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Results for “systematics”

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PubMed1999

[Examination for indication of systematic biopsy for diagnosis of prostate cancer].

BACKGROUND: Systematic biopsy has been commonly used for detection of prostate cancer. Nevertheless, as this examination occasionally gives patients severe complications it is necessary to give careful consideration for application of this examination. Thus, we analyzed retrospectively 145 cases who underwent transrectal ultrasonography (TRUS) guided systematic biopsy to evaluate the application of systematic biopsy, correlating with the findings of digital rectal examination (DRE), prostate specific antigen (PSA), the findings of transrectal ultrasonography (TRUS) and the results of biopsies. METHODS: Between May, 1995 and May, 1997, 143 patients who were suspected to have prostate cancer with either of PSA and DRE, and 2 patients who received visual laser ablation of prostate (VLAP), underwent TRUS guided systematic biopsy of prostate. We evaluated diagnostic efficacy of PSA, DRE, TRUS, prostate-volume-specific PSA, and PSA density (PSAD). RESULTS: Sensitivity, specificity and positive predictive value (P.P.V.) are 78.4%, 62.8% and 53.5% for DRE, 100.0%, 4.4% and 41.8% for PSA, 88.2%, 60.0% and 52.9% for TRUS, 87.8%, 72.1% and 64.2% for prostate-volume-specific PSA, 100.0%, 30.6% and 45.4% for PSAD, respectively. Ten of 69 patients (14.5%) whose PSA levels were 4.0 to 10.0 ng/ml were diagnosed as cancer, and positive for both or either of DRE and TRUS. Twenty-seven who were negative for both of DRE and TRUS were not diagnosed as prostate cancer. Using the combination of prostate-volume-specific PSA, DRE and TRUS, we could eliminate 29 non-cancer men (21.5%) whose PSA level was greater than 4.0 ng/ml from systematic biopsy. CONCLUSION: On the diagnosis of prostate cancer, the combination of prostate-volume-specific PSA, DRE and TRUS is very useful to exclude unnecessary systematic biopsy, if an urologist could be used to and trained for DRE and TRUS.

Aged↗

PubMed2000

The optimal systematic prostate biopsy scheme should include 8 rather than 6 biopsies: results of a prospective clinical trial.

PURPOSE: We define the optimal systematic biopsy regimen to detect carcinoma of the prostate. MATERIALS AND METHODS: A total of 483 consecutive patients referred for an abnormal digital rectal examination and/or prostate specific antigen (PSA) 4.0 ng./ml. or greater underwent transrectal ultrasound and systematic biopsy. Lateral biopsies of the peripheral zone at the base and mid gland were added to the routine sextant biopsy regimen for a total of 10 systematic biopsies of the peripheral zone. Patients with a prostate greater than 50 cc also underwent systematic sextant transition zone biopsy in the mid lobar parasagittal plane. Detection rates of the various regions were assessed. Various biopsy schemes were then created and cancer detection rates were compared using McNemar's test. RESULTS: Of the patients 42% (202 of 483) had cancer on biopsy. Traditional sextant biopsies missed 20%, while a sextant regimen incorporating lateral peripheral zone biopsies of the mid gland and base along with the apex missed 11% of the cancers. The combination of sextant and lateral peripheral zone biopsies (10-biopsy scheme) detected 194 cancers (96%). The 8 missed cancers were detected by lesion directed (5) or transition zone (3) biopsies. Eliminating the mid lobar base biopsies from the systematic 10-biopsy peripheral zone regimen resulting in an 8-biopsy peripheral zone regimen decreased detection from 96% to 95%. CONCLUSIONS: The 6 systematic biopsies of the peripheral zone are inadequate and a minimum of 8, including the apex, mid lobar mid gland, lateral mid gland and lateral base, should routinely be performed.

Aged↗

PubMed2001

Factors of the innovation, organization, environment, and individual that predict the influence five systematic reviews had on public health decisions.

OBJECTIVE: To determine the extent to which systematic reviews of public health interventions influenced public health decisions and which factors were associated with influencing these decisions. METHODS: This cross-sectional follow-up survey evaluated the use of five systematic reviews in public health decision making. Independent variables included characteristics of the innovation, organization, environment, and individual. Primary data were collected using a telephone survey and a self-administered organizational demographics questionnaire. Public health decision makers in all 41 public health units in Ontario were invited to participate in the study. Multiple linear regression analyses on the five program decisions were conducted. RESULTS: The systematic reviews were perceived as having the greatest amount of influence on decisions related to program justification and program planning, and the least influence on program evaluation decisions. The greater the perception that one's organization valued the use of research evidence for decision making and that ongoing training in the critical appraisal of research literature was provided, the greater the perception of the influence the systematic review had on public health decisions. CONCLUSIONS: Organizational characteristics are important predictors of the use of systematic reviews in public health decision making. Future dissemination strategies need to promote the value of using systematic reviews for program decision making as well as promote ongoing training in critical appraisal among intended users in Ontario.

Cross-Sectional Studies↗

PubMed2002

Reading systematic reviews.

BACKGROUND: While systematic reviews should be of assistance in decision making, currently many reviews are unreliable, poorly reported or not clinically useful. It is therefore important that they are read critically. OBJECTIVES: The objective is to provide a logical way to appraise systematic reviews. Particular objectives are to demonstrate how to use a validated general guide for appraising systematic reviews; amend the guide so that it can be used to appraise systematic reviews of controlled trials, prognostic studies and studies evaluating diagnostic tests; choose between discordant reviews and assess the usefulness of good systematic reviews. DISCUSSION: Guidelines for undertaking and reporting systematic reviews should eventually improve their quality and usefulness. In the meantime, reviews must be appraised critically, particularly those outside the Cochrane Library.

Data Interpretation, Statistical↗

PubMed1989

[The systematization of the enzyme-linked immunosorbent assay (=ELISA)].

Using the example of the detectability of immunological methods the study shows the considerable influence exerted by this detectability on the quantitative and qualitative parameters and the necessity of a systematization of the methods. This systematization already starts with the product labeling: A sufficient description of antibodies has to contain five qualities. The profitability of the experimental research is improved by optimized product and method systematization. ELISA is presented in a systematized form as a modular system optimizing the comparability of these methods. In order to detect the gain of information transparency obtained by systematization, an ELISA, described in the literature, is presented in the original and in the systematized form.

Antibodies↗

PubMed1996

Value of systematic transition zone biopsies in the early detection of prostate cancer.

PURPOSE: A prospective study was done to determine the value of performing 2 systematic transition zone biopsies in addition to systematic sextant peripheral zone biopsies for early detection of prostate cancer. MATERIALS AND METHODS: From January 1 to August 31, 1994 we evaluated 847 consecutive patients referred to us for a suspicious lesion on digital rectal examination or an elevated serum prostate specific antigen level. All patients underwent 2 systematic transition zone biopsies in addition to systematic sextant biopsies of the peripheral zone. RESULTS: Of the transition zone biopsies 68 (24.4%) contained malignancy, including only 8 (2.9%) with cancer found exclusively in the transition zone. The remaining 271 cases (97.1%) had 1 or more positive peripheral zone biopsies and would have been detected with or without additional systematic transition zone biopsies. The same analysis of 552 patients with a negative digital rectal examination yielded 6 (4.1%) exclusively transition zone tumors among 145 cancers detected in this group. CONCLUSIONS: The low additional yield of transition zone biopsies (2.9 to 4.1%) does not warrant their systematic use for the early detection of prostate cancer.

Adult↗

PubMed1996

[Value of systematic lymphadenectomy in stomach carcinoma].

In a retrospective study of 157 patients undergoing a curative resection of a gastric carcinoma between 1982 and 1992 the correlation of the lymph node status and histomorphologic parameters of the gastric cancer and the significance of the systematic lymphadenectomy were analysed. The patients were divided into two historical groups (exclusively D1- and systematic D1-/D2-lymphadenectomy). Among the histomorphological parameters only the depth of infiltration (pT) revealed a high correlation with the extent of metastatic lymph node involvement. Tumor form, Laurén-classification and tumor localisation only showed a marginal influence on the nodal status. The overall 5-year survival rate was not significantly changed by the systematic lymphadenectomy, only the subgroup of the UICC-stadium II demonstrated a small benefit. The extended systematic lymph node dissection did not rise the complication rate but lowered the rate of local recurrences. In conclusion, the indication for a systematic lymphadenectomy cannot be deducted from the constellation of different histomorphological parameters, but the feasibility of a systematic lymphadenectomy results from the improvement of staging and survival rate at least for the UICC-II-stadium and the reduction of local recurrences.

Adult↗

PubMed2000

How to read a systematic review.

A systematic review is a carefully planned and conducted study designed to answer a specific focused clinical question. A systematic review differs from the frequently encountered narrative review article. Systematic review must be completed using a prespecified methodology. The reader must ask eight important questions when reading a systematic review: (i) did the review address a focused clinical question (ii) is it likely that important, relevant studies are missed (iii) were the inclusion criteria used to select appropriate articles (iv) was the validity of the included studies assessed (v) were the assessments of studies reproducible (vi) were the results similar from study to study (vii) what were the overall results and how precise are they and (viii) will the results help in caring for patients. The article also provides sources for systematic reviews.

Evidence-Based Medicine↗

PubMed2001

[Evidence-based medicine and the systematic review in perioperative medicine].

The aim of Evidence-based medicine (EBM) is the unbiased and systematic identification and synthesis of valid scientific data. These best-evidence data may then be used for clinical decision-making. The systematic review is the most important tool of EBM and gives a specific answer to a specific question. More than 200 systematic reviews have been published in perioperative medicine. They treat complications and risks related to anaesthesia, postoperative and labour analgesia, nausea and vomiting, regional anaesthesia, blood transfusion and fluids replacement, and resuscitation. The majority of these systematic reviews are of good quality. In the specific settings of perioperative medicine the number of systematic reviews has become so important that recommendations for evidenced-based strategies of prevention and therapy can be formulated.

Anesthesiology↗

PubMed2000

Batrachology of Japan and adjacent regions - a systematic review.

As is the case with most other organisms, studies of amphibians started with systematics as the basis for many other biological fields, but systematics itself has endured a slower progress than other fields of biology have enjoyed for a long time. Nevertheless, philosophical and methodological 'revolutions' in the past 30 years, combined with more recent progress in biochemical and molecular techniques, have been forcing current systematics into a great change. Stejneger's (1907) monumental book, the first thorough review of amphibians from Japan and adjacent regions, was published nearly a century ago, and since then, the increase in number of areas that have been closely surveyed, together with the application of new theories and methods, have greatly enlarged our knowledge of the amphibian fauna in this region. For example, extensive experiments by the Hiroshima School using artificial hybridization techniques greatly contributed to our understandings of relationships among some groups of amphibians that had been taxonomically confusing. In addition to this, new species discovered by more detailed field surveys in a wider area and cryptic species revealed by analyses of isozymes and acoustic properties have made for a great increment in the number of taxa in this region. Further, analyses of DNA sequences now enable us to infer the affinities of taxa with few phylogenetically informative phenotypic properties, and the resultant phylogenetic hypotheses further contribute to our understandings of biogeography and many other issues on amphibian evolution. From these advances, it has been clarified that the amphibian species diversity is far greater than was previously expected, which in turn means a high endemism within particular regions. It is expected that future studies will also reveal exact systematic relationships of wide-ranging species, both those occurring within this region and those extending outside of it. For that purpose, international and interdisciplinary studies are indispensable. But what is also necessary is to conserve amphibian populations so that they will not disappear before their true relationships are realized. Knowledge of systematics among young amphibian biologists is also a matter of high priority.

Amphibians↗

PubMed2000

Conducting a systematic review.

In response to the growing volume of health care literature and the variable quality of reported studies, systematic reviews have increasingly been used to guide health care decisions because of their rigorous summary of the research. Systematic reviews utilise planned methods of identifying, appraising, then summarising the results from individual studies. The steps in performing a systematic review include: preparing a detailed research protocol; selecting criteria for inclusion of articles in the review; systematically searching the published and unpublished literature; determining which articles meet the predefined inclusion criteria; critically appraising the quality of the research; extracting outcome data from the research report and statistically combining data, where appropriate, in order to summarise the best available evidence on the topic of interest. These processes are documented in the systematic review report, and can be subject to peer review and critique like other research.

Humans↗

PubMed2003

Beyond Medline: reducing bias through extended systematic review search.

OBJECTIVE: To evaluate the sensitivity and precision of various extended search methods in identifying randomized controlled trials (RCTs) for systematic reviews. METHOD: Prospective analysis of extended search methods (specialized databases or trial registries, reference lists, hand-searching, personal communication, and Internet) used in two systematic reviews of RCTs. The gold standard was the total number of RCTs identified by major databases (MEDLINE, EMBASE, etc.) and extended search strategies combined. Sensitivity was the proportion of all known RCTs identified by any extended search method. Precision reflected the proportion of all items uncovered by any extended search method that actually were RCTs. RESULTS: The extended search identified 94 additional RCTs for the systematic reviews beyond those identified with the major databases. Specialized databases and trial registries had the highest sensitivity and precision for the lipid-lowering project (13.6% and 52.7%, respectively; p < .05) followed by scanning of reference lists (7.2% sensitivity and 41.9% precision; p <.05). Hand-searching was more effective than personal communication and Internet searching (1.7% sensitivity and 12.2% precision; p < .05). The acupuncture project had slightly different results, with the specialized databases and trial registries tied with the review of reference lists for highest sensitivity (14.2%). The precision followed the same trend as the lipid-lowering project (17.6% specialized databases; 8.3% reference lists; p < .05). A post-hoc analysis showed that 75 of the 94 RCTs were indexed in the major databases but missed by the major database search. CONCLUSIONS: Extended searching identified additional RCTs for the systematic reviews beyond those found in major databases. Specialized databases and trial registries were most effective. An important number of RCTs were missed by the major database search. Timing and accuracy of indexing may explain this finding. The definitive measure, whether there is an association between the method used to uncover RCTs, the quality of the items uncovered and their impact on systematic review results, is yet to be determined.

Humans↗

PubMed2006

Reanalysis of systematic reviews: the case of invasive strategies for acute coronary syndromes.

OBJECTIVES: The objective of this study was to collect all systematic reviews on invasive strategies for acute coronary syndromes (ACS) and reanalyze the data in these reviews to reach combined estimates, as well as to make predictions on the effectiveness and risk of harm so as to facilitate relevant decision making in health care. METHODS: The data sources used were the following electronic databases, searched from 1994 to September 2004: Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; DARE, HTA, EED (NHS CRD); MEDLINE In-Process, Other Non-Indexed Citations, MEDLINE, and PubMed (2000 to 2004). References to the identified systematic reviews were checked. An ancillary search to identify recent randomized controlled trials (RCTs) covering the period from January 2003 to January 2006 was done in MEDLINE(R). We included systematic reviews of RCTs on patients with ACS. In unstable angina and non-ST-elevation myocardial infarction (UA/NSTEMI), eligible reviews had to compare early routine invasive strategy with early selective invasive strategy. In ST-elevation myocardial infarction (STEMI), a comparison between primary percutaneous coronary intervention (PCI) and thrombolytic therapy was required. The methodological quality of the reviews was assessed, and a standardized data extraction form was used. Results for the main outcomes of the RCTs in the reviews were reanalyzed. An additional search of those RCTs not included in the meta-analyses was performed for UA/NSTEMI and short-term morality data on STEMI. Bayesian models were constructed to estimate the uncertainty about a possible treatment effect and to make predictions and probability statements. Main results are based on these analyses. Mortality was considered as the primary outcome measure. RESULTS: One systematic review on invasive strategies was identified for UA/NSTEMI and nine on invasive strategies for STEMI. Five reviews of the latter that were published after the year 2000 were included for the final analysis. The median quality score was 10.5 (range, 7-13; n = 6) on a scale from 0 to 18 points. An updated literature search identified one further RCT on UA/NSTEMI. Regarding NSTEMI and mortality, the average risk difference favoring an early invasive treatment strategy compared with early conservative strategy was .6 percent (95 percent credible interval [CrI], -2.1 to 1.0). Predicted risk (relative risk/risk difference scales) of doing harm was 26.7/26.6 percent. Regarding STEMI and mortality, the absolute risk reduction in favor of primary PCI over thrombolysis was 4.1 percent (95 percent CrI, -7.1 to -1.1) when PCI was compared with streptokinase and 1.2 percent (95 percent CrI, -2.7 to .2) when compared with fibrin-specific thrombolytics. Predicted risk of harm was 8.9/5.3 percent and 8.0/13.3 percent, respectively. CONCLUSIONS: There seems to be at present no solid evidence for survival benefit on early invasive strategy for UA/NSTEMI as a broad diagnostic group, and the risk of doing harm should be considered. Also, the evidence for PCI to decrease early mortality after STEMI is scanty. Estimations of predicted harm may further aid decisions on whether to implement the new treatment over the old one. It may also give an additional dimension for interpreting the results of any meta-analysis.

Angioplasty, Balloon, Coronary↗

PubMed2005

Complementary therapies for reducing body weight: a systematic review.

The prevalence of obesity is increasing at an alarming rate and a plethora of complementary therapies are on offer claiming effectiveness for reducing body weight. The aim of this systematic review is to critically assess the evidence from randomized controlled trials (RCTs) and systematic reviews of complementary therapies for reducing body weight. Literature searches were conducted on Medline, Embase, Amed, and the Cochrane Library until January 2004. Hand-searches of relevant medical journals and bibliographies of identified articles were conducted. There were no restrictions regarding the language of publication. Trial selection, quality assessment and data abstraction were performed systematically and independently by two authors. Data from RCTs and systematic reviews, which based their findings on the results of RCTs, were included. Six systematic reviews and 25 additional RCTs met our inclusion criteria and were reviewed. The evidence related to acupuncture, acupressure, dietary supplements, homeopathy and hypnotherapy. Except for hypnotherapy, Ephedra sinica and other ephedrine-containing dietary supplements the weight of the evidence is not convincing enough to suggest effectiveness. For these interventions, small effects compared with placebo were identified. In conclusion, our findings suggest that for most complementary therapies, the weight of the evidence for reducing body is not convincing. Hypnotherapy, E. sinica and other ephedrine-containing dietary supplements may lead to small reductions in body weight. However, the intake of E. sinica and ephedrine is associated with an increased risk of adverse events. Interventions suggesting positive effects in single RCTs require independent replication.

Acupuncture Therapy↗

PubMed2004

Application of systematic review methods to qualitative research: practical issues.

AIM: This paper explores practical methodological issues which arise from the application of systematic review and meta-synthesis techniques to qualitative research studies in the context of a pragmatic health services research question. BACKGROUND: The emphasis on, and volume of, qualitative research is increasing. As a result, there is a need to integrate and disseminate qualitative research findings. However, relatively little has been written about the methodology of systematically reviewing and meta-synthesizing qualitative research studies, and about the practical issues which arise in the course of these processes. METHODS: A systematic review and meta-synthesis was undertaken of qualitative research studies reporting data relevant to the pragmatic health services research question: "What factors facilitate or impede role development and/or effective practice as a clinical nurse specialist, nurse practitioner, advanced nurse practitioner or consultant nurse based in acute hospital settings?" FINDINGS: The identification of relevant studies is substantially more time-consuming than the identification of relevant studies for a systematic review of randomized controlled trials. A substantially larger proportion of papers has to be retrieved for full reading. Articles with unclear titles which lack abstracts cannot be dismissed as irrelevant. Study appraisal and data analysis, being iterative processes, are also more time-consuming than the appraisal and meta-analysis of quantitative studies. It may be possible to reduce the frustrations inherent in the distance between the reviewer and the participants in the primary research by using full project reports rather than published articles. CONCLUSIONS: Conducting a systematic review and meta-synthesis of qualitative research studies is a rewarding but demanding activity, and adequate time and resources must be made available. Some recommendations are made which may facilitate those processes.

Databases, Bibliographic↗

PubMed2005

A systematic review for effective management of central venous catheters and catheter sites in acute care paediatric patients.

BACKGROUND: Central venous catheters (CVCs) have provided many benefits in modern-day medical practice; however, they also put patients at risk of catheter-related complications. Numerous studies have been carried out in relation to the management of central venous catheters with conflicting results. While there were several systematic reviews of central venous catheter-related issues, it is clear that there was no systematic review of CVC-related studies specific to the paediatric population in the acute care setting. OBJECTIVE: To present the best available evidence for effective management of central venous catheters and catheter sites in the prevention and/or reduction of catheter-related complications in hospitalised paediatric patients. METHODS: A systematic review was undertaken according to the approach of the Centre for Reviews and Dissemination (CRD; http://www.york.ac.uk/inst/crd). DATA SOURCE: Literature was identified by electronic searching of Cochrane Library, MEDLINE, CINAHL, HealthSTAR, and CancerLit; checking references of all review articles; hand searching of key relevant journals and conference proceedings; and contact with expert informants, medical suppliers, and pharmaceutical companies. INCLUSION/EXCLUSION CRITERIA: The review included randomised and non-randomised controlled trials conducted with hospitalised paediatric patients. Studies that included mixed adult and paediatric populations and mixed hospitalised and home care settings were excluded. DATA EXTRACTION: Two independent reviewers extracted data onto a standard data extraction form, with differences resolved by discussion. QUALITY ASSESSMENT: The quality assessment of retrieved studies included: study design, the degree to which systematic bias was avoided or minimised, the degree to which the assessment was "blind," the degree to which follow up was completed. DATA SYNTHESIS: Quantitative pooling of studies was not feasible due to the diversity of interventions and outcome measures between similar studies. A narrative account of the study characteristics and results was therefore undertaken. RESULTS: Thirty-eight randomised and quasi-randomised controlled trials were retrieved for critical appraisal. Of these, 32 were excluded from the review because the studies did not meet the inclusion criteria and some lacked reporting of appropriate data. Six studies met the criteria with interventions such as antibiotic flushes, antiseptic skin preparations, and dressing materials. CONCLUSION: Quality of reporting was generally lacking. Statistical pooling of results was not possible due to diversity in the reporting of outcomes. There was no evidence to make recommendations on the degree of barrier precautions and the type of aseptic technique to be used at the time of catheter insertion in the paediatric population to prevent catheter-related infection. There was insufficient evidence to support the routine use of an antibiotic flushing solution. There was a lack of randomised controlled trial (RCT) evidence on the benefit of heparin flushes, the use of in-line filters, the frequency of fluid administration set changes, or the type of dressing to use and the frequency of dressing changes. There was some evidence to suggest that chlorhexidine lotion is superior to povidone iodine as a cutaneous antiseptic at the catheter insertion site. However, no recommendation can be made for the use of chlorhexidine in neonates less than 2 weeks old or in premature infants. This systematic review concluded that there is an urgent need for well-designed randomised controlled trials with sufficient power to determine the effectiveness of various interventions in relation to management of CVCs.

Adolescent↗

PubMed1994

Systematic reviews--theory and practice.

The consumer of health care services experts that medical practice is based on scientific evidence with regard to efficacy and effectiveness. Randomized controlled trials provide the most valid basis for comparison of interventions in health care and offer the most reliable information to guide clinical practice. The need for well-designed and performed systematic reviews of the available information to address a specific clinical question should be obvious both to the practicing clinician and the consumer. A systematic review is defined as "the application of scientific strategies that limits bias to the systematic assembly, critical appraisal, and synthesis of all relevant studies on a specific topic". "Meta-analysis (quantitative overview) is a systematic review that employs statistical methods to combine and summarize the results of several trials". In a meta-analysis the individual studies are weighted according to the inverse of the variance; that is more weight is given to studies with more events. The pooling of data allows for an increase in power and thus a more precise estimate of the effect size. Systematic reviews that meet explicit criteria for validity offer the reader information that as a rule is less biased than the unstructured overview which has traditionally been performed by one or several experts in a specific content area. Recently statistical methods have been developed to summarize data from studies of diagnostic tests. Cumulative meta-analyses offer the caregiver and the health-care consumer with answers regarding the effectiveness of a certain intervention at the earliest possible date in time.

Humans↗

PubMed2006

Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model.

OBJECTIVES: To determine the diagnostic accuracy of tests for detecting urinary tract infection (UTI) in children under 5 years of age and to evaluate the effectiveness of tests used to investigate further children with confirmed UTI. Also, to evaluate the effectiveness of following up children with UTI and the cost-effectiveness of diagnostic and imaging tests for the diagnosis and follow-up of UTI in children under 5. An additional objective was to develop a preliminary diagnostic algorithm for healthcare professionals. DATA SOURCES: Electronic databases were searched up to the end of 2002/early 2003. Consultation with experts in the field. REVIEW METHODS: A systematic review was undertaken using published guidelines and results were analysed according to test grouping: diagnosis of UTI and further investigation of UTI. The cost-effectiveness results from existing evaluations were synthesised. A separate cost-effectiveness model was developed using the best available evidence, in part derived from the results of the systematic review, to illustrate the potential cost-effectiveness of some alternative management strategies in a UK setting. The results of the systematic review were used to propose diagnostic algorithms for the diagnosis and further investigation of UTI in children. Economic analyses did not contribute directly to the development of these algorithms. RESULTS: The studies included in the review provided very little data on the accuracy of clinical investigations for the diagnosis of UTI, and criteria for clinical suspicion of UTI were not further defined. The majority of studies included in the review found that clean voided midstream urine (CVU) samples had similar accuracy to suprapubic aspiration (SPA) samples when cultured with the advantage of being a non-invasive collection method that can be used in the GP's surgery. Pad, nappy or bag specimens may be appropriate methods for obtaining a urine sample in non-toilet-trained children, although only limited data were available. Although the glucose test was reported to have the highest accuracy in terms of both ruling in and ruling out disease, only a limited number of studies of this test were included and these were conducted over 30 years ago. Dipstick tests are easy to perform in the GP's surgery, give an immediate result and are relatively cheap. The results of the systematic review showed that a dipstick for leucocyte esterase (LE) and nitrite, where both test results are interpreted in combination, was a good test both for ruling in (both positive) and ruling out (both negative) a UTI. A dipstick positive for either LE or nitrite and negative for the other provides inconclusive diagnostic information and further testing is therefore required in these patients. Microscopy is more time consuming and expensive to perform than a dipstick test, but potentially quicker and cheaper than culture. As with dipstick tests, a combination of microscopy for pyuria and bacteriuria can be used accurately to rule in and rule out a UTI. An indeterminate test result is again obtained if microscopy is positive for either pyuria or bacteriuria, and negative for the other. Confirmatory culture is required in these patients. In patients considered to have a UTI, further culture to determine antibiotic sensitivities may be an option to inform treatment decisions. Only one study satisfied the inclusion criteria of the economic review and the review highlighted a number of potential limitations of this study for NHS decision-making. A separate decision-analytic model was therefore developed to provide a more reliable estimate of the optimal strategy regarding the diagnosis and further investigation of children under 5 with suspected UTI from the perspective of the NHS. The economic model found that the optimal diagnostic strategy for children presenting with symptoms suggestive of UTI depends on a number of key factors. These included the relevant subgroup of children concerned, in terms of gender and age, and the health service's maximum willingness to pay for an additional quality-adjusted life-year. CONCLUSIONS: The results of the systematic review were used to derive an algorithm for the diagnosis of UTI in children under 5. This algorithm represents the conclusions of the review in terms of effective practice. There were insufficient data to propose an algorithm for the further investigation of UTI in children under 5. The quality assessment highlighted several areas that could be improved upon in future diagnostic accuracy studies.

Algorithms↗