A Systematic Review on the Diagnosis of Pediatric Bacterial Pneumonia: When Gold Is Bronze

In developing countries, pneumonia is one of the leading causes of death in children under five years of age and hence timely and accurate diagnosis is critical. In North America, pneumonia is also a common source of childhood morbidity and occasionally mortality. Clinicians traditionally have used the chest radiograph as the gold standard in the diagnosis of pneumonia, but they are becoming increasingly aware that it is not ideal. Numerous studies have shown that chest radiography findings lack precision in defining the etiology of childhood pneumonia. There is no single test that reliably distinguishes bacterial from non-bacterial causes. These factors have resulted in clinicians historically using a combination of physical signs and chest radiographs as a 'gold standard', though this combination of tests has been shown to be imperfect for diagnosis and assigning treatment. The objectives of this systematic review are to: 1) identify and categorize studies that have used single or multiple tests as a gold standard for assessing accuracy of other tests, and 2) given the 'gold standard' used, determine the accuracy of these other tests for diagnosing childhood bacterial pneumonia.Search strategies were developed using a combination of subject headings and keywords adapted for 18 electronic bibliographic databases from inception to May 2008. Published studies were included if they: 1) included children one month to 18 years of age, 2) provided sufficient data regarding diagnostic accuracy to construct a 2x2 table, and 3) assessed the accuracy of one or more index tests as compared with other test(s) used as a 'gold standard'. The literature search revealed 5,989 references of which 256 were screened for inclusion, resulting in 25 studies that satisfied all inclusion criteria. The studies examined a range of bacterium types and assessed the accuracy of several combinations of diagnostic tests. Eleven different gold standards were studied in the 25 included studies. Criterion validity was calculated for fourteen different index tests using eleven different gold standards. The most common gold standard utilized was blood culture tests used in six studies. Fourteen different tests were measured as index tests. PCT was the most common measured in five studies each with a different gold standard.We have found that studies assessing the diagnostic accuracy of clinical, radiological, and laboratory tests for bacterial childhood pneumonia have used a heterogeneous group of gold standards, and found, at least in part because of this, that index tests have widely different accuracies. These findings highlight the need for identifying a widely accepted gold standard for diagnosis of bacterial pneumonia in children

Surgical treatment of the congenital dislocation of the hip after walking age: open reduction and Salter's osteotomy Tratamento cirúrgico da luxação congênita do quadril pós marcha: redução aberta e osteotomia de Salter

The congenital dislocation of the hip, after the function of weight bearing begins or walking phase requires surgical treatment, and one of the options is the open reduction combined to innominate osteotomy (Salter). In this study, the results of 18 patients, 22 surgically treated hips with congenital dislocation, were evaluated from 1989 and 1995, using innominate osteotomy, by Salter's technique after open reduction. The age of the patients at the time of surgery ranged from 12 to 30 months (age after march), mean age of 19 months. Fifteen were female and 3 were male, 4 patients had bilateral dislocation and in the remaining, 8 had their left hip dislocated and 6 had their right hip dislocated. The results were evaluated according to Dutoit et al.(3) clinical criteria and to Severin(12) radiological criteria, after a mean follow-up of 48 months. Eighteen percent of excellent clinical results (4); 54% of good results (12); 14% of regular results (3) and 14% of bad results(3) were obtained. As to the radiologic criteria, 36% of the hips were classified as excellent (8); 45% as good (10); 5% regular (1) and 14% bad (3). There were 3 cases of re-dislocation which were treated by a different surgical technique. No cases of infection, graft fracture and vascular or nervous injury were reported.<br>A luxação congênita do quadril (LCQ), após a marcha, requer o tratamento cirúrgico, sendo uma das opções a redução aberta associada a osteotomia do osso inominado (tipo Salter). Neste estudo foram avaliados 18 pacientes, 22 quadris, que apresentavam LCQ tratados cirurgicamente, entre 1989 e 1995, utilizando a osteotomia do osso inominado, pela técnica de Salter, pós redução aberta. A idade dos pacientes, na época da cirurgia, variou de 12 a 30 meses, com média de 19 meses, sendo 15 do sexo feminino e 3 do masculino, 4 pacientes tinham acometimento bilateral, sendo que nos demais, 8 tinham o quadril esquerdo acometido e 6 o lado direito. Os resultados foram avaliados segundo critérios clínicos de Dutoit et al.(3) e radiográficos de Severin(12), após um seguimento médio de 48 meses. Clinicamente foram obtidos 18% de resultados excelentes (4); 54% resultados bons (12); 14% regulares (3); e 14% ruins (3). Quanto aos critérios radiográficos, encontramos 36% dos quadris classificados como excelentes (8); 45% bons (10); 5% regulares (1); e 14% ruins(3). Como complicações foram constatados 3 casos de reluxação, tratados com outra técnica cirúrgica. Não foi observado nenhum caso de infecção, fratura do enxerto e lesão vascular ou nervosa