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Coon E.R.,University of Utah | Quinonez R.A.,Baylor College of Medicine | Moyer V.A.,American Board of Pediatrics | Schroeder A.R.,Santa Clara Valley Medical Center
Pediatrics | Year: 2014

Overdiagnosis occurs when a true abnormality is discovered, but detection of that abnormality does not benefit the patient. It should be distinguished from misdiagnosis, in which the diagnosis is inaccurate, and it is not synonymous with overtreatment or overuse, in which excess medication or procedures are provided to patients for both correct and incorrect diagnoses. Overdiagnosis for adult conditions has gained a great deal of recognition over the last few years, led by realizations that certain screening initiatives, such as those for breast and prostate cancer, may be harming the very people they were designed to protect. In the fall of 2014, the second international Preventing Overdiagnosis Conference will be held, and the British Medical Journal will produce an overdiagnosis-themed journal issue. However, overdiagnosis in children has been less well described. This special article seeks to raise awareness of the possibility of overdiagnosis in pediatrics, suggesting that overdiagnosis may affect commonly diagnosed conditions such as attention-deficit/hyperactivity disorder, bacteremia, food allergy, hyperbilirubinemia, obstructive sleep apnea, and urinary tract infection. Through these and other examples, we discuss why overdiagnosis occurs and how it may be harming children. Additionally, we consider research and education strategies, with the goal to better elucidate pediatric overdiagnosis and mitigate its influence. Copyright © 2014 by the American Academy of Pediatrics.

Schroeder A.R.,Santa Clara Valley Medical Center | Chang P.W.,Kaiser Permanente | Shen M.W.,Dell | Biondi E.A.,University of Rochester | Greenhow T.L.,Kaiser Permanente
Pediatrics | Year: 2015

BACKGROUND: The 2011 American Academy of Pediatrics urinary tract infection (UTI) guideline suggests incorporation of a positive urinalysis (UA) into the definition of UTI. However, concerns linger over UA sensitivity in young infants. Infants with the same pathogenic organism in the blood and urine (bacteremic UTI) have true infections and represent a desirable population for examination of UA sensitivity. METHODS: We collected UA results on a cross-sectional sample of 276 infants <3 months of age with bacteremic UTI from 11 hospital systems. Sensitivity was calculated on infants who had at least a partial UA performed and had ≥50 000 colony-forming units per milliliter from the urine culture. Specificity was determined by using a random sample of infants from the central study site with negative urine cultures. RESULTS: The final sample included 245 infants with bacteremic UTI and 115 infants with negative urine cultures. The sensitivity of leukocyte esterase was 97.6% (95% confidence interval [CI] 94.5%-99.2%) and of pyuria (>3 white blood cells/high-power field) was 96% (95% CI 92.5%-98.1%). Only 1 infant with bacteremic UTI (Group B Streptococcus) and a complete UA had an entirely negative UA. In infants with negative urine cultures, leukocyte esterase specificity was 93.9% (95% CI 87.9 - 97.5) and of pyuria was 91.3% (84.6%-95.6%). CONCLUSIONS: In young infants with bacteremic UTI, UA sensitivity is higher than previous reports in infants with UTI in general. This finding can be explained by spectrum bias or by inclusion of faulty gold standards (contaminants or asymptomatic bacteriuria) in previous studies. Copyright © 2015 by the American Academy of Pediatrics.

Chetty S.,Stanford University | Garabedian M.J.,Santa Clara Valley Medical Center | Norton M.E.,Stanford University
Prenatal Diagnosis | Year: 2013

Objective: The aim of this study was to investigate how the introduction of noninvasive prenatal testing (NIPT) impacted women's testing choices following a positive prenatal screening (PNS) result. Methods: Beginning in March 2012, women referred to our Prenatal Diagnosis Center following a positive PNS result were offered NIPT or invasive prenatal diagnosis. Rates of invasive testing and declining follow-up were compared with testing decisions the prior year. Differences were compared using t-test and chi-square. Multivariable logistic regression was performed to identify predictors of test choice. Results: Between March 2012 and February 2013, 398 screen positive women were seen: 156 (39.2%) underwent invasive testing, 157 (39.4%) had NIPT and 84 (21.1%) declined further testing. In the prior year, 638 screen positive patients were seen: 301 (47.2%) had invasive testing and 337 (52.8%) declined. The rate of invasive testing declined significantly (p=0.012). Moreover, fewer women declined follow-up testing after introduction of NIPT, 21.2% versus 52.8%, p≤0.001. Race/ethnicity and timing of results (first versus second trimester) were predictors of testing choices; payer and maternal age were not. Conclusion: The introduction of NIPT resulted in a significant decrease in invasive diagnostic testing. Additionally, fewer women declined further testing when NIPT was available. © 2013 John Wiley & Sons, Ltd.

Kochar R.,Stanford University | Shah N.,Stanford University | Shah N.,Santa Clara Valley Medical Center
Gastrointestinal Endoscopy | Year: 2013

Because of significant advances in endoscopic techniques and the development of high-quality stents, endoscopic enteral stent placement is increasingly being performed for the management of malignant GI obstruction. Palliative stenting is now routinely performed for malignant esophageal, gastric, duodenal, and colon obstruction. In addition to palliative indications, preoperative stenting in the colon may be performed as a bridge to surgery to achieve immediate decompression and convert an emergent surgery into an elective, 1-stage procedure. The realm of enteral stenting has recently expanded to include management of benign conditions such as leaks, fistulas, and benign strictures in the GI tract. Further research is required to study the use of enteral stents in benign conditions and to adequately compare endoscopic stent placement with surgical intervention. Promising new technologies such as biodegradable stents and drug-eluting stents also require further investigation. With continued innovation in endoscopic techniques and stenting devices, the field of enteral stenting is likely to expand further, with an increase in indications and improvement in outcomes. Copyright © 2013 by the American Society for Gastrointestinal Endoscopy.

Mission J.F.,Oregon Health And Science University | Ohno M.S.,Santa Clara Valley Medical Center | Cheng Y.W.,University of California at San Francisco | Caughey A.B.,Oregon Health And Science University
American Journal of Obstetrics and Gynecology | Year: 2012

Objective: This study investigates the cost effectiveness of gestational diabetes mellitus screening using the new International Association of Diabetes in Pregnancy Study Group (IADPSG) guidelines. Study Design: A decision analytic model was built comparing routine screening with the 2-hour (2h) oral glucose tolerance test (OGTT) vs the 1-hour glucose challenge test. All probabilities, costs, and benefits were derived from the literature. Base case, sensitivity analyses, and a Monte Carlo simulation were performed. Results: Screening with the 2h OGTT was more expensive, more effective, and cost effective at $61,503/quality-adjusted life year. In a 1-way sensitivity analysis, the more inclusive IADPSG diagnostic approach remained cost effective as long as an additional 2.0% or more of patients were diagnosed and treated for gestational diabetes mellitus. Conclusion: Screening at 24-28 weeks' gestational age under the new IADPSG guidelines with the 2h OGTT is expensive but cost effective in improving maternal and neonatal outcomes. How the health care system will provide expanded care to this group of women will need to be examined. © 2012 Mosby, Inc. All rights reserved.

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