The pediatrician makes a judgment of the degree of illness (toxicity) of a febrile child based on observation prior to history and physical examination. In order to define valid and reliable observation data for that judgment, data from two previous studies were used to construct three-point scales of 14 observation items correlated with serious illness in those reports. Between Nov 1, 1980 and March 1, 1981, these 14 scaled items were scored simultaneously by attending physicians, residents, and nurses prior to history and physical examination on 312 febrile children aged ≤24 months seen consecutively in our Primary Care Center-Emergency Room and in one private practice. Of these 312 children, 37 had serious illness. Multiple regression analysis based on patients seen by at least one attending physician in the Primary Care Center revealed six items (quality of cry, reaction to parents, state variation, color, state of hydration, and response to social overtures) that were significant and independent predictors of serious illness (multiple R = 0.63). The observed agreement for scoring these six items between two attending physicians who saw one third of the patients ranged from 88% to 97%. The chance corrected agreement levels (κw) for these six items were, with one exception, clinically significant (κw = .47 to .73). A discriminant function analysis revealed that these six items when used together had a specificity of 88% and a sensitivity of 77% for serious illness. Individual scores for each of the six key items were added to yield a total score for each patient. Only 2.7% of patients with a score ≤10 had a serious illness; 92.3% with a score ≥l6 had a serious illness. The sensitivity of the six-item model for serious illness when combined with history and physical examination was 92%. In the population studied, this predictive model, when used prior to history and physical examination, was reliable, predictive, specific, and sensitive for serious illness in febnile children. It was most sensitive when combined with history and physical examination. The model wifi need to be validated on a new population of patients.
The chest roentgenograms of 128 consecutive ambulatory children with radiologic pneumonia were read independently and without clinical information by a faculty general pediatrician (Ped), a pediatric radiologist (R-P) and a general radiologist (R-G). The films were classified as normal, indicative of a viral or bacterial process, or indeterminate. Readings were compared with results of viral titers and bacterial cultures. Agreement between any two observers in classifying films, measured by unweighted Kappa, while statistically significant (p less than 0.001) for any pair, was low. There was no significant difference between the agreement scores of Ped/R-P, Ped/R-G, and R-P/R-G. Twenty-one patients had fourfold viral titer increases (N = 16) or positive bacterial cultures of blood or pulmonary aspirate (N = 5). The sensitivity of viral readings for titers increases varied from 19% to 68% depending on observer type; the sensitivity of bacterial readings for positive bacterial cultures varied from 60% to 80%. The three observers agreed on a correct reading in only three children with viral and three with bacterial pneumonia. Because of poor observer agreement and appreciable false-negative errors when viral and bacterial readings were compared to titer increases and positive bacterial cultures, respectively, we conclude that radiographic findings are poor indicators of etiology diagnosis in ambulatory childhood pneumonias and, of themselves, are an insufficient data base for making therapeutic decisions.
The records of 250 consecutive children presenting to a university pediatric service with joint complaints of unknown cause were reviewed to determine the frequency of diagnoses and the utility of laboratory data and physical examination findings. Eighteen per cent of children had orthopedic disorders (Group I), 17.6 per cent had autoimmune disorders (Group II), 19.6 per cent had joint complaints related to a bacterial infection (Group III), and 44 per cent had miscellaneous problems (Group IV). Autoimmune or infectious disd/or erythrocyte sedimentation rate was greater than or equal to 30 mm/h was present than if absent (65% vs. 8% respectively); the sensitivity of fever and/or elevated erythrocyte sedimentation rate was 93 per cent for Group II and III patients. The presence of rash was predictive of an autoimmune disorder in 67 per cent of the instances; a positive joint examination was seen disproportionately in Group I patients. A negative joint examination all but ruled out an infectious etiology. Other test results, such as diagnostic radiograms, WBC greater than or equal to 15,000 per cu mm; or a positive ANA or rheumatoid factor were predictive but not sensitive indicators of selected groups. If the tiology of a child's joint complaints is unknown, the likelihood of an orthopedic, autoimmune or infectious disorder may be suggested by reviewing temperature and ESR data and skin and joint findings.
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