BACKGROUNDWorldwide, many newborns who are preterm, small or large for gestational age, or born to mothers with diabetes are screened for hypoglycemia, with a goal of preventing brain injury. However, there is no consensus on a treatment threshold that is safe but also avoids overtreatment. METHODSIn a multicenter, randomized, noninferiority trial involving 689 otherwise healthy newborns born at 35 weeks of gestation or later and identified as being at risk for hypoglycemia, we compared two threshold values for treatment of asymptomatic moderate hypoglycemia. We sought to determine whether a management strategy that used a lower threshold (treatment administered at a glucose concentration of <36 mg per deciliter [2.0 mmol per liter]) would be noninferior to a traditional threshold (treatment at a glucose concentration of <47 mg per deciliter [2.6 mmol per liter]) with respect to psychomotor development at 18 months, assessed with the Bayley Scales of Infant and Toddler Development, third edition, Dutch version (Bayley-III-NL; scores range from 50 to 150 [mean {±SD}, 100±15]), with higher scores indicating more advanced development and 7.5 points (one half the SD) representing a clinically important difference). The lower threshold would be considered noninferior if scores were less than 7.5 points lower than scores in the traditional-threshold group. RESULTS Bayley-III-NL scores were assessed in 287 of the 348 children (82.5%) in the lower-threshold group and in 295 of the 341 children (86.5%) in the traditional-threshold group. Cognitive and motor outcome scores were similar in the two groups (mean scores [±SE], 102.9±0.7 [cognitive] and 104.6±0.7 [motor] in the lower-threshold group and 102.2±0.7 [cognitive] and 104. 9±0.7 [motor] in the traditional-threshold group). The prespecified inferiority limit was not crossed. The mean glucose concentration was 57±0.4 mg per deciliter (3.2±0.02 mmol per liter) in the lower-threshold group and 61±0.5 mg per deciliter (3.4±0.03 mmol per liter) in the traditional-threshold group. Fewer and less severe hypoglycemic episodes occurred in the traditional-threshold group, but that group had more invasive diagnostic and treatment interventions. Serious adverse events in the lower-threshold group included convulsions (during normoglycemia) in one newborn and one death. CONCLUSIONSIn otherwise healthy newborns with asymptomatic moderate hypoglycemia, a lower glucose treatment threshold (36 mg per deciliter) was noninferior to a traditional threshold (47 mg per deciliter) with regard to psychomotor development at 18 months. (Funded by the Netherlands Organization for Health Research and Development; HypoEXIT Current Controlled Trials number, ISRCTN79705768.

♦ Objective To analyze the late cardiovascular outcome of end-stage renal disease (ESRD) in children. ♦ Design A nation-wide long-term follow-up study. Determinants of outcomes and causes of death were retrospectively assessed. Patients underwent assessment of overall health state, B- and M-mode ultrasound of the carotid arteries, and echocardiography for cross-sectional analysis. ♦ Results We analyzed the medical course of all 249 adult Dutch patients with ESRD onset between 1972 and 1992 at age 0 – 14 years, and who were born before 1979. Of the 187 living patients, 140 participated in the cross-sectional part of the study. The standardized mortality rate was 31.0. Overall 5-, 10-, and 20-year survival after ESRD onset was 87%, 82%, and 78%, respectively. Cardiovascular disease accounted for most deaths (41%). In the whole group, left ventricular hypertrophy (LVH), aortic valve calcification, and arterial wall stiffening were highly prevalent. LVH was associated with hypertension at time of assessment. Aortic valve calcification was strongly associated with a long total duration of peritoneal dialysis (β = 0.33, p < 0.001). Arterial wall pathology was not associated with current treatment modality. ♦ Conclusions As in adults, cardiovascular disease is the most important cause of death in children with ESRD. Stricter reduction of volume overload, prevention of high serum calcium–phosphate product, and more vigorous treatment of hypertension are important targets to improve cardiovascular survival in children with ESRD.

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In Capita selecta worden evidence based handelen en de theorievorming daarover verder uitgediept. Belangwekkende publicaties, methoden, technieken, definities en discussies zullen in deze rubriek regelmatig aan de orde komen. Evidence based handelen wordt op deze wijze voor de paramedici in een breder perspectief geplaatst. In deze tweede aflevering van Capita selecta een gedeelte uit 'Inleiding in evidence-based medicine' (Offringa e.a., 2003). In onderstaande tekst kan waar 'medicus practicus' of 'arts' staat ook fysiotherapeut worden gelezen. InleidingVan de medicus practicus wordt verwacht dat hij beschikt over solide informatie over de oorzaken van ziekte, de waarde van diagnostische bevindingen, de prognose van de patie¨nt en de verwachte gevolgen van therapeutische opties. Deze kennis over de gevolgen van klinisch handelen wordt bij voorkeur ontleend aan bevindingen van klinisch-wetenschappelijk onderzoek.Moderne artsen worden echter overspoeld met informatie, terwijl de informatie die zij nodig hebben steeds moeilijker te vinden is. Drukbezette clinici kunnen nauwelijks overzicht houden over de continue stroom van nieuwe onderzoeken. We leven in het 'Informatietijdperk', maar de informatie die klinische beslissingen zou kunnen ondersteunen, is versnipperd. Zelfs met streng selecteren van tijdschriften en artikelen resteert een vaak onoverzichtelijke hoeveelheid leesmateriaal per week. De direct beschikbare informatie neemt inmiddels immense proporties aan nu medline en andere medische informatie eenvoudig en onbeperkt via Internet kan worden geraadpleegd. Onlangs schatte Olkin dat er 40 000 medisch-wetenschappelijke tijdschriften verschijnen met meer dan 1 miljoen artikelen per jaar. Dit betekent voor een internist dat deze tussen de 17 en 22 artikelen per dag moet lezen om het publicatietempo bij te houden. Voor een huisarts ligt dit aantal wellicht nog hoger.Daarnaast speelt dat er regelmatig wijzigingen zijn in inzichten; het gewicht van bestaand bewijsmateriaal is aan vrijwel continue verandering onderhevig. Bovendien zijn niet alle gepubliceerde onderzoeken van dezelfde hoge wetenschappelijke kwaliteit. Intussen krijgt de arts in toenemende mate te maken met de vraag wat de voor de te nemen behandelingsbeslissing het onderbouwende bewijs is.De patie¨nt verwacht van de arts de nieuwste diagnostiek en behandeling. Patie¨nten en hun familie hebben tegenwoordig via Internet toegang tot actuele en gedetailleerde medische informatie. Het is echter zeker dat lang niet alle informatie die kan worden gevonden ook de kwaliteitstoets kan doorstaan. Ook kan de patie¨nt devooral voor artsen bedoelde -informatie verkeerd interpreteren, waardoor verwarring ontstaat.Richtlijnen zoals de Standaarden van het Nederlands Huisartsen Genootschap, de CBO-consensusrichtlijnen, het Farmacotherapeutisch Kompas en het Diagnostisch Kompas scheppen welkome orde in deze gegevensstroom, maar dekken lang niet alle facetten van het vak. Over bepaalde onderwerpen kan weliswaar genoeg bekend zijn, maar de informatie kan simpelweg nog...

SummaryIn a large study project we tried to determine the number of children and adolescents in the Netherlands with a chronic disease, and to evaluate the consequences of living with this. Therefore we defined and operationalised chronic diseases and health conditions in childhood, in a consensus procedure. Consensus was attained on a definition consisting of four criteria. A disease or condition is considered to be a chronic condition in childhood if (1) it occurs in children aged 0 up to 18 years, (2) the diagnosis is based on medical scientific knowledge and it can be diagnosed using reproducible and valid methods or instruments according to professional standards, (3) it is not (yet) curable, and (4) it has been present longer than three months or it will very probably last longer than three months, or it has occurred three times or more during the past year and will probably reoccur.Adding upon research findings and prevalence rates we estimated that at least 14% of children in the Netherlands are growing up with a chronic disease; counting for at least 500.000 children and adolescents. This is definitely an underestimation because for only a limited number of diseases reliable information was available. We also paid attention to studies on the social consequences of young adults who have been growing up with a chronic disease. Studies in the Netherlands in this area are limited as well. To evaluate the effects of pediatric and child health care on a societal level, and for the planning of health care facilities and other services for children and young adults with chronic conditions, valid and reliable prevalence estimates are needed. Samenvatting Eind 2003 is een onderzoek gestart om inzicht te krijgen in de gevolgen van chronische ziekten op de kinderleeftijd. Al snel werd duidelijk dat niemand weet hoeveel kinderen en jongeren in Nederland opgroeien met een chronische ziekte en welke aandoeningen onder het begrip 'chronische ziekten bij kinderen' vallen. Daarom werd een inventarisatie gedaan van definities, meetmethoden en prevalentie van chronische aandoeningen bij kinderen. Tevens werd in een landelijke werkgroep consensus bereikt over een definitie, die vier criteria omvat. We spreken over chronische aandoeningen bij kinderen indien aan alle vier deze criteria is voldaan:1. de aandoening komt voor bij kinderen en adolescenten tot 19 jaar; 2. de aandoening is vast te stellen met behulp van medisch-wetenschappelijke kennis middels een meetproces -waarbij de methode en instrumenten volgens de beroepsgroep valide en reproduceerbaar zijn; 3. de aandoening is (nog) niet te genezen; 4. de aandoening bestaat ten minste drie maanden, dan wel zal waarschijnlijk langer duren, of er zijn in het afgelopen jaar drie ziekte-episoden geweest.Er kon worden vastgesteld dat ten minste 14% van de kinderen en jongeren in Nederland een chronische ziekte heeft: dit zijn 500.000 kinderen en jongeren. Dit is zeker een onderschatting, omdat van het merendeel van de aandoeningen geen nauwkeurige prevalentiecijfers bes...

We reviewed published data on the frequency of underlying disorders in schoolchildren with microscopic or gross isolated haematuria (IH), and evaluated management strategies. We found five reports of microscopic IH in screened asymptomatic schoolchildren, three reports of microscopic IH detected by case-finding, and five surveys of kidney biopsies in referred children with microscopic and gross IH. We listed the reported underlying disorders, and estimated the benefit from their early detection and treatment. Most children with microscopic IH, whether detected by screening or case-finding, had no significant underlying disease. Some had disorders that may benefit from early treatment (membranoproliferative glomerulonephritis, obstructive uropathy, urolithiasis), or counselling (hereditary nephropathy, renal cystic disease). The combined prevalence of these five diseases was 0-7.2% in children with microscopic IH detected by screening, and 3.3%-13.6% in those with microscopic IH detected by case-finding. The combined prevalence of membranoproliferative glomerulonephritis and hereditary nephropathy among kidney biopsies was 11.6%-31.6% in children with microscopic IH, and 3.6%-42.1% in children with gross IH. Variable management strategies for schoolchildren with IH result from uncertainty about the frequency of underlying disorders and the efficacy of their early treatment. With no evidence that detecting IH leads to prevention of renal function impairment, screening for IH in symptomless schoolchildren is not warranted. Once detected, however, IH justifies further investigation.

Aim-To summarise the evidence on the eYcacy of elective high frequency ventilation compared with conventional ventilation in preterm infants with respiratory distress syndrome. Methods-A search from 1987 onwards was made on Embase, Medline, and the Cochrane Library. A questionnaire was also circulated during an international meeting on high frequency ventilation. To be included in the data synthesis, studies had to be randomised controlled trials comparing elective high frequency ventilation with conventional ventilation in preterm infants with respiratory failure due to respiratory distress syndrome; indices of mortality, chronic pulmonary morbidity, and other clinically relevant outcomes were compared. Studies were assessed for methodological validity according to explicit criteria. Results-Ten studies (a total number of 1345 preterm infants) were considered for data synthesis. No diVerence in mortality at 28 or 30 days, nor in oxygen dependency at 28 days was found between both types of ventilation. Reduced oxygen dependency at the postconceptional age of 36 weeks (RR 0.50, 95% CI 0.32-0.78) was found, but so was an increase in grades 3 and 4 intraventricular haemorrhage (IVH) (RR 1.31, 95% CI 1.04-1.66). Those studies using a high lung volume ventilatory strategy showed a significant decrease in oxygen dependency at the postconceptional age of 36 weeks (RR 0.44, 95% CI 0.27-0.73), but no increase in severe IVH (RR 0.78, 95% CI 0.45-1.37). Conclusions-Although high frequency ventilation reduces chronic lung disease, it seems to increase the risk of severe IVH. These results are dominated by an early study where the absence of benefit on pulmonary outcomes, and the increase in adverse neurological events, could be related to the low volume ventilatory strategy used. Recent studies, using a high lung volume approach, show better pulmonary outcomes without any increase in intracranial morbidity. Still, uncertainty remains about long term pulmonary and neurodevelopmental outcome. (Arch Dis Child Fetal Neonatal Ed 1999;80:F15-F20) Keywords: elective high frequency ventilation; respiratory distress syndrome; intraventricular haemorrhage Despite advances in management, such as the use of surfactant, the mortality and morbidity of respiratory distress syndrome in premature infants remain high. Chronic pulmonary morbidity after mechanical ventilation is still a major clinical problem. In particular, very low birthweight infants are at high risk of chronic lung disease: at least one in four infants between 500 and 750 g is oxygen dependent at the postconceptional age of 36 weeks.1 It is now thought that this lung damage is largely caused by repetitive collapse and overexpansion of surfactant deficient lungs, creating shear forces, with subsequent epithelial injury and inflammatory responses.2 3 In an attempt to avoid such lung injury alternative ventilation modalities were examined.High frequency ventilation (HFV) was first described by Bohn et al in 1980. 4 Animal studies showed that it could obtain eVectiv...