Bianca Nogrady

There is no one perfect diagnostic algorithm for children with a first uncomplicated febrile urinary tract infection, according to a retrospective cohort simulation comparing six diagnostic approaches for yield, cost, and radiation dose.

Five diagnostic algorithms possibly using ultrasound, voiding cystourethrography (VCUG), and late technetium⁹⁹ dimercaptosuccinic acid (DMSA) scan renal scintigraphy, plus an "all tests performed" protocol were retrospectively simulated using data from 304 children aged 2-36 months with a first uncomplicated febrile UTI who had participated in an earlier multicenter trial.

While the National Institute of Clinical Excellence (NICE 2007) and American Academy of Pediatrics (AAP 2011) algorithms had the highest specificities for vesicoureteral reflux (91% and 90% respectively), the Italian Society of Pediatric Nephrology (ISPN 2011) had the highest specificity for scars (86%), according to Dr. Claudio La Scola and colleagues. The report was published online in the Feb. 25 issue of Pediatrics (2013;131:e665–71 [doi:10.1542/peds.2012-0164]).

The "top down approach" (TDA 2007) had the highest sensitivity for detecting vesicoureteral reflux (VUR) (76%) and scarring (100%), but also was the most costly financially (52,268 euros) and in radiation dose (624 mSv). The study also evaluated the Royal Children’s Hospital of Melbourne algorithm (RCH 2006).

"An aggressive protocol has a high sensitivity for detecting abnormalities, which in some cases could be of questionable benefit to the infants, and it is burdened with high financial and radiation costs," wrote Dr. La Scola of Azienda Ospedaliero-Universitaria, Bologna, Italy, and his coauthors.

Researchers found that the NICE approach would have been the least costly (26,838 euros), and the AAP algorithm would have resulted in the lowest radiation exposure (42 mSv).

The primary outcomes of the study were the yield of abnormal tests – all grades of reflux, grades III-V reflux, and UTI related renal scarring, with secondary outcomes of total costs and total radiation dose.

"Whereas the all tests protocol would perform ultrasonography, VCUG, and DMSA scan in all children and would not miss any reflux or scar, the five guidelines formulated algorithms with the aim of identifying a high-risk population for VUR or scarring," Dr. La Scola and colleagues reported. "All five selective protocols missed a variable proportion of reflux and scars (with the exception of the TDA protocol, which detected 100% of the scars), and none would have diagnosed all the nephrourologic abnormalities."

When it came to detecting reflux grades I-V and III-V, the TDA, which uses the acute DMSA scan result as its first step, showed the highest sensitivity (76% and 85% respectively) and negative predictive value (89% and 97% respectively) but low specificity (54% and 50%).

The other four diagnostic algorithms all use the results of ultrasonography, with or without the presence of risk factors, as their first step.

"This approach would fail to detect all children with reflux, because it is well known that ultrasonography, after an initial febrile UTI, is not able to reliably identify changes associated with reflux or subsequent renal damage," the researchers reported.

The researchers suggested that a less aggressive diagnostic approach to uncomplicated febrile UTI is becoming more popular, with growing awareness that acquired pyelonephritic scarring is less of a contributor to renal damage than previously thought.

None of the authors had any financial disclosures and the study received no external funding.

There is no one perfect diagnostic algorithm for children with a first uncomplicated febrile urinary tract infection, according to a retrospective cohort simulation comparing six diagnostic approaches for yield, cost, and radiation dose.

Five diagnostic algorithms possibly using ultrasound, voiding cystourethrography (VCUG), and late technetium⁹⁹ dimercaptosuccinic acid (DMSA) scan renal scintigraphy, plus an "all tests performed" protocol were retrospectively simulated using data from 304 children aged 2-36 months with a first uncomplicated febrile UTI who had participated in an earlier multicenter trial.

While the National Institute of Clinical Excellence (NICE 2007) and American Academy of Pediatrics (AAP 2011) algorithms had the highest specificities for vesicoureteral reflux (91% and 90% respectively), the Italian Society of Pediatric Nephrology (ISPN 2011) had the highest specificity for scars (86%), according to Dr. Claudio La Scola and colleagues. The report was published online in the Feb. 25 issue of Pediatrics (2013;131:e665–71 [doi:10.1542/peds.2012-0164]).

The "top down approach" (TDA 2007) had the highest sensitivity for detecting vesicoureteral reflux (VUR) (76%) and scarring (100%), but also was the most costly financially (52,268 euros) and in radiation dose (624 mSv). The study also evaluated the Royal Children’s Hospital of Melbourne algorithm (RCH 2006).

"An aggressive protocol has a high sensitivity for detecting abnormalities, which in some cases could be of questionable benefit to the infants, and it is burdened with high financial and radiation costs," wrote Dr. La Scola of Azienda Ospedaliero-Universitaria, Bologna, Italy, and his coauthors.

Researchers found that the NICE approach would have been the least costly (26,838 euros), and the AAP algorithm would have resulted in the lowest radiation exposure (42 mSv).

The primary outcomes of the study were the yield of abnormal tests – all grades of reflux, grades III-V reflux, and UTI related renal scarring, with secondary outcomes of total costs and total radiation dose.

"Whereas the all tests protocol would perform ultrasonography, VCUG, and DMSA scan in all children and would not miss any reflux or scar, the five guidelines formulated algorithms with the aim of identifying a high-risk population for VUR or scarring," Dr. La Scola and colleagues reported. "All five selective protocols missed a variable proportion of reflux and scars (with the exception of the TDA protocol, which detected 100% of the scars), and none would have diagnosed all the nephrourologic abnormalities."

When it came to detecting reflux grades I-V and III-V, the TDA, which uses the acute DMSA scan result as its first step, showed the highest sensitivity (76% and 85% respectively) and negative predictive value (89% and 97% respectively) but low specificity (54% and 50%).

The other four diagnostic algorithms all use the results of ultrasonography, with or without the presence of risk factors, as their first step.

"This approach would fail to detect all children with reflux, because it is well known that ultrasonography, after an initial febrile UTI, is not able to reliably identify changes associated with reflux or subsequent renal damage," the researchers reported.

The researchers suggested that a less aggressive diagnostic approach to uncomplicated febrile UTI is becoming more popular, with growing awareness that acquired pyelonephritic scarring is less of a contributor to renal damage than previously thought.

None of the authors had any financial disclosures and the study received no external funding.

There is no one perfect diagnostic algorithm for children with a first uncomplicated febrile urinary tract infection, according to a retrospective cohort simulation comparing six diagnostic approaches for yield, cost, and radiation dose.

Five diagnostic algorithms possibly using ultrasound, voiding cystourethrography (VCUG), and late technetium⁹⁹ dimercaptosuccinic acid (DMSA) scan renal scintigraphy, plus an "all tests performed" protocol were retrospectively simulated using data from 304 children aged 2-36 months with a first uncomplicated febrile UTI who had participated in an earlier multicenter trial.

While the National Institute of Clinical Excellence (NICE 2007) and American Academy of Pediatrics (AAP 2011) algorithms had the highest specificities for vesicoureteral reflux (91% and 90% respectively), the Italian Society of Pediatric Nephrology (ISPN 2011) had the highest specificity for scars (86%), according to Dr. Claudio La Scola and colleagues. The report was published online in the Feb. 25 issue of Pediatrics (2013;131:e665–71 [doi:10.1542/peds.2012-0164]).

The "top down approach" (TDA 2007) had the highest sensitivity for detecting vesicoureteral reflux (VUR) (76%) and scarring (100%), but also was the most costly financially (52,268 euros) and in radiation dose (624 mSv). The study also evaluated the Royal Children’s Hospital of Melbourne algorithm (RCH 2006).

"An aggressive protocol has a high sensitivity for detecting abnormalities, which in some cases could be of questionable benefit to the infants, and it is burdened with high financial and radiation costs," wrote Dr. La Scola of Azienda Ospedaliero-Universitaria, Bologna, Italy, and his coauthors.

Researchers found that the NICE approach would have been the least costly (26,838 euros), and the AAP algorithm would have resulted in the lowest radiation exposure (42 mSv).

The primary outcomes of the study were the yield of abnormal tests – all grades of reflux, grades III-V reflux, and UTI related renal scarring, with secondary outcomes of total costs and total radiation dose.

"Whereas the all tests protocol would perform ultrasonography, VCUG, and DMSA scan in all children and would not miss any reflux or scar, the five guidelines formulated algorithms with the aim of identifying a high-risk population for VUR or scarring," Dr. La Scola and colleagues reported. "All five selective protocols missed a variable proportion of reflux and scars (with the exception of the TDA protocol, which detected 100% of the scars), and none would have diagnosed all the nephrourologic abnormalities."

When it came to detecting reflux grades I-V and III-V, the TDA, which uses the acute DMSA scan result as its first step, showed the highest sensitivity (76% and 85% respectively) and negative predictive value (89% and 97% respectively) but low specificity (54% and 50%).

The other four diagnostic algorithms all use the results of ultrasonography, with or without the presence of risk factors, as their first step.

"This approach would fail to detect all children with reflux, because it is well known that ultrasonography, after an initial febrile UTI, is not able to reliably identify changes associated with reflux or subsequent renal damage," the researchers reported.

The researchers suggested that a less aggressive diagnostic approach to uncomplicated febrile UTI is becoming more popular, with growing awareness that acquired pyelonephritic scarring is less of a contributor to renal damage than previously thought.

None of the authors had any financial disclosures and the study received no external funding.

Corticosteroids may offer short-term relief from the symptoms of lateral epicondylalgia, but they significantly increase the risk of recurrence compared with physiotherapy or placebo, according to a randomized controlled trial reported in JAMA.

The 1-year study of 165 patients also examined the interaction between corticosteroids and physiotherapy, finding that patients randomized to placebo injection and physiotherapy had better outcomes than did those who received corticosteroids and physiotherapy, or corticosteroids alone.

The senior author of the study, Bill Vicenzino, Ph.D., said the study was not quite the death knell for use of corticosteroids in the treatment of lateral epicondylalgia but it did call for more careful consideration.

"The take-home message is that both physician and patient need to be informed that there’s a higher risk of recurrence and delayed healing and that other approaches should be taken, such as good exercise, good advice, and physiotherapy, and then if that doesn’t work, then maybe you need to consider steroids," Dr. Vicenzino of the University of Queensland, Australia, said in an interview.

Lead author Brooke K. Coombes, Ph.D., of the School of Health and Rehabilitation Sciences at the University of Queensland and her associates conducted the study in patients over age 18, with unilateral lateral epicondylalgia lasting longer than 6 weeks. The patients were randomized to one of four groups: corticosteroid injection, placebo injection, corticosteroid injection plus multimodal physiotherapy, or placebo injection plus multimodal physiotherapy (JAMA 2013;309:461-9).

Of the patients treated with 10 mg/mL of triamcinolone in a 1-mL injection, 83% demonstrated complete recovery or much improvement at 1 year, compared with 96% of patients treated with saline injection (relative risk, 0.86; 99% confidence interval, 0.75-0.99). Symptoms recurred in 54% of those given the corticosteroid, compared with 12% of those given placebo (RR, 0.23; 99% CI, 0.10-0.51).

Among patients treated with multimodal physiotherapy, consisting of eight 30-minute sessions of local elbow manipulation and exercise over 8 weeks, there was no significant difference in outcomes at 1 year or in the risk of recurrence, compared with patients who did not receive physiotherapy.

However, at 4 weeks, patients given corticosteroid injections alone were significantly more likely to experience complete recovery or much improvement than were those given placebo (RR, 7.32; 99% CI, 2.1-25.5). They also reported less pain and disability and improved quality of life.

But patients who received physiotherapy and placebo injection also had improved outcomes at 4 weeks, compared with the no-physiotherapy placebo group, reporting higher rates of complete recovery or much improvement (RR, 4.00; 99% CI, 1.07-15.00).

"Physiotherapy should not be dismissed altogether because in the absence of the corticosteroid, it provided short-term benefit across all outcomes, as well as the lowest recurrence rates (4.9%) and 100% complete recovery or much improvement at 1 year," the investigators reported.

The study was funded by the Australian National Health and Medical Research Council. The researchers reported receiving payment and travel reimbursement for lectures and conference presentations on physiotherapy and musculoskeletal-related topics.

rhnews@elsevier.com

Corticosteroids may offer short-term relief from the symptoms of lateral epicondylalgia, but they significantly increase the risk of recurrence compared with physiotherapy or placebo, according to a randomized controlled trial reported in JAMA.

The 1-year study of 165 patients also examined the interaction between corticosteroids and physiotherapy, finding that patients randomized to placebo injection and physiotherapy had better outcomes than did those who received corticosteroids and physiotherapy, or corticosteroids alone.

The senior author of the study, Bill Vicenzino, Ph.D., said the study was not quite the death knell for use of corticosteroids in the treatment of lateral epicondylalgia but it did call for more careful consideration.

"The take-home message is that both physician and patient need to be informed that there’s a higher risk of recurrence and delayed healing and that other approaches should be taken, such as good exercise, good advice, and physiotherapy, and then if that doesn’t work, then maybe you need to consider steroids," Dr. Vicenzino of the University of Queensland, Australia, said in an interview.

Lead author Brooke K. Coombes, Ph.D., of the School of Health and Rehabilitation Sciences at the University of Queensland and her associates conducted the study in patients over age 18, with unilateral lateral epicondylalgia lasting longer than 6 weeks. The patients were randomized to one of four groups: corticosteroid injection, placebo injection, corticosteroid injection plus multimodal physiotherapy, or placebo injection plus multimodal physiotherapy (JAMA 2013;309:461-9).

Of the patients treated with 10 mg/mL of triamcinolone in a 1-mL injection, 83% demonstrated complete recovery or much improvement at 1 year, compared with 96% of patients treated with saline injection (relative risk, 0.86; 99% confidence interval, 0.75-0.99). Symptoms recurred in 54% of those given the corticosteroid, compared with 12% of those given placebo (RR, 0.23; 99% CI, 0.10-0.51).

Among patients treated with multimodal physiotherapy, consisting of eight 30-minute sessions of local elbow manipulation and exercise over 8 weeks, there was no significant difference in outcomes at 1 year or in the risk of recurrence, compared with patients who did not receive physiotherapy.

However, at 4 weeks, patients given corticosteroid injections alone were significantly more likely to experience complete recovery or much improvement than were those given placebo (RR, 7.32; 99% CI, 2.1-25.5). They also reported less pain and disability and improved quality of life.

But patients who received physiotherapy and placebo injection also had improved outcomes at 4 weeks, compared with the no-physiotherapy placebo group, reporting higher rates of complete recovery or much improvement (RR, 4.00; 99% CI, 1.07-15.00).

"Physiotherapy should not be dismissed altogether because in the absence of the corticosteroid, it provided short-term benefit across all outcomes, as well as the lowest recurrence rates (4.9%) and 100% complete recovery or much improvement at 1 year," the investigators reported.

The study was funded by the Australian National Health and Medical Research Council. The researchers reported receiving payment and travel reimbursement for lectures and conference presentations on physiotherapy and musculoskeletal-related topics.

rhnews@elsevier.com

Corticosteroids may offer short-term relief from the symptoms of lateral epicondylalgia, but they significantly increase the risk of recurrence compared with physiotherapy or placebo, according to a randomized controlled trial reported in JAMA.

The 1-year study of 165 patients also examined the interaction between corticosteroids and physiotherapy, finding that patients randomized to placebo injection and physiotherapy had better outcomes than did those who received corticosteroids and physiotherapy, or corticosteroids alone.

The senior author of the study, Bill Vicenzino, Ph.D., said the study was not quite the death knell for use of corticosteroids in the treatment of lateral epicondylalgia but it did call for more careful consideration.

"The take-home message is that both physician and patient need to be informed that there’s a higher risk of recurrence and delayed healing and that other approaches should be taken, such as good exercise, good advice, and physiotherapy, and then if that doesn’t work, then maybe you need to consider steroids," Dr. Vicenzino of the University of Queensland, Australia, said in an interview.

Lead author Brooke K. Coombes, Ph.D., of the School of Health and Rehabilitation Sciences at the University of Queensland and her associates conducted the study in patients over age 18, with unilateral lateral epicondylalgia lasting longer than 6 weeks. The patients were randomized to one of four groups: corticosteroid injection, placebo injection, corticosteroid injection plus multimodal physiotherapy, or placebo injection plus multimodal physiotherapy (JAMA 2013;309:461-9).

Of the patients treated with 10 mg/mL of triamcinolone in a 1-mL injection, 83% demonstrated complete recovery or much improvement at 1 year, compared with 96% of patients treated with saline injection (relative risk, 0.86; 99% confidence interval, 0.75-0.99). Symptoms recurred in 54% of those given the corticosteroid, compared with 12% of those given placebo (RR, 0.23; 99% CI, 0.10-0.51).

Among patients treated with multimodal physiotherapy, consisting of eight 30-minute sessions of local elbow manipulation and exercise over 8 weeks, there was no significant difference in outcomes at 1 year or in the risk of recurrence, compared with patients who did not receive physiotherapy.

However, at 4 weeks, patients given corticosteroid injections alone were significantly more likely to experience complete recovery or much improvement than were those given placebo (RR, 7.32; 99% CI, 2.1-25.5). They also reported less pain and disability and improved quality of life.

But patients who received physiotherapy and placebo injection also had improved outcomes at 4 weeks, compared with the no-physiotherapy placebo group, reporting higher rates of complete recovery or much improvement (RR, 4.00; 99% CI, 1.07-15.00).

"Physiotherapy should not be dismissed altogether because in the absence of the corticosteroid, it provided short-term benefit across all outcomes, as well as the lowest recurrence rates (4.9%) and 100% complete recovery or much improvement at 1 year," the investigators reported.

The study was funded by the Australian National Health and Medical Research Council. The researchers reported receiving payment and travel reimbursement for lectures and conference presentations on physiotherapy and musculoskeletal-related topics.

rhnews@elsevier.com