should include teaching the properties of individual drugs and, more importantly, an understanding of the measures used to determine therapeutic effectiveness. Sibley's group11 described a peer review method of ambulatory drug prescribing that could be incorporated into medical practice on a regular basis. Systems of organization and payment for medical services that place a premium on the quality rather than quantity of patient encounters might also reduce the tendency to seek chemical solutions to patients' problems. Physicians in group practice, with its built-in peer review, were found to be more critical prescribers than solo practitioners.12 With additional training in the behavioural sciences, doctors might rely less on medicines and use themselves more as agents in the therapeutic encounter. The government can play a major role in controlling drugs and drug companies and their advertising practices. Thorough testing of drugs available in Canada before the 1963 regulations became effective is essential to deter-
mine their safety and efficacy. Governmental controls are required since the pharmaceutical industry has neither voluntarily nor adequately controlled itself in the past. Provincial or national formularies, such as those used in Ontario, Saskatchewan and Manitoba, should include all medicines, prescribed or not. Formularies would control overthe-counter preparations, limit pharmaceuticals to those with proven efficacy, and eliminate those that duplicate existing preparations. Regular drug bulletins published by provincial ministries of health or the federal government should be publicized and made available to both physicians and patients, and independent publications like the Medical Letter must be encouraged. Perhaps, with better controls, increased self-awareness, greater personal responsibility and improved education, the trend towards increased use of medication in Canada can be reversed. EUGENE VAYDA, MD
Department of clinical epidemiology and biostatistics McMaster University Medical Centre Hamilton, ON
References 1. Josia GH (ed): World Health Organizationi international Collaborative Study of Medical Care Utilization. Report on Basic Canadian Data, Saskatoon, Dept of social and preventive medicine, U of Saskatchewan, 1973 2. RABIN DL (ed): International comparisons of medical care. Preliminary report of the World Health Organization/International Collaborative Study of Medical Care Utilization. Milbank Mem Fund Q 50 (3): 40, 1972 3. RABIN DL, BUSH PJ: The use of medicines: historical trends and international comparisons. mt J Health Serv 4: 61, 1974 4. Idem: Who's using medicines? J Community Health 1: 106, 1975 5. National Center for Health Statistics: International Comparisons of Medical Care Utilization: A Feasibility Study. Public Health Service publ no 1000, series 2, no 33, Washington, US Health Services and Mental Health Administration, 1969 6. CHASTON A, Ss'rrzaa WO, Roaawrs RS, et al: Patterns of medical drug use - a community focus. Can Med Assoc J 114: 33, 1976 7. RUDERMAN AP: The drug business in the
context of Canadian health care programs. mt J Health Serv 4: 641, 1974 8. JIcK H: Drugs - remarkably nontoxic. N
Engl J Med 291: 824, 1974 9. COOPERSTOCK R (ed): Some factors involved in the increased prescribing of psychotropic drugs, in Social Aspects of the Medical Use of Psychotropic Drugs, Toronto, Addiction Research Foundation of Ontario 1974 10. ILLIcH I: Medical Nemesis: The Expropriation of Health, Toronto, McClelland and Stewart, 1975, pp 15-60 11. SIBLEY I, Ss'srzaR WO, RUDNIcK Ky, et al: Quality of care appraisal in primary care: a quantitative method. Ann Intern Med 83: 46, 1975 12. STOLLEY PD, BECKER MH, LASAGNA L, et al: The relationship between physician charac-
teristics and prescribing appropriateness. Med Care 10: 17, 1972
Screening for asymptomatic bacteriuria in childhood Bacteriuria in children, especially girls, is a perennial problem in medicine. Approximately 2% of schoolgirls have a substantial growth of pathogens, usually Escherichia ccli, in a midstream urine specimen but have no symptoms of urinary tract disease. Is it worth screening whole populations of schoolgirls to detect this 2% with bacteriuria? Do these children continue to shed E. ccli if they are not treated? What longterm effect does bacteriuria have on the kidneys? Is treatment necessary or even effective? What physical or social circumstances favour bacteriuria? Is it often associated with abnormalities that can be detected by radiography, and what should be done about those abnormalities? Forbes and Drummond1 have pointed out that some of these questions are still controversial, and in this issue of the Journal (page 316) Arbus and Williams describe a public health program designed to answer some of these questions. Two epidemiologic surveys from Britain have recently been published.2'3
Both deal with what is known as asymptomatic bacteriuria (ASB) - an inappropriate term, since about three quarters of these children have had symptoms earlier. McLachlan and colleagues2 prefer the term covert bacteriuria. They screened 17 571 schoolgirls aged 4 to 12 years in Cardiff and Oxford, and paid particular attention to the radiologic findings. Of the total, 246 (1.7%) children had ASB - a figure similar to those in most recent studies, but higher than the 1.1% noted in the first extensive survey in the United States.4 The screening technique used by McLachlan was described in 1973 by Asscher and colleagues.5 The criterion for the diagnosis of bacteriuria was the presence of at least 100 000 microorganisms per millilitre in two successive midstream specimens. Micturating cystography and intravenous urography were carried out on all 246 children. Radiologically, 47% of these children with ASB had a urinary tract abnormality: 26% had pyelonephritis with or 288 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114
without ureteric reflux; 16% had reflux alone; 4.5% had irregularities of the bladder wall; and none had an abnormal bladder neck. Many girls in McLachlan's series had sterile catheter specimens later; one wonders, therefore, whether a single test is of value. McLachlan and his associates plan to follow their children closely over the next 4 years and their study will show whether the children with signs of renal lesions develop progressive disease. In their series they found no indication of renal failure unless the kidneys were already scarred. Davies and colleagues6 have recommended the screening of preschool children to detect such scarring. In a second study,7 from Newcastle upon Tyne, also the first of a series of studies designed to elucidate the natural history of ASB, the object of screening 13 464 schoolchildren aged 4 to 18 was to determine whether the prevalence of bacteriuria or associated renal lesions increased with age. The criterion for the diagnosis of this con-
dition was that noted above. Of the 13 464 children 254 girls had ASB. All 254 underwent intravenous pyelography and 252 underwent micturating cystography. The overall prevalence of ASB in these girls was 1.9%, but this prevalence did not increase progressively with age; up to the age of 7 it increased to a peak of 2.6%, then it decreased to 1.6% later. The incidence of renal scarring did not increase with age. Renal scarring alone was present in 15% of the children and ureteric reflux alone in 21 %. It was apparent that the more extensive the scarring, the more likely it was to be associated with reflux (18 cases). The urine leukocyte count was of no help in detecting either ASB or renal scarring. The infectmg organism was E. coli in 9 1.8% of cases and Kiebsiella in 5%; the nature of the organism did not change with time. Prevalence of ASB was not related to social class. Clinical examination rarely yielded useful information. Of the 254 children 34 had previously had a urinary tract infection. The commonest symptom had been urgency, followed by abdominal pain and enuresis. Enuresis was often associated with renal scarring. As in McLachlan's study2 ASB was not always a chronic condition in the Newcastle upon Tyne study: in 10% of the children it disappeared without treatment. The most important point that emerges from these series is that 76% of children had had symptoms at some time, though these were mild and not related to renal involvement. Hence the only reason for mass screening is to detect in any sample of children with ASB the*15% who have renal involvement. These authors concluded, as did Savage and associates,8 that this is not worth while. S.S.B. GILDER, MB, ES 110 Nuffield St. Rietondale Pretoria Republic of South Africa
References 1. FORBES PA, DRUMMOND KN: Urine screening programs in schools. Can Med Assoc 1 109: 979, 1973 2. MCLACHLAN MSF, MELLER ST, VElIRIER JONES ER, et al: Urinary tract in schoolgirls with
covert bacteriuria. Arch Dis Child 50: 253, 1975 3. SILVERBERO DS, ALLARD MI, ULAlI RA, et al: City-wide screening for urinary RbnormalitieS in schoolgirls. Can Med Assoc / 109: 981, 1973
4. KUNIN CM, ZACHA E, PAQUIN Al JR: Urinary-tract infections in schoolchildren. I. Prevalence of bacteriuria and associated urologic findings. N Engi J Med 266: 1287, 1962 5. Assciiai. AW, MCLAcHLAN MSF, VEIuuRB
JONES ER, et al: Screening for asymptomatic urinary-tract infections in schoolgirls. A twocentre feasibility study. Lancet 2: 1, 1973
6. DAVIES JM, GIESoN GL, LITrLEWOOD JM, et al: Prevalence of bacteriuria in infants and preschool children. Lancet 2: 7, 1974
7. Newcastle Asymptomatic Bacteriuria Research Group: Asymptomatic bacteriuria in schoolchildren in Newcastle upon Tyne. Arch Dis Child 50: 90, 1975 8. SAVAGE DCL, WILSON MI, McHuwy M, et al: Covert bacteriuriE of childhood: a clinical and epidemiological study. Arch Dis Child 48: 8, 1973
em Am
A AS
5£
0
I
A
A
A
5
£5
rfllt
. j.G
THE HOLLISTER DRAINING-WOUND
MANAGEMENT SYSTEM
KEEPS FLUIDS AWAY FROM PATIENT'S SKIN AND GUARDS AGAINST iRRITATION AND CONTAMINATION. Skin-conforming Karaya Blanket protects skin around wound site. It directs discharge into odor-barner, translucent Drainage Collector which holds exudate for visual assessment and accurate measurement There are no messy, wet dressings to handle or change no need for painful dressing removal Supplied sterile, for application in 0 R or patient's room.
The better alternative to absorbent dressings. I Write for more information.
HOLLISTER
Hollister Ltd., 332 Consumers Rd Willowdale, Ont. M2J 1P8
CMA JOURNAL/FEBRUARY 21, 1976/VOL 114 289
mine their safety and efficacy. Governmental controls are required since the pharmaceutical industry has neither voluntarily nor adequately controlled itself in the past. Provincial or national formularies, such as those used in Ontario, Saskatchewan and Manitoba, should include all medicines, prescribed or not. Formularies would control overthe-counter preparations, limit pharmaceuticals to those with proven efficacy, and eliminate those that duplicate existing preparations. Regular drug bulletins published by provincial ministries of health or the federal government should be publicized and made available to both physicians and patients, and independent publications like the Medical Letter must be encouraged. Perhaps, with better controls, increased self-awareness, greater personal responsibility and improved education, the trend towards increased use of medication in Canada can be reversed. EUGENE VAYDA, MD
Department of clinical epidemiology and biostatistics McMaster University Medical Centre Hamilton, ON
References 1. Josia GH (ed): World Health Organizationi international Collaborative Study of Medical Care Utilization. Report on Basic Canadian Data, Saskatoon, Dept of social and preventive medicine, U of Saskatchewan, 1973 2. RABIN DL (ed): International comparisons of medical care. Preliminary report of the World Health Organization/International Collaborative Study of Medical Care Utilization. Milbank Mem Fund Q 50 (3): 40, 1972 3. RABIN DL, BUSH PJ: The use of medicines: historical trends and international comparisons. mt J Health Serv 4: 61, 1974 4. Idem: Who's using medicines? J Community Health 1: 106, 1975 5. National Center for Health Statistics: International Comparisons of Medical Care Utilization: A Feasibility Study. Public Health Service publ no 1000, series 2, no 33, Washington, US Health Services and Mental Health Administration, 1969 6. CHASTON A, Ss'rrzaa WO, Roaawrs RS, et al: Patterns of medical drug use - a community focus. Can Med Assoc J 114: 33, 1976 7. RUDERMAN AP: The drug business in the
context of Canadian health care programs. mt J Health Serv 4: 641, 1974 8. JIcK H: Drugs - remarkably nontoxic. N
Engl J Med 291: 824, 1974 9. COOPERSTOCK R (ed): Some factors involved in the increased prescribing of psychotropic drugs, in Social Aspects of the Medical Use of Psychotropic Drugs, Toronto, Addiction Research Foundation of Ontario 1974 10. ILLIcH I: Medical Nemesis: The Expropriation of Health, Toronto, McClelland and Stewart, 1975, pp 15-60 11. SIBLEY I, Ss'srzaR WO, RUDNIcK Ky, et al: Quality of care appraisal in primary care: a quantitative method. Ann Intern Med 83: 46, 1975 12. STOLLEY PD, BECKER MH, LASAGNA L, et al: The relationship between physician charac-
teristics and prescribing appropriateness. Med Care 10: 17, 1972
Screening for asymptomatic bacteriuria in childhood Bacteriuria in children, especially girls, is a perennial problem in medicine. Approximately 2% of schoolgirls have a substantial growth of pathogens, usually Escherichia ccli, in a midstream urine specimen but have no symptoms of urinary tract disease. Is it worth screening whole populations of schoolgirls to detect this 2% with bacteriuria? Do these children continue to shed E. ccli if they are not treated? What longterm effect does bacteriuria have on the kidneys? Is treatment necessary or even effective? What physical or social circumstances favour bacteriuria? Is it often associated with abnormalities that can be detected by radiography, and what should be done about those abnormalities? Forbes and Drummond1 have pointed out that some of these questions are still controversial, and in this issue of the Journal (page 316) Arbus and Williams describe a public health program designed to answer some of these questions. Two epidemiologic surveys from Britain have recently been published.2'3
Both deal with what is known as asymptomatic bacteriuria (ASB) - an inappropriate term, since about three quarters of these children have had symptoms earlier. McLachlan and colleagues2 prefer the term covert bacteriuria. They screened 17 571 schoolgirls aged 4 to 12 years in Cardiff and Oxford, and paid particular attention to the radiologic findings. Of the total, 246 (1.7%) children had ASB - a figure similar to those in most recent studies, but higher than the 1.1% noted in the first extensive survey in the United States.4 The screening technique used by McLachlan was described in 1973 by Asscher and colleagues.5 The criterion for the diagnosis of bacteriuria was the presence of at least 100 000 microorganisms per millilitre in two successive midstream specimens. Micturating cystography and intravenous urography were carried out on all 246 children. Radiologically, 47% of these children with ASB had a urinary tract abnormality: 26% had pyelonephritis with or 288 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114
without ureteric reflux; 16% had reflux alone; 4.5% had irregularities of the bladder wall; and none had an abnormal bladder neck. Many girls in McLachlan's series had sterile catheter specimens later; one wonders, therefore, whether a single test is of value. McLachlan and his associates plan to follow their children closely over the next 4 years and their study will show whether the children with signs of renal lesions develop progressive disease. In their series they found no indication of renal failure unless the kidneys were already scarred. Davies and colleagues6 have recommended the screening of preschool children to detect such scarring. In a second study,7 from Newcastle upon Tyne, also the first of a series of studies designed to elucidate the natural history of ASB, the object of screening 13 464 schoolchildren aged 4 to 18 was to determine whether the prevalence of bacteriuria or associated renal lesions increased with age. The criterion for the diagnosis of this con-
dition was that noted above. Of the 13 464 children 254 girls had ASB. All 254 underwent intravenous pyelography and 252 underwent micturating cystography. The overall prevalence of ASB in these girls was 1.9%, but this prevalence did not increase progressively with age; up to the age of 7 it increased to a peak of 2.6%, then it decreased to 1.6% later. The incidence of renal scarring did not increase with age. Renal scarring alone was present in 15% of the children and ureteric reflux alone in 21 %. It was apparent that the more extensive the scarring, the more likely it was to be associated with reflux (18 cases). The urine leukocyte count was of no help in detecting either ASB or renal scarring. The infectmg organism was E. coli in 9 1.8% of cases and Kiebsiella in 5%; the nature of the organism did not change with time. Prevalence of ASB was not related to social class. Clinical examination rarely yielded useful information. Of the 254 children 34 had previously had a urinary tract infection. The commonest symptom had been urgency, followed by abdominal pain and enuresis. Enuresis was often associated with renal scarring. As in McLachlan's study2 ASB was not always a chronic condition in the Newcastle upon Tyne study: in 10% of the children it disappeared without treatment. The most important point that emerges from these series is that 76% of children had had symptoms at some time, though these were mild and not related to renal involvement. Hence the only reason for mass screening is to detect in any sample of children with ASB the*15% who have renal involvement. These authors concluded, as did Savage and associates,8 that this is not worth while. S.S.B. GILDER, MB, ES 110 Nuffield St. Rietondale Pretoria Republic of South Africa
References 1. FORBES PA, DRUMMOND KN: Urine screening programs in schools. Can Med Assoc 1 109: 979, 1973 2. MCLACHLAN MSF, MELLER ST, VElIRIER JONES ER, et al: Urinary tract in schoolgirls with
covert bacteriuria. Arch Dis Child 50: 253, 1975 3. SILVERBERO DS, ALLARD MI, ULAlI RA, et al: City-wide screening for urinary RbnormalitieS in schoolgirls. Can Med Assoc / 109: 981, 1973
4. KUNIN CM, ZACHA E, PAQUIN Al JR: Urinary-tract infections in schoolchildren. I. Prevalence of bacteriuria and associated urologic findings. N Engi J Med 266: 1287, 1962 5. Assciiai. AW, MCLAcHLAN MSF, VEIuuRB
JONES ER, et al: Screening for asymptomatic urinary-tract infections in schoolgirls. A twocentre feasibility study. Lancet 2: 1, 1973
6. DAVIES JM, GIESoN GL, LITrLEWOOD JM, et al: Prevalence of bacteriuria in infants and preschool children. Lancet 2: 7, 1974
7. Newcastle Asymptomatic Bacteriuria Research Group: Asymptomatic bacteriuria in schoolchildren in Newcastle upon Tyne. Arch Dis Child 50: 90, 1975 8. SAVAGE DCL, WILSON MI, McHuwy M, et al: Covert bacteriuriE of childhood: a clinical and epidemiological study. Arch Dis Child 48: 8, 1973
em Am
A AS
5£
0
I
A
A
A
5
£5
rfllt
. j.G
THE HOLLISTER DRAINING-WOUND
MANAGEMENT SYSTEM
KEEPS FLUIDS AWAY FROM PATIENT'S SKIN AND GUARDS AGAINST iRRITATION AND CONTAMINATION. Skin-conforming Karaya Blanket protects skin around wound site. It directs discharge into odor-barner, translucent Drainage Collector which holds exudate for visual assessment and accurate measurement There are no messy, wet dressings to handle or change no need for painful dressing removal Supplied sterile, for application in 0 R or patient's room.
The better alternative to absorbent dressings. I Write for more information.
HOLLISTER
Hollister Ltd., 332 Consumers Rd Willowdale, Ont. M2J 1P8
CMA JOURNAL/FEBRUARY 21, 1976/VOL 114 289
