ABSTRACT De and colleagues present the validation results of the National Institute for Health an... more ABSTRACT De and colleagues present the validation results of the National Institute for Health and Care Excellence (NICE) “traffic light” system to detect serious bacterial infections in young children with fever.1 Such research is welcome, because timely recognition of the small number of children with serious bacterial infections among the majority with self limiting infections is difficult and consumes considerable frontline healthcare resources.2 We recently examined the diagnostic accuracy of several clinical prediction rules, including the NICE traffic light system with any amber or red feature present,...
'Safety netting' advice allows general practitioners (GPs) to cope with diagnosti... more 'Safety netting' advice allows general practitioners (GPs) to cope with diagnostic uncertainty in primary care. It informs patients on 'red flag' features and when and how to seek further help. There is, however, insufficient evidence to support useful choices regarding 'safety netting' procedures. To explore how GPs apply 'safety netting' in acutely ill children in Flanders. We designed a qualitative study consisting of semi-structured interviews with 37 GPs across Flanders. Two researchers performed qualitative analysis based on grounded theory components. Although unfamiliar with the term, GPs perform 'safety netting' in every acutely ill child, guided by their intuition without the use of specific guidelines. They communicate 'red flag' features, expected time course of illness and how and when to re-consult and try to tailor their advice to the context, patient and specific illness. Overall, GPs perceive 'safety netting' as an important element of the consultation, acknowledging personal and parental limitations, such as parents' interpretation of their advice. GPs do not feel a need for any form of support in the near future. GPs apply 'safety netting' intuitively and tailor the content. Further research should focus on the impact of 'safety netting' on morbidity and how the advice is conveyed to parents.
ABSTRACT De and colleagues present the validation results of the National Institute for Health an... more ABSTRACT De and colleagues present the validation results of the National Institute for Health and Care Excellence (NICE) “traffic light” system to detect serious bacterial infections in young children with fever.1 Such research is welcome, because timely recognition of the small number of children with serious bacterial infections among the majority with self limiting infections is difficult and consumes considerable frontline healthcare resources.2 We recently examined the diagnostic accuracy of several clinical prediction rules, including the NICE traffic light system with any amber or red feature present,...
Acute infection is the most common presentation of children in primary care with only few having ... more Acute infection is the most common presentation of children in primary care with only few having a serious infection (eg, sepsis, meningitis, pneumonia). To avoid complications or death, early recognition and adequate referral are essential. Clinical prediction rules have the potential to improve diagnostic decision-making for rare but serious conditions. In this study, we aimed to validate a recently developed decision tree in a new but similar population. Diagnostic accuracy study validating a clinical prediction rule. Acutely ill children presenting to ambulatory care in Flanders, Belgium, consisting of general practice and paediatric assessment in outpatient clinics or the emergency department. Physicians were asked to score the decision tree in every child. The outcome of interest was hospital admission for at least 24 h with a serious infection within 5 days after initial presentation. We report the diagnostic accuracy of the decision tree in sensitivity, specificity, likeliho...
Samenvatting Het tijdig herkennen van ernstige infecties is de basis om de kindermortaliteit en-m... more Samenvatting Het tijdig herkennen van ernstige infecties is de basis om de kindermortaliteit en-morbiditeit te verminderen. In Vlaanderen varieert het voorkomen van ernstige infecties bij kinderen volgens de klinische setting. Dit is vermoedelijk het hoogst op een pediatrische spoedafdeling, maar exacte cijfers hierover ontbreken. Daarom werd gedurende zes maanden het voorkomen van ernstige infecties op de pediatrische spoedgevallendienst van het UZ Leuven bestudeerd. Aan de hand van het elektronisch medisch dossier werden, retrospectief, kinderen van één maand tot zestien jaar die zich tussen oktober 2011 en maart 2012 met een acute ziekte-episode aanboden op de spoedafdeling opgenomen in de studie. Hieruit werden de ernstige infecties gese-lecteerd op basis van het volledige dossier na het ontslag. Van de 3.107 kinderen die zich aanmeldden met een acute ziekte-episode, voldeden 2.221 aan de inclusiecriteria. 241 van hen (11%) hadden een ernstige infectie: pneumonie (126), meningit...
To examine the relation between static and dynamic blood pressure (BP) measurements and the evolu... more To examine the relation between static and dynamic blood pressure (BP) measurements and the evolution of kidney function in older people, adjusted for the presence of multimorbidity. Retrospective cohort study during a 10-year time interval (2002-2012) in three age strata of patients aged 60 and older. Primary care registration network with 97 general practitioners working in 55 practices regularly submitting collected patient data. All patients with at least one BP measurement in 2002 and at least four serum creatine measurements after 2002 (n=8636). A modified Charlson Comorbidity Index (mCCI) at baseline was registered. Change in systolic and diastolic BP (DBP) and pulse pressure (PP) from 2002 onwards was calculated. The relation between kidney function evolution and baseline BP and change in BP was examined using linear and logistic regression analysis. The slope of the estimated glomerular filtration rate (eGFR, MDRD, Modification of Diet in Renal Disease equation) was calcula...
Despite huge public campaigns, there is still overconsumption of antibiotics in children with sel... more Despite huge public campaigns, there is still overconsumption of antibiotics in children with self-limiting diseases. Possible explanations may be the physicians' and parents' uncertainty about the gravity of the disease and inadequate communication between physicians and parents leading to lack of reassurance for the parents. In this paper we describe the design and methods of a trial aiming to rationalize antibiotic prescribing by decreasing this uncertainty and parental anxiety. Acutely ill children without suspected serious disease consulting their family physician will be consecutively included in a four-armed cluster randomized factorial controlled trial. The intervention will consist a Point-of-Care C-reactive protein test and/or a brief intervention with safety net advice. The control group will receive usual care. We intend to include 2560 patients in 88 family practices. Patients will be followed up until cure. The primary outcome measure is the immediate antibioti...
Acute illness is the most common presentation of children to ambulatory care. In contrast, seriou... more Acute illness is the most common presentation of children to ambulatory care. In contrast, serious infections are rare and often present at an early stage. To avoid complications or death, early recognition and adequate referral are essential. In a recent large study children were included prospectively to construct a symptom-based decision tree with a sensitivity and negative predictive value of nearly 100%. To reduce the number of false positives, point-of-care tests might be useful, providing an immediate result at bedside. The most probable candidate is C-reactive protein, as well as a pulse oximetry. This is a diagnostic accuracy study of signs, symptoms and point-of-care tests for serious infections. Acutely ill children presenting to a family physician or paediatrician will be included consecutively in Flanders, Belgium. Children testing positive on the decision tree will get a point-of-care C-reactive protein test. Children testing negative will randomly either receive a poi...
Mostly, it is impossible to establish the type of arrhythmias, based on signs and symptoms only. ... more Mostly, it is impossible to establish the type of arrhythmias, based on signs and symptoms only. An ECG device is not always within reach. We presumed the heartscan, a handheld wireless device, to be of value to a GP in emergency situations. We therefore studied inter- and intra-observer variability and the accuracy of the screen readings. All consecutive patients visiting the emergency department (ED) of the Gasthuisberg University Hospital in Leuven, Belgium, as well as patients hospitalised in three hospital wards on one day, were included. Immediately after the heartscan recording, a standard 12-lead ECG was recorded and read by an experienced hospital-based cardiologist. The recordings were read on the device screen by two general practitioners. All readers were blinded to the 12-lead ECG readings and vice versa, and for each other's ones. We compared both the heartscan reading of the first reader and the automatic reading of the device with the readings of the second GP an...
Health technology assessment (Winchester, England), 2012
Although the vast majority of children with acute infections are managed at home, this is one of ... more Although the vast majority of children with acute infections are managed at home, this is one of the most common problems encountered in children attending emergency departments (EDs) and primary care. Distinguishing children with serious infection from those with minor or self-limiting infection is difficult. This can result in misdiagnosis of children with serious infections, which results in a poorer health outcome, or a tendency to refer or admit children as a precaution; thus, inappropriately utilising secondary-care resources. We systematically identified clinical features and laboratory tests which identify serious infection in children attending the ED and primary care. We also identified clinical prediction rules and validated those using existing data sets. We searched MEDLINE, Medion, EMBASE, Cumulative Index to Nursing and Allied Health Literature and Database of Abstracts of Reviews of Effects in October 2008, with an update in June 2009, using search terms that include...
Feverish illness is a common presentation to acute pediatric services. Clinical staff faces the c... more Feverish illness is a common presentation to acute pediatric services. Clinical staff faces the challenge of differentiating the few children with meningitis or sepsis from the majority with self-limiting illness. We aimed to determine the diagnostic value of clinical features and their prediction rules (CPR) for identifying children with sepsis or meningitis among those children admitted to a District General Hospital with acute febrile illness. Acutely ill children admitted to a District General Hospital in England were included in this case-control study between 2000 and 2005. We examined the diagnostic accuracy of individual clinical signs and 6 CPRs, including the National Institute for Clinical Excellence "traffic light" system, to determine clinical utility in identifying children with a diagnosis of sepsis or meningitis. Loss of consciousness, prolonged capillary refill, decreased alertness, respiratory effort, and the physician's illness assessment had high po...
Early recognition and treatment of febrile children with serious infections (SI) improves prognos... more Early recognition and treatment of febrile children with serious infections (SI) improves prognosis, however, early detection can be difficult. We aimed to validate the predictive rule-in value of the National Institute for Health and Clinical Excellence (NICE) most severe alarming signs or symptoms to identify SI in children. The 16 most severe ("red") features of the NICE traffic light system were validated in seven different primary care and emergency department settings, including 6,260 children presenting with acute illness. We focussed on the individual predictive value of single red features for SI and their combinations. Results were presented as positive likelihood ratios, sensitivities and specificities. We categorised "general" and "disease-specific" red features. Changes in pre-test probability versus post-test probability for SI were visualised in Fagan nomograms. Almost all red features had rule-in value for SI, but only four individual re...
ABSTRACT De and colleagues present the validation results of the National Institute for Health an... more ABSTRACT De and colleagues present the validation results of the National Institute for Health and Care Excellence (NICE) “traffic light” system to detect serious bacterial infections in young children with fever.1 Such research is welcome, because timely recognition of the small number of children with serious bacterial infections among the majority with self limiting infections is difficult and consumes considerable frontline healthcare resources.2 We recently examined the diagnostic accuracy of several clinical prediction rules, including the NICE traffic light system with any amber or red feature present,...
'Safety netting' advice allows general practitioners (GPs) to cope with diagnosti... more 'Safety netting' advice allows general practitioners (GPs) to cope with diagnostic uncertainty in primary care. It informs patients on 'red flag' features and when and how to seek further help. There is, however, insufficient evidence to support useful choices regarding 'safety netting' procedures. To explore how GPs apply 'safety netting' in acutely ill children in Flanders. We designed a qualitative study consisting of semi-structured interviews with 37 GPs across Flanders. Two researchers performed qualitative analysis based on grounded theory components. Although unfamiliar with the term, GPs perform 'safety netting' in every acutely ill child, guided by their intuition without the use of specific guidelines. They communicate 'red flag' features, expected time course of illness and how and when to re-consult and try to tailor their advice to the context, patient and specific illness. Overall, GPs perceive 'safety netting' as an important element of the consultation, acknowledging personal and parental limitations, such as parents' interpretation of their advice. GPs do not feel a need for any form of support in the near future. GPs apply 'safety netting' intuitively and tailor the content. Further research should focus on the impact of 'safety netting' on morbidity and how the advice is conveyed to parents.
ABSTRACT De and colleagues present the validation results of the National Institute for Health an... more ABSTRACT De and colleagues present the validation results of the National Institute for Health and Care Excellence (NICE) “traffic light” system to detect serious bacterial infections in young children with fever.1 Such research is welcome, because timely recognition of the small number of children with serious bacterial infections among the majority with self limiting infections is difficult and consumes considerable frontline healthcare resources.2 We recently examined the diagnostic accuracy of several clinical prediction rules, including the NICE traffic light system with any amber or red feature present,...
Acute infection is the most common presentation of children in primary care with only few having ... more Acute infection is the most common presentation of children in primary care with only few having a serious infection (eg, sepsis, meningitis, pneumonia). To avoid complications or death, early recognition and adequate referral are essential. Clinical prediction rules have the potential to improve diagnostic decision-making for rare but serious conditions. In this study, we aimed to validate a recently developed decision tree in a new but similar population. Diagnostic accuracy study validating a clinical prediction rule. Acutely ill children presenting to ambulatory care in Flanders, Belgium, consisting of general practice and paediatric assessment in outpatient clinics or the emergency department. Physicians were asked to score the decision tree in every child. The outcome of interest was hospital admission for at least 24 h with a serious infection within 5 days after initial presentation. We report the diagnostic accuracy of the decision tree in sensitivity, specificity, likeliho...
Samenvatting Het tijdig herkennen van ernstige infecties is de basis om de kindermortaliteit en-m... more Samenvatting Het tijdig herkennen van ernstige infecties is de basis om de kindermortaliteit en-morbiditeit te verminderen. In Vlaanderen varieert het voorkomen van ernstige infecties bij kinderen volgens de klinische setting. Dit is vermoedelijk het hoogst op een pediatrische spoedafdeling, maar exacte cijfers hierover ontbreken. Daarom werd gedurende zes maanden het voorkomen van ernstige infecties op de pediatrische spoedgevallendienst van het UZ Leuven bestudeerd. Aan de hand van het elektronisch medisch dossier werden, retrospectief, kinderen van één maand tot zestien jaar die zich tussen oktober 2011 en maart 2012 met een acute ziekte-episode aanboden op de spoedafdeling opgenomen in de studie. Hieruit werden de ernstige infecties gese-lecteerd op basis van het volledige dossier na het ontslag. Van de 3.107 kinderen die zich aanmeldden met een acute ziekte-episode, voldeden 2.221 aan de inclusiecriteria. 241 van hen (11%) hadden een ernstige infectie: pneumonie (126), meningit...
To examine the relation between static and dynamic blood pressure (BP) measurements and the evolu... more To examine the relation between static and dynamic blood pressure (BP) measurements and the evolution of kidney function in older people, adjusted for the presence of multimorbidity. Retrospective cohort study during a 10-year time interval (2002-2012) in three age strata of patients aged 60 and older. Primary care registration network with 97 general practitioners working in 55 practices regularly submitting collected patient data. All patients with at least one BP measurement in 2002 and at least four serum creatine measurements after 2002 (n=8636). A modified Charlson Comorbidity Index (mCCI) at baseline was registered. Change in systolic and diastolic BP (DBP) and pulse pressure (PP) from 2002 onwards was calculated. The relation between kidney function evolution and baseline BP and change in BP was examined using linear and logistic regression analysis. The slope of the estimated glomerular filtration rate (eGFR, MDRD, Modification of Diet in Renal Disease equation) was calcula...
Despite huge public campaigns, there is still overconsumption of antibiotics in children with sel... more Despite huge public campaigns, there is still overconsumption of antibiotics in children with self-limiting diseases. Possible explanations may be the physicians' and parents' uncertainty about the gravity of the disease and inadequate communication between physicians and parents leading to lack of reassurance for the parents. In this paper we describe the design and methods of a trial aiming to rationalize antibiotic prescribing by decreasing this uncertainty and parental anxiety. Acutely ill children without suspected serious disease consulting their family physician will be consecutively included in a four-armed cluster randomized factorial controlled trial. The intervention will consist a Point-of-Care C-reactive protein test and/or a brief intervention with safety net advice. The control group will receive usual care. We intend to include 2560 patients in 88 family practices. Patients will be followed up until cure. The primary outcome measure is the immediate antibioti...
Acute illness is the most common presentation of children to ambulatory care. In contrast, seriou... more Acute illness is the most common presentation of children to ambulatory care. In contrast, serious infections are rare and often present at an early stage. To avoid complications or death, early recognition and adequate referral are essential. In a recent large study children were included prospectively to construct a symptom-based decision tree with a sensitivity and negative predictive value of nearly 100%. To reduce the number of false positives, point-of-care tests might be useful, providing an immediate result at bedside. The most probable candidate is C-reactive protein, as well as a pulse oximetry. This is a diagnostic accuracy study of signs, symptoms and point-of-care tests for serious infections. Acutely ill children presenting to a family physician or paediatrician will be included consecutively in Flanders, Belgium. Children testing positive on the decision tree will get a point-of-care C-reactive protein test. Children testing negative will randomly either receive a poi...
Mostly, it is impossible to establish the type of arrhythmias, based on signs and symptoms only. ... more Mostly, it is impossible to establish the type of arrhythmias, based on signs and symptoms only. An ECG device is not always within reach. We presumed the heartscan, a handheld wireless device, to be of value to a GP in emergency situations. We therefore studied inter- and intra-observer variability and the accuracy of the screen readings. All consecutive patients visiting the emergency department (ED) of the Gasthuisberg University Hospital in Leuven, Belgium, as well as patients hospitalised in three hospital wards on one day, were included. Immediately after the heartscan recording, a standard 12-lead ECG was recorded and read by an experienced hospital-based cardiologist. The recordings were read on the device screen by two general practitioners. All readers were blinded to the 12-lead ECG readings and vice versa, and for each other's ones. We compared both the heartscan reading of the first reader and the automatic reading of the device with the readings of the second GP an...
Health technology assessment (Winchester, England), 2012
Although the vast majority of children with acute infections are managed at home, this is one of ... more Although the vast majority of children with acute infections are managed at home, this is one of the most common problems encountered in children attending emergency departments (EDs) and primary care. Distinguishing children with serious infection from those with minor or self-limiting infection is difficult. This can result in misdiagnosis of children with serious infections, which results in a poorer health outcome, or a tendency to refer or admit children as a precaution; thus, inappropriately utilising secondary-care resources. We systematically identified clinical features and laboratory tests which identify serious infection in children attending the ED and primary care. We also identified clinical prediction rules and validated those using existing data sets. We searched MEDLINE, Medion, EMBASE, Cumulative Index to Nursing and Allied Health Literature and Database of Abstracts of Reviews of Effects in October 2008, with an update in June 2009, using search terms that include...
Feverish illness is a common presentation to acute pediatric services. Clinical staff faces the c... more Feverish illness is a common presentation to acute pediatric services. Clinical staff faces the challenge of differentiating the few children with meningitis or sepsis from the majority with self-limiting illness. We aimed to determine the diagnostic value of clinical features and their prediction rules (CPR) for identifying children with sepsis or meningitis among those children admitted to a District General Hospital with acute febrile illness. Acutely ill children admitted to a District General Hospital in England were included in this case-control study between 2000 and 2005. We examined the diagnostic accuracy of individual clinical signs and 6 CPRs, including the National Institute for Clinical Excellence "traffic light" system, to determine clinical utility in identifying children with a diagnosis of sepsis or meningitis. Loss of consciousness, prolonged capillary refill, decreased alertness, respiratory effort, and the physician's illness assessment had high po...
Early recognition and treatment of febrile children with serious infections (SI) improves prognos... more Early recognition and treatment of febrile children with serious infections (SI) improves prognosis, however, early detection can be difficult. We aimed to validate the predictive rule-in value of the National Institute for Health and Clinical Excellence (NICE) most severe alarming signs or symptoms to identify SI in children. The 16 most severe ("red") features of the NICE traffic light system were validated in seven different primary care and emergency department settings, including 6,260 children presenting with acute illness. We focussed on the individual predictive value of single red features for SI and their combinations. Results were presented as positive likelihood ratios, sensitivities and specificities. We categorised "general" and "disease-specific" red features. Changes in pre-test probability versus post-test probability for SI were visualised in Fagan nomograms. Almost all red features had rule-in value for SI, but only four individual re...
Uploads