myocardial infarction, to alleviate the complications of acute infarction and to restore function of the cardiac pump so that effective circulation can be sustained. For patients in cardiogenic shock (blood pressure, K 80 mm Hg; venous pressure, . 15 mm Hg; signs of peripheral vascular insufficiency; clouded sensorium; urine output, K 20 ml/h; left ventricular end-diastolic pressure at catheterization, . 30 mm Hg; and cardiac index, K 2 1/rn2) we graft only major vessels with serious (>75%) obstruction and do so without cardiac arrest. For patients with acute unstable myocardial infarction (infarction occurring during catheterization, extending infarction, infarction with uncontrollable arrhythmia or infarction with low cardiac output) we graft all vessels with serious lesions; we use aortic crossclamping for occasional short periods if myocardial function is good. For patients with preinfarction angina (acute coronary insufficiency, unstable angina and crescendo angina) we use the elective technique of aortic crossclamping and cardiac arrest. Conclusions Left ventricular contractility is the most important predictor of death associated with aortocoronary bypass grafting. Inadequate surgical procedure, as
indicated by little increase in coronary blood flow, is the other identifiable cause of death. Controlled studies to assess the effect of aortocoronary bypass on survival must establish rigid criteria to assess these two factors. Insertion of several grafts decreases mortality. Patients with triple vessel disease who have good ventricular function have a much better prognosis when treated surgically. We continue to advocate emergency grafting for patients with cardiogenic shock, acute unstable myocardial infarction and preinfarction angina. We thank Mrs. Elizabeth Masson for her help in preparing the manuscript. This study was supported by the Ontario Heart Foundation. References 1. FAVALORO RG: Saphenous vein autograft replacement of severe segmental coronary artery occlusion. Operative technique. Ann Thorac Surg 5: 334, 1968 2. JOHNSON .D, FLEMMA RD, LEPLEY D ja, et al: Extended treatment of severe coronary artery disease: a total surgical approach. Ann Surg 170: 460, 1969 3. DUNKMAN WB, PERLOFF JK, KASTOR JA, et al: Medical perspectives in coronary artery surgery - a caveat. Ann Intern Med 81: 817, 1974 4. CANNOM DS, MILLER DC, SHUMWAY NE, et
al: The long-term follow-up of patients undergoing saphenous vein bypass surgery. Circulaion 49: 77, 1974 5. NAJMI M, U5HIMAYAK, BLANCO G, et al: Results of aorto-coronary artery saphenous vein bypass surgery for ischemic heart disease. Am I Cardiol 29: 180, 1972 6. Loop FD, FAvALORO RG, SHIXEY EK, et al:
Surgery for combined valvular and coronary heart disease. JAMA 220: 372, 1972 Myocardial revascularization: operative mortality in the Cleveland Clinic experience. Cleve Clin Q 41: 51, 1974 8. JOHNSON WD: Surgical techniques of myocardial revascularization: an overview. Bull NYAcad Med 48: 46, 1972 9. The University of Toronto Interhospital Cardiovascular Surgery Group: The first 1000 coronary artery repair operations in Toronto. Can Med Assoc J 111: 525, 1974 10. HuTcHisoN JE, GREEN GE, MEKHJIAN NA, et al: Coronary bypass grafting in 376 consecutive patients, with three operative deaths. J Tlzorac Cardiovasc Surg 67: 7, 1974 7. BENNEi-r D, LooP RD, SHELDON WS, et al:
11. ANDERSON
RP,
RAHIMTOOLA
SH,
BONCHEK
LI, et al: The prognosis of patients with coronary artery disease after coronary bypass operations. Circulation 50: 274 1974 12. HALL RJ, DAwsoN JT, COOLEY DA, et al: Coronary artery bypass. Circulation 47
(suppl 3): 146, 1973 13. OBERMAN A, JONES WB, Ruay CP, et al: Natural history of coronary artery disease. Bull NY Acad Med 48: 1109, 1972 14. Loot FD, BERRETiTONI JN, PICHARD A, et al: Selection of the candidate for myocardial revascularization. J Thorac Cardiovasc Surg
69: 40, 1975 15. B.DARD P, KEON WJ, TAYLOR G, et al: Surgery for coronary artery disease and congestive heart failure. Can J Surg 18: 237, 1975 16. REA WJ, EcItER RR, MuLLsNs CR, et al: Importance of ventricular function in predicting operative mortality in aorto-coronary bypass
grafts. Circulation 43 (suppl 2): 215, 1971 17. KONG Y, BARTEL AG, BEHAR VS, et al: Aorto-coronary bypass graft: pre-operative correlates of mortality. Ibid p 101
18. KEON WJ, ABBAs SZ, SHANKAR KR, et al:
Emergency aorto-coronary venous bypass graft in cardiogenic shock. Can Med Assoc J
105: 1293, 1971 Experience with emergency aorto-coronary bypass grafts in the presence of acute myocardial infarction. Circulation 48 (suppi 3):
19. KEON WJ, B.DARD P, SHANKAR KR, et al:
151, 1973
20. KEON WJ, B.o4stD P, SHANKAR KR, et al:
Experience with emergency aortocoronary bypass grafts. Can J Surg 16: 268, 1973 21. HILL DJ, KERTIS WJ, KELLY JJ, et al: Emergency aorto-coronary bypass for impending or extending myocardial infarction. Circula-
tion 43 (suppl 1): 105, 1971
Preschool detection of asymptomatic bacteriuria: a public health program G.S. ARBUS, MD, FRCP[C1; R.C. WILLIAMS, B SC HONS, MD, DPH
A total of 9501o of parents registering their children for kindergarten agreed to screening for urinary tract Infection (UTI) in their children. Urine specimens from 1591 children (8701o), obtained at the school or at home, were tested. Only minor problems were encountered when parents prepared the specimens at home and mailed them to the laboratory for reading; the proportion of false-positive results was higher in these samples. If screening for UTI becomes established, it appears worth while to conduct this at the time of registration for kindergarten, either in From the department of pediatrics, The Hospital for Sick Children and the University of Toronto, and the Niagara Regional Health Unit, Niagara Falls, Ont. Reprint requests to: Dr. G.S. Arbus, Rm. 5109, The Hospital for Sick Children, 555 University Ave., Toronto, ON M5G 1X8
the school by lay persons or in the home by parents.
par des noninities, ou A Ia maison par les parents.
Ouatre-vingt-quinze pourcent (950/o) des parents inscrivant leurs enfants a un jardin d'enfants accepterent de faire subir un test de depistage des infections des voies urinaires a leurs enfants. Des echantillons d'urine provenant de 1591 enfants (870/o), obtenus a l'ecole ou a Ia maison, ont ete examines. On n'a rencontr6 que des problemes b6nins lorsque les echantillons furent pr6par6s a Ia maison par les parents et adress6s au laboratoire pour examen; c'est parmi ces echantillons que l'on releva Ia plus forte proportion de r6sultats faux.positifs. Si le depistage des infections des voies urinaires devient coutumier, ii apparait valable d'effectuer celui-ci au moment de l'inscription au jardin d'enfants, a l'6cole m6me
Generally, screening programs for the early detection of treatable diseases have been considered worth while,1 but recently the value of screening for asymptomatic bacteriuria in children has been questioned.2 Support for such a program will depend, initially, on research into the history of urinary tract infection (UTI) and, finally, on a cost/benefit analysis of these findings.2 We explored the possibility of combining a screening program to detect asymptomatic bacteriuria in children with other such programs at the time of registration for kindergarten, parental participation in the home being part of the procedure. We also compared two methods for detecting UTI; results of this comparison are not included here.
CMA JOURNAL/FEBRUARY 21, 1976/VOL 114 315
Material and methods
Early in 1974 we wrote to parents in the Niagara region whose children would begin senior kindergarten later that year, inviting them to bring their children to the school they would be attending for early registration and health evaluation. At this session the child's health history was obtained and immunization status updated if neces¬ sary. Screening tests for vision, hearing and development were offered. In addi¬ tion, a screening test to detect UTI was offered in one of the four schoolboard areas (St. Catharines-Grimsby); physicians had been notified of its pur¬ pose and type. Testing was done over a period of 14 school days in April. At the urinetesting station the importance of the program was explained to the parents, and those who agreed to participate were asked to collect a urine sample from their child; no cleansing technique was required. Urine was tested by dipslide and dipspoon. The Uricult dipslides, which hang vertically from the lids of sterile resealable plastic con¬ tainers (ICN Canada Ltd.), had one side impregnated with cystine lactose electrolyte-deficient (CLED) medium and the other with MacConkey's medi¬ um. Dipspoons filled with CLED medium were supplied, attached to the lids of sterile resealable glass contain¬ ers, by the Public Health Laboratories, Ontario Ministry of Health. Testing was done by lay persons who had been trained briefly in a technique in which the dipslide and dipspoon are dipped vertically into a sample of urine freshly voided into a clean paper cup and resealed in their sterile containers. For comparison of test results each parent was given a clean paper cup and dip¬ spoon in a prepaid, addressed mailing canister and was asked to return the
dipspoon, properly inoculated, as soon as possible from home. The technique was demonstrated at the school and parents were given written instructions to take home. All inoculated dipslides were read by a technician at The Hospital for Sick Children; dipspoons inoculated at the
school clinics were read at the Public Health Laboratories in Toronto, and those mailed in were read at the Public Health Laboratories in St. Catharines. Upon receipt, all test material was in¬ cubated for 12 to 24 hours at 37°C before it was read. A test was con¬ sidered positive for bacteriuria if it yielded 100 000 or more colonies per millilitre. If the first test was positive, regardless of whether the sample had been obtained at school or at home, a public health nurse made a home visit to repeat the test. If the results of the school dipspoon and dipslide tests did 316 CMA
not agree, and the
dipspoon sent from home yielded no growth, the nurse did not visit. Children whose tests at home by the nurse were positive were re¬ ferred to their family physician. Chil¬ dren who could not produce a urine sample at school and whose parents did not send a sample from home were not followed up. A questionnaire to assess parental acceptance of the screening program was mailed to every 10th parent on the school registration lists in the St.
for
only 3.0% of specimens obtained
at school but for 6.6% of specimens prepared at home (Table II). Repeat
testing by the public health nurse yielded positive results in 14 children (13 girls and 1 boy) less than 1% of all the children initially tested. The incidence of false-positive results was higher in specimens sent from home than in those taken at school. Forty-seven (3.5%) of the 1353 spe¬ cimens sent by mail from the parents were unsatisfactory (Table III), most Catharines-Grimsby area (total, 205), commonly because the bottle contained along with a stamped, addressed en- urine that had mistakenly been poured velope. A random selection of parents in from the paper cup. Most of these who had agreed to submit a dipspoon specimens were received in the 1st specimen from home but failed to do week; in the 2 later weeks we stressed so within 6 weeks of registration was to the parents that there should be no urine in the bottle. Reasons beyond surveyed by telephone. parental control, chiefly fungal overgrowth on the dipspoon, were respon¬ Results sible for 11 (23%) of the 47 specimens A total of 1825 children aged 4 to being unsatisfactory. 5 years attended the voluntary clinic Of the 1705 parents who took a dip¬ and 1725 (95%) of the parents agreed spoon home for testing, 352 (21%) did to have their children's urine tested. not return the inoculated dipspoon Eventually 1591 (87%) of the regis- within 6 weeks. When we telephoned, trants had their urine tested, which we were given various reasons for nonrepresents 92% of children whose par¬ return of the test material (Table IV). ents had agreed to participate in the Of the 205 randomly distributed urine-testing program (Table I). questionnaires 135 (66%) were re¬ Initial urine cultures were positive turned within 3 weeks; the responses
First test at school First test at home
1226 365
37* (3.0) 24* (6.6)
11 (0.90) 25 (2.0) 3 (0.82) 20 (5.5) Total 1591 61 (3.8) 14 (0.88) 45 (2.8) *ln each group one child had left the district and could not be tested by the public health nurse.
Table lll.Return of dipspoons distributed to parents
*No agar in spoon (2) and no dipspoon in canister (1). flncluding 1 containing feces. JTwenty additional parents agreed to participate in the urine-testing program but were not given dipspoons because supplies had run out.
JOURNAL/FEBRUARY 21, 1976/VOL 114
indicated that most parents favoured screening tests in the school (Table V). At the completion of the program, dipspoons had been received from the parents of 365 (73%) of the 499 children not tested at school and 988 (81%) of the 1226 who had been tested at school. Discussion One problem with any mass screening program is gaining access to an entire population. The parents at registration were able to ask questions about the urine test, see it performed and give immediate consent to testing, a method more successful than sending information and consent forms home. This probably accounts for the unusually high degree of participation. The 5.5% of parents who did not wish to participate gave such reasons as recent testing by their physician for possible urinary problems and current care for a urinary abnormality. The large number of children able to produce a urine sample on request (71% of the children whose parents agreed to participate) was encouraging. Physicians often cite the difficulty of obtaining a sample from young children as their reason for excluding urine testing from routine physical examination; in our study the 1-hour stay at the screening clinic appeared to provide a favourable opportunity for obtaining a sample. Although early school registration is not mandatory, the parents of 1825 children (83% of the 2189 registered by September 1974) attended the registration session, indicating much interest in the screening programs. It might be argued that the people who failed to register their children early Table IV-Response by 101 parents to queries about nonreturn of dipspoons Reason Forgot 40 Said to have been sent 19 Procrastinated 15 Not sent because of mail strike* 6 Other 20 *This 4-day country-wide strike started 10 days after completion of the screening program, and the public was asked not to use the mails until the backlog had been cleared. Table V-Responses of 135 parents to questionnaire Question Yes Should school clinics screen vision? 130 (96%) hearing? 130 (96%) development? 129 (96%) urine? 116 (86%) Was the school screening session "advantageous? 128 (95%)
are the people who are outside the health-care delivery system and, therefore, are those to whom we should address our efforts. However, subsequent screening of these children for vision, hearing and development (but not urinary abnormalities) revealed a prevalence of potential defects similar to that in the children who were registered early. Thus, it seems that the children who were not registered early were at no greater health risk, and it is unlikely that urine testing, had it been offered, would have given different results. We had anticipated difficulty in instructing parents in how to obtain and process a urine sample for bacterial culture. At the clinic, however, despite occasional language problems the parents appeared to learn the procedure quickly, and the written instructions taken home reinforced the teaching at the clinic. Only 3.5% of samples sent by parents were unsatisfactory, and in only 2.7% was this the fault of the parents. One might have thought that parents whose children had not been tested at school would be more anxious to submit a specimen from home, but the opposite was true. Perhaps parents who saw the testing procedure carried out on their children's urine were more confident about sampling at home and so were more likely to perform the test. Our study showed that parents can do the testing if carefully instructed; further, this use of parents as testers resulted in the inclusion of an additional 365 children and the detection of three more possible cases of UTI. A visit to the home by the public health nurse to obtain a second specimen is not recommended. The nurse found it necessary to telephone before visiting so that the parent could give the child a drink and distract him from urinating until the nurse arrived. It seems preferable for the nurse to discuss the first positive result over the telephone or by mail and provide a canister so that the parents can send another specimen. The latter method yields a slightly higher proportion of false-positive results but is much less
expensive. We are indebted to Dr. R.F. Manning, Mrs. C. Barber and Mrs. C. Hogg for help with this study, which was supported by the Kidney Foundation of Canada and the Public Health Laboratories, Ontario Ministry of Health.
LtT slows thegut fast COMPOSITION: Each tablet and each 5 ml of liquid contain 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulfate. INDICATIONS: Acute and chronic diarrhea; whether functional, or aaaociated with conditiona such aa gaatroenteritis, irritable bowel ayndrome, regional enteritia, ulcerative colitia, infectioua diarrhea and diarrhea following drug therapy. Also may provide effective intestinal control in patients following gastric surgery, ileoatomy or colostomy. CONTRAINDICATIONS: Jaundiced patienta or patients hyperaenaitive to the components of Lomotil. WARNINGS: Keep out of reach of children aince accidental overdoae may cauae aevere respiratory depression. The uae of LOMOTIL in children less than two yeara of age ia not generally recommended. PRECAUTIONS: Uae with extreme caution in tients with cirrhoaia, advanced hepatic diaeaae, paor abnormal liver function teata. Diphenoxylate HCL may potentiate the action of barbituratea, tranquilizers, and alcohol. Concurrent use of LOMOTIL with MAO inhibitors may in theory precipitate tensive criais. Asseas riska/benefits prior to usehyperduring pregnancy, lactation or in women of childbearing age. Diphenoxylate HCL and atropine sulfate are excreted in breast milk. Adminiater with caution to patienta who are receiving addicting druga or who areaddiction proneAddiction to diphenoxylate HCL ia theoretically possible at high doaage; no addicting liability haa been noted in however, patienta. Recommended doaage ahould not be exceeded. There should be atrict obaervance of the contraindications and precautiona relative to the uae of atropine. In children, aigna of atropiniam may occur even with recommended doaes, ADVERSE REACTIONS: Are relatively uncommon; moat frequently, nauaea; less frequently, drowsineaa, dizziness, vomiting, pruritua, akin eruption, restlesaness, insomnia, bloating and cramps have been reported; and rare incidences of numbness of the extremities, headache, blurring of vision, swelling of gums, euphoria, depression and general malaise have occurred. Many of these might be symptoms of disease being treated; accurate differentiation is often impossible. DOSAGE AND ADMINISTRATION: ADULTS: the usual initial dose is 5 mg (2 LOMOTIL tablets) 3 or 4 times daily. (20 mg/ 24 hours in divided doses is the maximum recommended dosage.) CHILDREN: an adequate pediatric daily dose of LOMOTIL (to be given in divided doses 3 or times daily) determined by the child's age is as4 follows: 2 to 5 years 6.0 mg (12.5 ml). Sto 8 years 8.0mg (15.0 ml). 8 to 12 years io.o mg (20.0 ml). NOTE: THIS IS TOTAL DAILY MEDICATION TO BE GIVEN IN 3 OR 4 DIVIDED DOSES. Wolume of LOMOTIL Liquid containing approximate total daily dosage of diphenoxylate HCL. 5 ml is equal to approximately i teaspoonful.
AVAILABILITY:
TABLETS: 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulphate in bottles of 100, 500. LIQUID: 2.5 mg diphenoxylate hydrochloride 0.025 mg atropine sulphate/S ml in 60 ml (2 and oz.)
bottles.
Product monograph available on request.
.,
.
References 1. WILSON JMG, JUNONER G: Principles and practice
for screening for disease, health paper no 34, Geneva, WHO, public 1968, p7 2. FORBES PA, DRUMMOND KN: Urine screening programs in schools. Can Med Assoc 1 109: 979, 1973
318 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114
Searle PharmaceutIcals Oakville Ontano
indicated by little increase in coronary blood flow, is the other identifiable cause of death. Controlled studies to assess the effect of aortocoronary bypass on survival must establish rigid criteria to assess these two factors. Insertion of several grafts decreases mortality. Patients with triple vessel disease who have good ventricular function have a much better prognosis when treated surgically. We continue to advocate emergency grafting for patients with cardiogenic shock, acute unstable myocardial infarction and preinfarction angina. We thank Mrs. Elizabeth Masson for her help in preparing the manuscript. This study was supported by the Ontario Heart Foundation. References 1. FAVALORO RG: Saphenous vein autograft replacement of severe segmental coronary artery occlusion. Operative technique. Ann Thorac Surg 5: 334, 1968 2. JOHNSON .D, FLEMMA RD, LEPLEY D ja, et al: Extended treatment of severe coronary artery disease: a total surgical approach. Ann Surg 170: 460, 1969 3. DUNKMAN WB, PERLOFF JK, KASTOR JA, et al: Medical perspectives in coronary artery surgery - a caveat. Ann Intern Med 81: 817, 1974 4. CANNOM DS, MILLER DC, SHUMWAY NE, et
al: The long-term follow-up of patients undergoing saphenous vein bypass surgery. Circulaion 49: 77, 1974 5. NAJMI M, U5HIMAYAK, BLANCO G, et al: Results of aorto-coronary artery saphenous vein bypass surgery for ischemic heart disease. Am I Cardiol 29: 180, 1972 6. Loop FD, FAvALORO RG, SHIXEY EK, et al:
Surgery for combined valvular and coronary heart disease. JAMA 220: 372, 1972 Myocardial revascularization: operative mortality in the Cleveland Clinic experience. Cleve Clin Q 41: 51, 1974 8. JOHNSON WD: Surgical techniques of myocardial revascularization: an overview. Bull NYAcad Med 48: 46, 1972 9. The University of Toronto Interhospital Cardiovascular Surgery Group: The first 1000 coronary artery repair operations in Toronto. Can Med Assoc J 111: 525, 1974 10. HuTcHisoN JE, GREEN GE, MEKHJIAN NA, et al: Coronary bypass grafting in 376 consecutive patients, with three operative deaths. J Tlzorac Cardiovasc Surg 67: 7, 1974 7. BENNEi-r D, LooP RD, SHELDON WS, et al:
11. ANDERSON
RP,
RAHIMTOOLA
SH,
BONCHEK
LI, et al: The prognosis of patients with coronary artery disease after coronary bypass operations. Circulation 50: 274 1974 12. HALL RJ, DAwsoN JT, COOLEY DA, et al: Coronary artery bypass. Circulation 47
(suppl 3): 146, 1973 13. OBERMAN A, JONES WB, Ruay CP, et al: Natural history of coronary artery disease. Bull NY Acad Med 48: 1109, 1972 14. Loot FD, BERRETiTONI JN, PICHARD A, et al: Selection of the candidate for myocardial revascularization. J Thorac Cardiovasc Surg
69: 40, 1975 15. B.DARD P, KEON WJ, TAYLOR G, et al: Surgery for coronary artery disease and congestive heart failure. Can J Surg 18: 237, 1975 16. REA WJ, EcItER RR, MuLLsNs CR, et al: Importance of ventricular function in predicting operative mortality in aorto-coronary bypass
grafts. Circulation 43 (suppl 2): 215, 1971 17. KONG Y, BARTEL AG, BEHAR VS, et al: Aorto-coronary bypass graft: pre-operative correlates of mortality. Ibid p 101
18. KEON WJ, ABBAs SZ, SHANKAR KR, et al:
Emergency aorto-coronary venous bypass graft in cardiogenic shock. Can Med Assoc J
105: 1293, 1971 Experience with emergency aorto-coronary bypass grafts in the presence of acute myocardial infarction. Circulation 48 (suppi 3):
19. KEON WJ, B.DARD P, SHANKAR KR, et al:
151, 1973
20. KEON WJ, B.o4stD P, SHANKAR KR, et al:
Experience with emergency aortocoronary bypass grafts. Can J Surg 16: 268, 1973 21. HILL DJ, KERTIS WJ, KELLY JJ, et al: Emergency aorto-coronary bypass for impending or extending myocardial infarction. Circula-
tion 43 (suppl 1): 105, 1971
Preschool detection of asymptomatic bacteriuria: a public health program G.S. ARBUS, MD, FRCP[C1; R.C. WILLIAMS, B SC HONS, MD, DPH
A total of 9501o of parents registering their children for kindergarten agreed to screening for urinary tract Infection (UTI) in their children. Urine specimens from 1591 children (8701o), obtained at the school or at home, were tested. Only minor problems were encountered when parents prepared the specimens at home and mailed them to the laboratory for reading; the proportion of false-positive results was higher in these samples. If screening for UTI becomes established, it appears worth while to conduct this at the time of registration for kindergarten, either in From the department of pediatrics, The Hospital for Sick Children and the University of Toronto, and the Niagara Regional Health Unit, Niagara Falls, Ont. Reprint requests to: Dr. G.S. Arbus, Rm. 5109, The Hospital for Sick Children, 555 University Ave., Toronto, ON M5G 1X8
the school by lay persons or in the home by parents.
par des noninities, ou A Ia maison par les parents.
Ouatre-vingt-quinze pourcent (950/o) des parents inscrivant leurs enfants a un jardin d'enfants accepterent de faire subir un test de depistage des infections des voies urinaires a leurs enfants. Des echantillons d'urine provenant de 1591 enfants (870/o), obtenus a l'ecole ou a Ia maison, ont ete examines. On n'a rencontr6 que des problemes b6nins lorsque les echantillons furent pr6par6s a Ia maison par les parents et adress6s au laboratoire pour examen; c'est parmi ces echantillons que l'on releva Ia plus forte proportion de r6sultats faux.positifs. Si le depistage des infections des voies urinaires devient coutumier, ii apparait valable d'effectuer celui-ci au moment de l'inscription au jardin d'enfants, a l'6cole m6me
Generally, screening programs for the early detection of treatable diseases have been considered worth while,1 but recently the value of screening for asymptomatic bacteriuria in children has been questioned.2 Support for such a program will depend, initially, on research into the history of urinary tract infection (UTI) and, finally, on a cost/benefit analysis of these findings.2 We explored the possibility of combining a screening program to detect asymptomatic bacteriuria in children with other such programs at the time of registration for kindergarten, parental participation in the home being part of the procedure. We also compared two methods for detecting UTI; results of this comparison are not included here.
CMA JOURNAL/FEBRUARY 21, 1976/VOL 114 315
Material and methods
Early in 1974 we wrote to parents in the Niagara region whose children would begin senior kindergarten later that year, inviting them to bring their children to the school they would be attending for early registration and health evaluation. At this session the child's health history was obtained and immunization status updated if neces¬ sary. Screening tests for vision, hearing and development were offered. In addi¬ tion, a screening test to detect UTI was offered in one of the four schoolboard areas (St. Catharines-Grimsby); physicians had been notified of its pur¬ pose and type. Testing was done over a period of 14 school days in April. At the urinetesting station the importance of the program was explained to the parents, and those who agreed to participate were asked to collect a urine sample from their child; no cleansing technique was required. Urine was tested by dipslide and dipspoon. The Uricult dipslides, which hang vertically from the lids of sterile resealable plastic con¬ tainers (ICN Canada Ltd.), had one side impregnated with cystine lactose electrolyte-deficient (CLED) medium and the other with MacConkey's medi¬ um. Dipspoons filled with CLED medium were supplied, attached to the lids of sterile resealable glass contain¬ ers, by the Public Health Laboratories, Ontario Ministry of Health. Testing was done by lay persons who had been trained briefly in a technique in which the dipslide and dipspoon are dipped vertically into a sample of urine freshly voided into a clean paper cup and resealed in their sterile containers. For comparison of test results each parent was given a clean paper cup and dip¬ spoon in a prepaid, addressed mailing canister and was asked to return the
dipspoon, properly inoculated, as soon as possible from home. The technique was demonstrated at the school and parents were given written instructions to take home. All inoculated dipslides were read by a technician at The Hospital for Sick Children; dipspoons inoculated at the
school clinics were read at the Public Health Laboratories in Toronto, and those mailed in were read at the Public Health Laboratories in St. Catharines. Upon receipt, all test material was in¬ cubated for 12 to 24 hours at 37°C before it was read. A test was con¬ sidered positive for bacteriuria if it yielded 100 000 or more colonies per millilitre. If the first test was positive, regardless of whether the sample had been obtained at school or at home, a public health nurse made a home visit to repeat the test. If the results of the school dipspoon and dipslide tests did 316 CMA
not agree, and the
dipspoon sent from home yielded no growth, the nurse did not visit. Children whose tests at home by the nurse were positive were re¬ ferred to their family physician. Chil¬ dren who could not produce a urine sample at school and whose parents did not send a sample from home were not followed up. A questionnaire to assess parental acceptance of the screening program was mailed to every 10th parent on the school registration lists in the St.
for
only 3.0% of specimens obtained
at school but for 6.6% of specimens prepared at home (Table II). Repeat
testing by the public health nurse yielded positive results in 14 children (13 girls and 1 boy) less than 1% of all the children initially tested. The incidence of false-positive results was higher in specimens sent from home than in those taken at school. Forty-seven (3.5%) of the 1353 spe¬ cimens sent by mail from the parents were unsatisfactory (Table III), most Catharines-Grimsby area (total, 205), commonly because the bottle contained along with a stamped, addressed en- urine that had mistakenly been poured velope. A random selection of parents in from the paper cup. Most of these who had agreed to submit a dipspoon specimens were received in the 1st specimen from home but failed to do week; in the 2 later weeks we stressed so within 6 weeks of registration was to the parents that there should be no urine in the bottle. Reasons beyond surveyed by telephone. parental control, chiefly fungal overgrowth on the dipspoon, were respon¬ Results sible for 11 (23%) of the 47 specimens A total of 1825 children aged 4 to being unsatisfactory. 5 years attended the voluntary clinic Of the 1705 parents who took a dip¬ and 1725 (95%) of the parents agreed spoon home for testing, 352 (21%) did to have their children's urine tested. not return the inoculated dipspoon Eventually 1591 (87%) of the regis- within 6 weeks. When we telephoned, trants had their urine tested, which we were given various reasons for nonrepresents 92% of children whose par¬ return of the test material (Table IV). ents had agreed to participate in the Of the 205 randomly distributed urine-testing program (Table I). questionnaires 135 (66%) were re¬ Initial urine cultures were positive turned within 3 weeks; the responses
First test at school First test at home
1226 365
37* (3.0) 24* (6.6)
11 (0.90) 25 (2.0) 3 (0.82) 20 (5.5) Total 1591 61 (3.8) 14 (0.88) 45 (2.8) *ln each group one child had left the district and could not be tested by the public health nurse.
Table lll.Return of dipspoons distributed to parents
*No agar in spoon (2) and no dipspoon in canister (1). flncluding 1 containing feces. JTwenty additional parents agreed to participate in the urine-testing program but were not given dipspoons because supplies had run out.
JOURNAL/FEBRUARY 21, 1976/VOL 114
indicated that most parents favoured screening tests in the school (Table V). At the completion of the program, dipspoons had been received from the parents of 365 (73%) of the 499 children not tested at school and 988 (81%) of the 1226 who had been tested at school. Discussion One problem with any mass screening program is gaining access to an entire population. The parents at registration were able to ask questions about the urine test, see it performed and give immediate consent to testing, a method more successful than sending information and consent forms home. This probably accounts for the unusually high degree of participation. The 5.5% of parents who did not wish to participate gave such reasons as recent testing by their physician for possible urinary problems and current care for a urinary abnormality. The large number of children able to produce a urine sample on request (71% of the children whose parents agreed to participate) was encouraging. Physicians often cite the difficulty of obtaining a sample from young children as their reason for excluding urine testing from routine physical examination; in our study the 1-hour stay at the screening clinic appeared to provide a favourable opportunity for obtaining a sample. Although early school registration is not mandatory, the parents of 1825 children (83% of the 2189 registered by September 1974) attended the registration session, indicating much interest in the screening programs. It might be argued that the people who failed to register their children early Table IV-Response by 101 parents to queries about nonreturn of dipspoons Reason Forgot 40 Said to have been sent 19 Procrastinated 15 Not sent because of mail strike* 6 Other 20 *This 4-day country-wide strike started 10 days after completion of the screening program, and the public was asked not to use the mails until the backlog had been cleared. Table V-Responses of 135 parents to questionnaire Question Yes Should school clinics screen vision? 130 (96%) hearing? 130 (96%) development? 129 (96%) urine? 116 (86%) Was the school screening session "advantageous? 128 (95%)
are the people who are outside the health-care delivery system and, therefore, are those to whom we should address our efforts. However, subsequent screening of these children for vision, hearing and development (but not urinary abnormalities) revealed a prevalence of potential defects similar to that in the children who were registered early. Thus, it seems that the children who were not registered early were at no greater health risk, and it is unlikely that urine testing, had it been offered, would have given different results. We had anticipated difficulty in instructing parents in how to obtain and process a urine sample for bacterial culture. At the clinic, however, despite occasional language problems the parents appeared to learn the procedure quickly, and the written instructions taken home reinforced the teaching at the clinic. Only 3.5% of samples sent by parents were unsatisfactory, and in only 2.7% was this the fault of the parents. One might have thought that parents whose children had not been tested at school would be more anxious to submit a specimen from home, but the opposite was true. Perhaps parents who saw the testing procedure carried out on their children's urine were more confident about sampling at home and so were more likely to perform the test. Our study showed that parents can do the testing if carefully instructed; further, this use of parents as testers resulted in the inclusion of an additional 365 children and the detection of three more possible cases of UTI. A visit to the home by the public health nurse to obtain a second specimen is not recommended. The nurse found it necessary to telephone before visiting so that the parent could give the child a drink and distract him from urinating until the nurse arrived. It seems preferable for the nurse to discuss the first positive result over the telephone or by mail and provide a canister so that the parents can send another specimen. The latter method yields a slightly higher proportion of false-positive results but is much less
expensive. We are indebted to Dr. R.F. Manning, Mrs. C. Barber and Mrs. C. Hogg for help with this study, which was supported by the Kidney Foundation of Canada and the Public Health Laboratories, Ontario Ministry of Health.
LtT slows thegut fast COMPOSITION: Each tablet and each 5 ml of liquid contain 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulfate. INDICATIONS: Acute and chronic diarrhea; whether functional, or aaaociated with conditiona such aa gaatroenteritis, irritable bowel ayndrome, regional enteritia, ulcerative colitia, infectioua diarrhea and diarrhea following drug therapy. Also may provide effective intestinal control in patients following gastric surgery, ileoatomy or colostomy. CONTRAINDICATIONS: Jaundiced patienta or patients hyperaenaitive to the components of Lomotil. WARNINGS: Keep out of reach of children aince accidental overdoae may cauae aevere respiratory depression. The uae of LOMOTIL in children less than two yeara of age ia not generally recommended. PRECAUTIONS: Uae with extreme caution in tients with cirrhoaia, advanced hepatic diaeaae, paor abnormal liver function teata. Diphenoxylate HCL may potentiate the action of barbituratea, tranquilizers, and alcohol. Concurrent use of LOMOTIL with MAO inhibitors may in theory precipitate tensive criais. Asseas riska/benefits prior to usehyperduring pregnancy, lactation or in women of childbearing age. Diphenoxylate HCL and atropine sulfate are excreted in breast milk. Adminiater with caution to patienta who are receiving addicting druga or who areaddiction proneAddiction to diphenoxylate HCL ia theoretically possible at high doaage; no addicting liability haa been noted in however, patienta. Recommended doaage ahould not be exceeded. There should be atrict obaervance of the contraindications and precautiona relative to the uae of atropine. In children, aigna of atropiniam may occur even with recommended doaes, ADVERSE REACTIONS: Are relatively uncommon; moat frequently, nauaea; less frequently, drowsineaa, dizziness, vomiting, pruritua, akin eruption, restlesaness, insomnia, bloating and cramps have been reported; and rare incidences of numbness of the extremities, headache, blurring of vision, swelling of gums, euphoria, depression and general malaise have occurred. Many of these might be symptoms of disease being treated; accurate differentiation is often impossible. DOSAGE AND ADMINISTRATION: ADULTS: the usual initial dose is 5 mg (2 LOMOTIL tablets) 3 or 4 times daily. (20 mg/ 24 hours in divided doses is the maximum recommended dosage.) CHILDREN: an adequate pediatric daily dose of LOMOTIL (to be given in divided doses 3 or times daily) determined by the child's age is as4 follows: 2 to 5 years 6.0 mg (12.5 ml). Sto 8 years 8.0mg (15.0 ml). 8 to 12 years io.o mg (20.0 ml). NOTE: THIS IS TOTAL DAILY MEDICATION TO BE GIVEN IN 3 OR 4 DIVIDED DOSES. Wolume of LOMOTIL Liquid containing approximate total daily dosage of diphenoxylate HCL. 5 ml is equal to approximately i teaspoonful.
AVAILABILITY:
TABLETS: 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulphate in bottles of 100, 500. LIQUID: 2.5 mg diphenoxylate hydrochloride 0.025 mg atropine sulphate/S ml in 60 ml (2 and oz.)
bottles.
Product monograph available on request.
.,
.
References 1. WILSON JMG, JUNONER G: Principles and practice
for screening for disease, health paper no 34, Geneva, WHO, public 1968, p7 2. FORBES PA, DRUMMOND KN: Urine screening programs in schools. Can Med Assoc 1 109: 979, 1973
318 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114
Searle PharmaceutIcals Oakville Ontano
