Pediatric Screening Urinalysis in the US

Sep 16 2014 Published by under [Medicine&Pharma]

A Brief History of Recommendations

Back in the 1980s when I trained, the American Academy of Pediatrics (AAP) recommended a screening urinalysis at four age points during childhood: infancy, early childhood, late childhood, and adolescence. Getting urine out of a child can be incredibly time consuming. Stick-on bags can be used in children not yet toilet trained, although results are often contaminated by skin flora. Bags can also leak, making the process a frustrating waiting game.

In 2000 the AAP published new guidelines with screening UA recommended only at 2 ages: 5 years old, the typical age of school entry, and in sexually active adolescents.

Hmm...UA doesn't seem to be a procedure...

Hmm...UA doesn't seem to be a procedure...

Today's well child preventive care guidelines are known as Bright Futures. The components of care are enlarged in the figure at the right; recommended lab studies are listed under Procedures, and no urinalysis can be found in this table or elsewhere in the document.

At present, it would appear that otherwise healthy, asymptomatic children do not need screening UAs.

What About Sports?

After exploring a number of professional sites, including the AAP, I found no recommendations for UAs prior to athletic participation. Blood pressure screening is included, with the recommendation that children with unexplained or uncontrolled hypertension should not participate in power lifting or body building. A urinalysis should be included in the work-up of hypertension in children, but that goes beyond the scope of the sports physical.

So the Answer is...?

Poll

None of the above wins!

None of the above. Currently, no UA is recommended at any age or before any activity for healthy, asymptomatic children.

So what are primary care providers actually doing? And why is this an issue? More fun to come, WhizBangers!

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When to Pee in the Cup

Sep 11 2014 Published by under Kidney Function

Screening urinalysis (UA), usually performed by dipstick in a physician's office, ultimately results in a lot of referrals for nephrologists. I am reviewing this topic, and I will have a series of posts about UAs over the coming weeks. First, I want to start with a poll about what is really recommended for healthy, asymptomatic children:

What are the current recommendations for screening urinalysis by the American Academy of Pediatrics?Next week I will reveal the answers from the crowd, as well as what the real answer is.

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Is the Answer at the RIVUR? #NephJC

Jul 16 2014 Published by under Evidence Based Medicine, Journal Club

This study will be discussed as part of the online, twitter-based Nephrology Journal Club on July 22,2014. More information about the workings of #NephJC can be found here.

The Problem of Reflux

Vesicoureteroreflux (VUR) occurs in approximately 10% of children overall, but about one-third of those with a febrile or otherwise symptomatic urinary tract infection (UTI). VUR is associated with an increased risk of renal "scars." Since it was first described in the 1960's, treatment of this backflow of urine from the bladder to the ureter has been recommended for all affected children. Surgery can create a competent valve at the vesicoureteral junction during voiding, but an early randomized trial showed that prophylactic antibiotics to prevent infection were just as effective as surgery in the scarring outcome.

Despite the recommendations for treatment for 50 years, permanent kidney failure attributed to VUR has not declined in the end-stage database of any country. Improved prenatal diagnosis of infant renal anomalies have allowed us to diagnose VUR in the first weeks of life, prior to any UTIs. Some children without UTIs still get renal scarring, leading some to suspect that "scars" may actually be areas of hypoplasia or other abnormal development due to an abnormal ureteric bud.

The original study showed equivalent results from surgery and antibiotic prophylaxis, but it included no untreated control group to assess the strategy of intermittent treatment of  UTIs when they occurred. The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial set out to determine if long-term prophylaxis prevented recurrence of UTIs, occurrence of "scars," or contributed to antimicrobial resistance.

The Study

The study was a randomized, double-blind, placebo-controlled trial of prophylaxis with trimethoprim-sulfamethoxazole (TMPS). Children were screened and enrolled after 1 or 2 febrile or otherwise symptomatic UTIs, including positive culture. Bagged urine samples were not allowed. Children in the study ranged in age from 2 months to 6 years and had grades I to IV VUR (severe grade V patients were excluded). Exclusion criteria included other urinary abnormalties, chronic kidney disease, inability to take TMPS, and other selected medical issues.

Studies included dimercaptosuccinic acid (DMSA) scans at baseline and 1 and 2 years later. These scans (the gold standard for kidney scars) were read and scored centrally by two pediatric nuclear medicine radiologists.

Treatment failure was defined as:

  • 2 febrile UTIs
  • 1 febrile and 3 symptomatic UTIs
  • 4 symptomatic UTIs
  • New or worsening "scars" at 1 year

The Results

Baseline characteristics of the children enrolled can be seen here. No significant differences on any parameter existed between the treatment and control groups. Time to first febrile or symptomatic UTI after trial enrollment is shown below:

Figure2

As shown in the paper’s figure 2 above, the two groups separated significantly within the first 6 months of treatment, with TMPS prophylaxis clearly preventing UTIs. By the end of 2 years, approximately one quarter of the placebo group had experienced an infection, while only half that many in the prophylaxis group had fallen ill.

A number of potential modifying factors were assessed for impact on the results, shown in the figure below:

Figure 3

As shown prophylaxis was more valuable for children who presented with febrile, as opposed to symptomatic but afebrile, UTI. Bowel and bladder dysfunction, determined via a standardized survey, also favored the use of TMPS.

Renal “scars” showed no difference throughout the study. Rectal swabs showed no significant difference in the rate of resistance of E. coli to TMPS between the prophylaxis and control groups.

Remaining Questions

Clearly antibiotic prophylaxis reduces the risk of recurrence of UTIs in children with VUR. However, about 75% of children receiving placebo had not suffered a recurrence after 2 years of study. UTIs cause discomfort, school absence, and lost work for parents; even after this trial we have no evidence of long-term damage prevention through the use of TMPS. Antibiotic resistance does not seem to be a big problem in this patient population.

So the question remains: what should we do about VUR?

In my mind, the question is still open. Many families today have qualms about long-term exposure to these medications. Other families dread missing a UTI and would far prefer to take the antibiotic. The tolerance of the family for illness vs the small risks of prophylaxis often prove to be a big factor driving therapy.

That leaves us each a lot of flexibility in our approach to VUR. My personal preference is to watch most cases without prophylaxis initially. Those who have further UTIs in the first few months after diagnosis are encouraged to start prophylaxis and consider surgical treatment. Those without significant recurrences receive follow-up on a regular basis. All of this requires ongoing discussion with the parents and input regarding their tolerance for urinary symptoms.

The pediatric nephrology community hoped that RIVUR would answer our managment questions about VUR. It would appear that we still have more we need to know.

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The American Way

Apr 10 2014 Published by under [Medicine&Pharma]

Today in one of my feeds, someone asked why a woman's employer should pay for her birth control. Seems if we ladies want to make the beast with two backs without creating new little beasts, we should be ready to put up our own funds for the privilege.

When you get right down to it, why should our employers pay for our check-ups? Or our blood pressure control? Or bypass surgery or Viagra for their executives (who are almost universally d00ds)?

Because it's the American Way! Not in a flag-waving, patriotic sense, but because, historically, health insurance became a benefit provided by employers in this country. Like-it-or-not, reproductive care is a major aspect of women's health. No contraception coverage? You'll be paying for babies then. Even women who practice celibacy (like nuns) may need interventions for polycystic ovary disease or other symptomatic conditions affecting those bits down there.*

As long as we have employers providing the bulk of health insurance, they will have to pay for reproductive services for women.

OK, I got that off my chest. I will try not to yell at my screen about it any longer.

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*I personally know of a case where the convent had no trouble buying oral contraceptives to control symptoms of polycystic ovary disease for a young nun. Intent, in this case, trumped the name of the drug. Of course, the Roman Catholic medical center that employed me would not cover the same pills for me.

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My Arch Enemy

Apr 08 2014 Published by under [Medicine&Pharma]

Oklahoma is recovering from an outbreak of Escherichia coli which has kept me away from the blog recently.

E. coli, as we usually call it, lives all around and in us. A good chunk of that microbiome we keep hearing about includes this bacteria. Most strains happily thrive in our guts, living a perfectly benign coexistence with us. At times they may find their way into our urine or other problematic place, but they can usually be rapidly dispatched.

Some strains produce a toxin first noted in the bacteria Shigella, thus named Shiga Toxin. Autocorrect on my iPhone wants to change "shiga" to "shiva." This may not be an error. This toxin causes incredible inflammation within the bowel. When the gut gets inflamed, it lets water and other material flow on through, producing diarrhea. In this case, the inflammation is so intense that the gut bleeds. A bloody gut produces bloody diarrhea. Nausea, vomiting, and intense cramping complete the clinical picture. This is a case of the runs you will never forget.

Click to Enlarge

Click to Enlarge

In a small number of cases of hemorrhagic colitis, the toxin enters the blood stream and produces a systemic response called a thrombotic microangiopathy (TMA for short). In tiny blood vessels throughout the body (capillaries), the toxin damages the inside. Platelets (oblong lavender thingies in the diagram) activate on these areas of damage to begin repairs. These tiny clots get bigger over time and form a mesh or halt blood blow to an organ, impairing or shutting down its function.

Not all organs seem as prone to TMA damage. The kidneys seem to provide a playground for the toxin and platelets; kidney involvement ranges from the trivial to irreversible infarction or scarring of the kidneys. This is why we call this TMA hemolytic uremic syndrome (HUS), uremia being another term for kidney failure. Other organs can be involved, including the brain, pancreas, liver, and heart.

Obviously the kidney provides a major clotting magnet, or I would not be discussing this entity. We do not really know why one child gets colitis and develops HUS while another gets just a horrible case of diarrhea. Using antibiotics and anti-diarrheal drugs during the colitis can increase the risk of HUS, but they do not explain it all.

Since this syndrome was described in the 1950's mortality has fallen from ~50% to <5% just with supportive care. Mortality generally is confined to patients with significant central nervous system involvement. Apparent kidney recovery occurs in 95% of survivors, although most will develop other signs and symptoms of chronic kidney disease over the decades.

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Trying to Stop a Disruptive Train

Apr 04 2014 Published by under Life of a Physician

My week involved a lot of work with patients as some hemolytic-uremic syndrome came to town. While driving to and fro and using the restroom, I have read some tweets. At one point in a discourse, we talked about "antique" portions of the physical exam.

For example, in medical school they taught us to percuss heart borders. Percussion involves tapping on the chest and listening for the difference between the air-filled lungs and the relatively solid heart as shown in the video:

I cannot remember the last time I percussed a heart. Children do not hold still and quiet for such nonsense, and we get much more information from a chest xray. The latter also provides a lasting objective record of the findings that can be shared with subsequent physicians (or legal professionals). Most of the medical students I queried had no idea what I was talking about.

Many medical schools now incorporate inexpensive portable ultrasound machines into their curriculum. I envy these students who will be able to hear a murmur and figure out what it means on-the-spot. I know several pediatric nephrologists who have trained to perform their own ultrasound exams in the clinic. Unfortunately, its use is not spreading as fast or as far as it should.

Why? Hospital privileges.

When a doctor establishes a practice in a clinical facility, they usually have to be approved by a group at that place to make sure they are competent. I could apply for privileges for many procedures, but then I have to document my proficiency. Generally, they want to know what training you have and how many of the procedure you completed in the past 1-5 years. Imaging studies have fallen under the procedures heading. All those formal ultrasounds in the radiology suite generate lots of income for facilities.

They may not want us doing our own, even when we have the capability to record and store our images for the record.

The nice thing about disruptive technologies is that they are usually hard to stop. Eventually pocket ultrasound may replace even more of those "artisanal" physical exam skills. And that's OK if it makes for better care.

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Real Family Values

Aug 12 2013 Published by under Access

Stay of Hope Foundation

Imagine your happy life with a loving partner, some happy children, and perhaps a pet or two. You have comfortable careers with healthcare coverage. You are not rich - losing a paycheck would be a big problem - but you do not feel insecure.

Now one of your children gets sick. Their kidneys have failed! In addition to learning about new drugs and diets and dialysis, you find out that your insurance has restrictions on specialty care. If you want them to pay for the surgery, then your child has to move to a contracted center in another state. Sure, your state has a hospital that can do it just 2 hours from home, but this is not the "preferred provider" so only 80% of costs will be covered. That means more than $20,000 out-of-pocket.

So how bad would living at the out-of-state center be? Since we are talking about a child, there will have to be a guardian of some sort with them. You will need to relocate to a strange location for weeks to months, leaving behind your support system. Of course, you cannot continue to work during this time, nor can you contribute to the maintenance of your family in non-monetary ways. Who will feed the dog? To top it off, your insurer will reimburse you for living expenses while out-of-town, but you have to pay to move and start a second residence out of your own pocket. Where do you get that money?

Well, Medicare also covers patients with end-stage kidney failure. You have worked and paid into the system, so your child is eligible...if you start paying Medicare premiums. There goes $800 each month to make sure your kid gets covered some way.

It's enough to break a family apart. Or enough to inspire a mother start a charitable organization.

The Stay of Hope Foundation will provide a number of services for children and families facing these medical and financial pressures. Beginning in Oklahoma (charity starts at home, folks) the foundation will offer advocacy in dealing with insurers and financial support for living expenses, Medicare premiums, and other out-of-pocket expenses. The group just got its LLC papers; as soon as we raise the application fee ($850) we will start the long and winding road to 501(c)(3) status! Eventually, we hope to offer services throughout the USA.

This scenario has occurred on a few occasions during the decades I have practiced, so when I heard about Heather MacDonald's new work I volunteered for their board. Forcing families under the stress of chronic disease to split geographically or face financial disaster seems unkind at best (mean, wicked, and grinchy come to mind).

I am supporting this group with my time and treasure and pride. More information can be found on the website, as can a Paypal donation button and an address for old-fashioned checks. As I noted, we do not have that 501(c)(3) status yet, but we are working on it.

So spread the word. Give if you can. And help families deal with that spot between the rock and the hard place.

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"The primary is just for check-ups" - Socioeconomic Status and Care Choices

Jul 18 2013 Published by under Access, General Health

In the US, un- and under-insured patients use the emergency department (ED) and inpatient services disproportionately. In part, this occurs because these facilities provide care for all who seek it, regardless of ability to pay. However, even in countries with universal health coverage, low socioeconomic status patients seek care with the same patterns.

Reigning in health expenses in the US includes efforts to shift non-emergency care from the ED and the inpatient ward to the outpatient setting. In the 1990's, many states experimented with Medicaid HMO's, assigning the poor to primary care clinics as part of the effort. Success was limited at best, and we now find those least able to pay seeking care in the most expensive venues.

 A recent study from the University of Pennsylvania explores reasons that those with low socioeconomic status (SES) use more acute care and less primary care than patients with high SES. They invited 64 adult inpatients of low SES based on Zip Codes to participate in structured qualitative interviews; 40 agreed to the study. Of these patients, 12 (Profile A) had 5 or more acute care episodes in the prior 6 months. The remaining 28 individuals (Profile B) had 4 or fewer hospital encounters over the same period. Patients of the two profiles had similar income, sex distribution, and ethnicity. The major difference between the two groups seemed to be the presence of  a social support network for subjects in Profile B.

Click to Enlarge

Click to Enlarge

The figure shows themes that differed between the two profiles. All patients identified ease of access and quality of care as reasons for choosing hospital-based services. Profile A patients reported more chaotic lives than those with fewer encounters; they experienced more trauma, dysfunction, substance abuse, survival insecurity, and problems with activities of daily living. Profile B patients also experienced barriers, including the need to be caregivers; however, their social networks also provided support as well as this burden. Finally, Profile B patients saw their health issues as concrete problems to be solved, rather than an intangible challenge.

The study provides an important first step in improving care for low SES patients by identifying themes that influence their care choices. Like all qualitative studies, it gives no results with a p value but provides data to generate new hypotheses and policies. The study population was also limited to urban, primarily African American patients; the rural poor we see in Oklahoma may identify different barriers. Further study is clearly needed.

The study is available here; this is the citation:

Kangovi et al. Understanding Why Patients of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care. Health Affairs 32 (2013): 1196-1203     DOI:  10.1377/hlthaff.2012.0825

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Ethics of Wellness and #247Health

Feb 22 2013 Published by under General Health

Since Science Online, I have been trying to summarize our session on Mobile Health, a discussion that raised more questions than it answered (like all good Science Online sessions). We started out with two major questions:

  1. How can we use smart phones and other mobile technology to improve health management?
  2. How can we harness this flood of data to learn more about health (and disease) without compromising privacy?

A number of ethical concerns came up, including who owns health data once it's logged? Who profits from data? How do we use these tools responsibly for mental health? Finally, how do we improve access if we do find that mobile health improves outcomes?

Yesterday I heard an interesting interview on NPR with Morgan Downey, an advocate for people with obesity and editor of the Downey Obesity Report. He discussed employee wellness programs:

Well, wellness programs come in two varieties: voluntary, participatory programs, where the employer may provide classes on smoking cessation or diet or lifestyle, maybe a membership in a gym - totally voluntary. And the rewards there are usually, you know, a baseball cap or tickets to a movie or a baseball game, or something like that.

The other type of program is a mandatory program where employees take a biometric, it's called - like blood pressure, for hypertension; like body mass index, for obesity - and set a target for what change they want to see. And if the employee meets the target, the employee would receive a benefit, an incentive. But if he or she doesn't, then they could be charged, in effect, up to 30 percent of their health insurance premium.

Click to enlarge

Click to enlarge

Corporate wellness programs are the new frontier and a prime method for generating profits in mobile health. The device I use, the Fitbit, clearly wants this market as shown in the picture. They promise that 88% of employees will take more steps with their tracking device; based on prior experiments with pedometers and other devices, I tend to believe this number. They then note that 69% of participants will improve their health. I have no idea what they mean by this statement. It could be some particular biometric parameter or merely a subjective reporting of health.

Given the number of hours we spend in the workplace, and the US employer-based insurance system, it makes sense that our bosses want us to improve our overall health. It is scary that what we pay for our benefits could depend on our performance in the gym.

Obesity treatment tops the list for most wellness programs. Certainly, excess body fat is associated with (and almost certainly causes) diabetes, cardiovascular disease, stroke, and other major causes of death and disability. Our treatment of obesity is not particularly impressive. A recent review of the medical evidence showed that most diets produced modest weight loss of 4-6 kg (8-13 lbs). All successful programs required calorie restriction of some sort, increased activity, and usually some sort of behavior modification. Most studies included less than 2 years of follow-up, so the long-term results are less clear. Modest weight loss can produce significant health benefits, even if the subject remains overweight. Will that accomplishment be sufficient for a corporate overseer? I have no idea. What if a participant regains the weight? Will there be financial penalties?

Right now I use my FitBit linked with a number of health apps to track my diet and exercise and other goals. I'm taking baby steps to my goals, but I am very glad that my employer is not following my efforts or linking my insurance rates to my success. I have enough to worry about with my job without making my fitness part of my career.

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More on #247Health for #scio13

Jan 21 2013 Published by under General Health

Click to Amazon

As Science Online draws near, I continue to gear up for the session on 24/7 Health. Another book on the topic, Jody Ranck's Connected Health: How Mobile Phones, Cloud and Big Data Will Reinvent Healthcare addresses the gee-whiz, look-what-we-can-do aspects of the topic but also takes a closer look at the limitations. Smart phones and home computers allow us to tract aspects of our health like never before. Doctors have more tools and access to immediate information. We are approaching a time when sequencing individual genomes will be affordable as well as feasible.

But what do we do with these data?

  • A number of twitter colleagues are currently participating in diet and fitness challenges, tracking runs and rides and calories and points. Will they accomplish more than those who have real-life, in-the-flesh work-out buddies?
  • Home appliances can now track heart rate and rhythm continuously. If a patient collects these data, how do I use the information? I have no idea at present.
  • Say a patient pays to have their genome sequenced. At this point in time, we simply do not know what most of it means, even in relation to known medical conditions or drugs. Sure, there have been some pharmacogenetics studies that produced useful information, but these represent a small portion of one individual's genomic made-up.

The revolution will require Big Data Services on many levels. First, only through the use of such analysis will we learn what the data mean. We cannot interpret one patient's genome until we have studied large populations to know what the results mean. We will need access to more than the gene sequences; accurate information about disorders, drug responses, side effects, and everything else we can consider will be needed to produce the brave new world of individualized medicine that we envision for the future.

As we have seen this week, there are risks involved. Even de-identified genetic data can be identified at some level. As Ranck states the problem:

Health care cannot afford the pervasive privacy policy conflicts of Facebook, nor can an overly rigid interpretation of HIPAA stand in the way of consumer sharing of data.

Finally, multiple streams of patient data will have to be crunched into a usable format. One of the chronic disorders that has led the tracking movement is diabetes. Smart phones allow patients to automatically log blood glucose levels and physical activity; integrated diet logs and insulin tracking can give a complete picture of the factors that influence glycemic control. If I am seeing this patient in the office for a quarterly visit, I really do not wish to manually sift through everything. I need a dashboard that can scan the record and point me to the times when something unexpected happened. The diabetes world is moving toward this endpoint; we are still awaiting these advances for other chronic diseases.

I'm looking forward to a spirited discussion of mobile health on Saturday, February 2, at Science Online. See you there, whether in real life or virtuallly.

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