost, the efficacy of the vaccine or net impregnation, and the percentage coverage of the population, confirmed the greater cost-effectiveness of the vaccine strategy for either of the outcomes examined under the conditions of the model. However, limitations on the absolute number of deaths and malaria attacks which can averted by currently available vaccines demonstrate that a vaccine of higher efficacy would be highly desirable.     

The etiology of idiopathic sudden sensorineural hearing loss. Experimental herpes simplex virus infection of the inner ear

PURPOSE: To evaluate dimercaptosuccinic acid (DMSA) scintigraphy and urography in the detection of renal involvement in children with urinary tract infection (UTI) in order to identify patients with a high risk of developing renal damage. MATERIAL AND METHODS: A total of 157 children (median age 0.4 years, range 5 days to 5.8 years) with first-time symptomatic UTI were examined scintigraphy (with an assessment of renal area involvement) and urography at the time of UTI and 1 year later. All evaluations were made blindly. RESULTS: Of the total 314 kidneys, 80 (25%) were abnormal at initial scintigraphy. Of these 80 kidneys, 44 (55%) had normalized at follow-up. Of the 234 initially normal kidneys, 29 (12%) were abnormal at follow-up. One year after UTI, abnormalities were seen in 59 children at scintigraphy and in 18 children at urography. Renal area involvement was larger and split function abnormalities more common in kidneys that were abnormal at both scintigraphy and urography than in kidneys with only scintigraphic abnormalities. CONCLUSION: Quantitation of renal area involvement and split renal function at early scintigraphy would seem to be useful in identifying patients at risk of developing renal damage. Urography at 1 year after infection identified mainly those with the most severe scintigraphic abnormalities. The clinical importance of scintigraphic abnormalities that are not confirmed by urography is not known.     

High prevalence of sexually transmitted diseases in women with urinary infections

OBJECTIVE: To determine the prevalence and factors associated with unrecognized sexually transmitted diseases (STDs) in women who had pelvic examinations and were subsequently released from the ED with a sole diagnosis of urinary tract infection (UTI). METHODS: A 3-month retrospective chart review was performed in an urban teaching hospital ED (> 70,000 visits/year). Women aged 12-45 years who had pelvic examinations and were released from the ED with a sole diagnosis of UTI were included. Patient complaints, physical findings, and laboratory results were reviewed. Laboratory evaluations included the complete blood count, urinalysis, urine pregnancy test, and cervical cultures for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas. RESULTS: Of the 94 women who met study criteria, 53% had proven STDs (19% N. gonorrhoeae, 22% C. trachomatis, 33% Trichomonas). There was no difference between the patients with positive and negative tests for STDs with regard to complaints, physical findings, and laboratory results (all p > 0.05). CONCLUSIONS: Women undergoing pelvic examinations who are subsequently released from this urban ED with the diagnosis of UTI have a high (> 50%) prevalence of occult STDs. No complaint, physical finding, or laboratory result reviewed was associated with the risk of an STD. Consideration should be given to empirical antibiotic therapy in similar urban populations.     

The contribution of polymorphism in the alcohol dehydrogenase beta subunit to alcohol sensitivity in a Japanese population

OBJECTIVE: To determine the additional value of the presence of microscopic haematuria in patients with benign prostatic hyperplasia (BPH). METHODS: In 750 consecutive patients with BPH urinalysis was performed and the grade of microhaematuria was correlated with other clinical findings. RESULTS: Microscopic haematuria was found in one third of the patients. Only 3 had a bladder tumour and 49 patients had urinary calculi for which only one patient required treatment. There was no correlations between any clinical parameter and the finding of microscopic haematuria. CONCLUSION: Microscopic haematuria is a frequent finding in assessment of BPH patients and additional tests should only be performed if indicated.     

Idiopathic anaphylaxis: long-term follow-up, cost, and outlook

To determine the efficacy of oral corticosteroids, antihistamines, and sympathomimetics in treating patients with idiopathic anaphylaxis, the charts of 225 patients diagnosed with idiopathic anaphylaxis from 1971 to 1990 treated at a single center were reviewed. Sixty-one patients (34 females and 27 males) were available for long-term follow-up. Ages ranged from 10 to 68 years with an average of 39 years. Patients with frequent episodes were treated with a protocol of oral corticosteroids, antihistamines, and sympathomimetics. Patients with infrequent episodes were treated for acute episodes only. The number of emergency room visits, hospitalizations, intensive care unit admissions, and length of time in remission were recorded. Sixty-five percent of patients with infrequent episodes and 91% of patients with frequent episodes of idiopathic anaphylaxis went into remission. Significant decreases in emergency room visits occurred for the idiopathic anaphylaxis-generalized-frequent group (P < 0.016), the idiopathic-anaphylaxis-generalized-infrequent group (P < 0.0001), and the idiopathic anaphylaxis-angioedema-infrequent group (P < 0.039). Significant decreases in the number of hospitalizations (P < 0.022) and intensive care unit admissions (P < 0.009) occurred for the idiopathic anaphylaxis-generalized-infrequent and frequent groups, respectively. Overall, an estimated $184 740 was saved with the treatment program, for 546 patient-years. Idiopathic anaphylaxis can be controlled and remission induced in most patients. An estimated $11 million per year can be saved for patients in the USA on the basis of the estimated prevalence in this country.     

Cholelithiasis and jaundice]

A case of significant proteinuria occurred as a result of bilateral renal vein thrombosis secondary to dehydration, which resolved after treatment with urokinase. The patient developed nausea and vomiting from viral gastroenteritis with subsequent volume contraction. He later noted the onset of aching lower abdominal and flank pain. On admission, he was noted to have a serum creatinine of 1.7 mg/dL, and 4+ proteinuria on urinalysis. A 24-hour urine collection showed 2.34 g protein. A renal venogram showed bilateral renal vein thrombosis (RVT) without involvement of the inferior vena cava. Therapy was initiated with heparin at 1,000 U/hr, followed by intravenous (IV) urokinase, 4,400 U/kg bolus, followed by 4,400 U/kg/hr with continuous infusion for 12 hours. A repeat renal venogram done at this time showed partial resolution of thrombosis bilaterally. A second 12-hour infusion of urokinase at 5,000 U/kg/hr was performed; at this time, the patient reported resolution of his flank and abdominal pain. A repeat 24-hour urine collection showed 60 mg protein with a normal creatinine clearance. Levels of antithrombin III, protein C, and protein S were all normal. A renal biopsy was performed and showed normal histology on light, immunofluorescent, and electron microscopic evaluation. The patient has done well on no therapy and has had no recurrence of thrombosis or proteinuria after 2.5 years. This is a US government work. There are no restrictions on its use.     

Childhood poisoning: a population study in Trieste, Italy, 1975-1994

We describe the epidemiology of 1918 cases of childhood poisoning referred to the emergency room in Trieste, Italy, from 1975 to 1994. The incidence rate of emergency room referral and subsequent hospitalization was calculated on the basis of the distribution of children resident in Trieste by calendar year. The occurrence of childhood poisoning was described according to time trends, age and gender of the child, route of exposure, symptoms at presentation to the emergency room, role of the child or others, intention, and substance involved in the poisoning. The association between presence of symptoms and characteristics of referral, host factors and substances involved was evaluated by estimating the odds ratio in multivariate models. Possible determinants of the clinical decision to treat certain cases were evaluated using logistic regression. Despite an increasing incidence of referral (from 155 per 100,000 persons per year in 1975-79 to 352 per 100,000 in 1990-94), hospital admission rates showed a two-fold decrease. Younger children (age 0-4 years) were more likely to be asymptomatic and required treatment and hospitalization less often than older children (age > or = 10 years). Trends show a decrease in pharmaceutical poisonings due probably to the introduction of child-resistant containers and an increase in domestic poisons. We also observed a steady increase in carbon monoxide inhalation and alcohol poisonings, mostly among teenagers.     

Learning as a Task or a Virtue: U.S. and Chinese Preschoolers Explain Learning.

The purpose of this study was to examine cultural influences on conceptual orientations of learning in U.S. and Chinese preschoolers. A sample of 188 preschoolers 4-6 years of age provided free-narrative responses to 2 story beginnings about the learning behavior of 2 protagonists, 1 who worked hard and 1 who gave up. Results showed that despite some differences in the younger age groups, children from both cultures valued learning similarly at age 6. However, important cultural differences emerged in children's construals of the learning process. U.S. children showed a heightened awareness of the mind/task attributes of the learner, that is, ability, task attempting, and strategy use. By contrast, Chinese children perceived more the learner's dispositional qualities of diligence, persistence, and concentration. These trends increased as children's age increased. The U.S. findings are interpreted as reflecting the U.S. cultural emphasis on learning as a task, and the Chinese results, as reflecting the Chinese cultural focus on learning as a process of cultivating personal virtue. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Quantitative changes in the ultrastructure of myocardial cells in Japanese quail during hypergravity, hypodynamia and space flight

To assess the consultation patterns of pediatric emergency physicians in the management of injured children and to describe the spectrum of pediatric trauma, we retrospectively reviewed 601 patients treated in the emergency department for injuries during four one-week periods at a designated level I regional pediatric trauma center (50,000 patients/year) with a pediatric emergency medicine fellowship. The majority (94%) of pediatric trauma was minor; only 2% of children had injuries severe enough to require direct transfer to the operating room. The highest volume of patients, the greatest number of consultations, and the majority of admissions to the operating room occurred between 4 PM and midnight. No patients went to the operating room on the night shift. Musculoskeletal injuries constituted the predominant category of pediatric trauma, and lacerations were the most common specific injury. One half of all procedures involved laceration repair, and one third involved splinting or casting. Four hundred ten patients (68%) were managed by physicians in the emergency department without consultation. The orthopedic service performed one half of all consultations and admitted the largest number of patients; the majority of patients taken directly to the operating room had musculoskeletal injuries.(ABSTRACT TRUNCATED AT 250 WORDS)