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W Feldman

Publications and source records attributed to W Feldman.

At least 19 recordsLinked to original sources
PubMed2001

Physician and population determinants of rates of middle-ear surgery in Ontario.

CONTEXT: Small-area variations in surgical rates raise concerns about access to care, treatment appropriateness, and the quality and cost of care. OBJECTIVE: To measure small-area variations in rates of myringotomy with insertion of tympanostomy tubes (TTs) and to identify determinants of rate variation. DESIGN AND SETTING: Retrospective analyses using hospital discharge data for patients who had undergone a myringotomy with insertion of TT by county in Ontario between April 1, 1996, and March 31, 1999. Information on possible determinants was taken from a survey of otolaryngologists and primary care physicians in 1996 and from the 1996 Canadian census and physician demographic databases for 1996-1999. PARTICIPANTS: A total of 75 358 hospitalizations for TT placement of children and adolescents (aged </=14 years). MAIN OUTCOME MEASURE: Small-area variation in rates of TT. RESULTS: An almost 10-fold difference between the areas with the highest and lowest rates was found (extremal quotient, 9.6; 95% confidence interval [CI], 8.2-11.1; P<.001). Higher rates occurred in counties with higher percentages of high school graduates (parameter estimate, 0.01; 95% CI, 0-0.02; P =.049); and where referring physicians were more likely to be male (parameter estimate, 0.01; 95% CI, 0-0.02; P =.01), North American-trained (parameter estimate, 0.01; 95% CI, 0.01-0.02; P<.001), and have higher propensities to refer for surgery (parameter estimate, 0.40; 95% CI, 0.09-0.72; P =.02). Otolaryngologist opinion was not a significant predictor. CONCLUSION: Substantial area variation in TT rates was observed. The opinion of primary care physicians was the dominant modifiable determinant, suggesting an area of research that may be important in reducing area variation in TT procedures.

Adolescent↗
PubMed2001

The role of adjuvant adenoidectomy and tonsillectomy in the outcome of the insertion of tympanostomy tubes.

BACKGROUND: Otitis media is the most common medical problem in young children. The usual surgical treatment is myringotomy with insertion of tympanostomy tubes. There is debate about the usefulness of concomitant adenoidectomy or adenotonsillectomy. We examined the effects of these adjuvant procedures on the rates of reinsertion of tympanostomy tubes and rehospitalization for conditions related to otitis media. METHODS: Using hospital discharge records for the period 1995 through 1997, we examined the results of surgery for all 37,316 children (defined as persons 19 years of age or younger) in Ontario, Canada, who received tympanostomy tubes as their first surgical treatment for otitis media. We determined the time to the first readmission for conditions related to otitis media and the time to the first reinsertion of tympanostomy tubes. RESULTS: As compared with treatment involving the insertion of tympanostomy tubes alone, adjuvant adenoidectomy was associated with a reduction in the likelihood of reinsertion of tympanostomy tubes (relative risk, 0.5; 95 percent confidence interval, 0.5 to 0.6; P<0.001) and the likelihood of readmission for conditions related to otitis media (relative risk, 0.5; 95 percent confidence interval, 0.5 to 0.6; P<0.001). The risk of these outcomes was further reduced if an adjuvant adenotonsillectomy was performed. The effect was age-related. Children as young as one year appeared to benefit from adjuvant adenotonsillectomy; the benefit of an adjuvant adenoidectomy was apparent in two-year-olds and was greatest for children three years of age or older. CONCLUSIONS: Performing an adenoidectomy at the time of the initial insertion of tympanostomy tubes substantially reduces the likelihood of additional hospitalizations and operations related to otitis media among children two years of age or older.

Adenoidectomy↗
PubMed2000

Otolaryngologists' perceptions of the indications for tympanostomy tube insertion in children.

BACKGROUND: Bilateral myringotomy with insertion of tympanostomy tubes is the most common operation that children in Canada undergo. Area variations in surgical rates for this procedure have raised questions about indications used to decide about surgery. The objective of this study was to describe the factors that influence otolaryngologists to recommend tympanostomy tube insertion in children with otitis media and their level of agreement about indications for surgery. METHODS: A survey was sent to all 227 otolaryngologists in Ontario in the fall of 1996. The influence of 17 clinical and social factors on recommendations to insert tympanostomy tubes were assessed. Case vignettes were used to determine the effect of multiple factors in decisions about the need for surgical management. RESULTS: Surveys were returned by 138 (68.3%) of the 202 eligible otolaryngologists. There was agreement (more than 90% of respondents) about 6 indications for surgery: persistent effusion, a lack of improvement after 3 months of antibiotic therapy, a history of persistent effusion for 3 or more months per episode of otitis media, more than 7 episodes of otitis media in 6 months, a bilateral conductive hearing loss of 20 dB or more and a persistently abnormal tympanic membrane. Some respondents were more likely to recommend tube insertion if there were parental concerns about hearing problems or the frequency or severity of episodes of otitis media. Otolaryngologists agreed about the role of tympanostomy tubes in 1 of 4 case vignettes but disagreed about whether adenoidectomy should also be performed in that instance. Most viewed tympanostomy tube insertion as beneficial, with few adverse effects. INTERPRETATION: There is a lack of consensus among practising otolaryngologists in Ontario as to which children with recurrent otitis media or persistent effusion should undergo bilateral myringotomy with tympanostomy tube insertion. These findings suggest the need to revisit clinical guidelines for this procedure.

Attitude of Health Personnel↗
PubMed2000

Referral of children with otitis media. Do family physicians and pediatricians agree?

OBJECTIVE: To determine factors influencing family physicians' and pediatricians' decisions to refer children with recurrent acute otitis media (RAOM) and otitis media with effusion (OME) to otolaryngologists for an opinion about tympanostomy tube insertion. DESIGN: Mailed survey. SETTING: Physicians' practices in Ontario. PARTICIPANTS: Random sample of 1459 family physicians and all 775 pediatricians in the province. MAIN OUTCOME MEASURES: Physicians' reports of the influence of 17 factors on decisions to refer (more likely, no influence, less likely to refer) and number of episodes of otitis media, months with effusion, level of hearing loss, or months of continuous antibiotics without improvement prompting referral. RESULTS: Physicians agreed (> 80% concordance) on six out of 17 factors as indications for referring children with RAOM or OME. Opinions about the importance of other factors varied widely. Family physicians would refer children with otitis media after fewer episodes of illness, fewer months of effusion, lower levels of hearing loss, and fewer months of prophylactic antibiotic therapy than pediatricians (all P < .001). Pediatricians would prescribe continuous antibiotics longer (11.8 weeks) than family physicians (8.9 weeks, P < .0001), which correlated with lower referral thresholds for family physicians. CONCLUSION: Family physicians' and pediatricians' self-reported referral practices for surgical opinions on children with otitis media varied considerably. These observations raise questions about the consistency of care for children with otitis media and whether revised clinical guidelines would be helpful.

Acute Disease↗
PubMed1999

Accuracy of clinical assessment of heart murmurs by office based (general practice) paediatricians.

AIM: To determine the diagnostic accuracy of physical examination by office based (general practice) paediatricians in the evaluation of heart murmurs. DESIGN: Each of 30 office based paediatricians blindly examined a random sample of children with murmurs (43% of which were pathological). Sensitivity and specificity were calculated and were related to paediatricians' characteristics. RESULTS: Mean (SD) sensitivity was 82 (24)% with a mean specificity of 72 (24)% in differentiating pathological from innocent murmurs, with further investigations requested for 54% of assessments. The addition of a referral strategy would have increased mean sensitivity to 87 (20)% and specificity to 98 (8)%. Diagnostic accuracy was not significantly related to the paediatricians' age, education or practice characteristics, but was related to referral practices and confidence in assessment. CONCLUSIONS: Diagnostic accuracy of clinical assessment of heart murmurs by office based paediatricians is suboptimal, and educational strategies are needed to improve accuracy and reduce unnecessary referrals and misdiagnosis.

Adolescent↗
PubMed1999

Genes for sale.

Explore the source record for details and available documents.

DNA↗
PubMed1998

Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection.

BACKGROUND: A decrease in risk of urinary-tract infection is one of the most commonly given reasons for circumcision of newborn boys. Previous studies have reported rates of UTI to be 10-20 times higher in uncircumcised than in circumcised boys. This population-based cohort study followed neonates in Ontario, Canada, prospectively to study the relation between circumcision and subsequent UTI risk. METHODS: Eligible boys were born to residents of Ontario between April 1, 1993, and March 31, 1994. We used hospital discharge data to follow up boys until March 31, 1996. FINDINGS: Of 69,100 eligible boys, 30,105 (43.6%) were circumcised and 38,995 (56.4%) uncircumcised. 888 boys circumcised after the first month of life were excluded. 29,217 uncircumcised boys were matched to the remaining circumcised boys by date of birth. The 1-year probabilities of hospital admission for UTI were 1.88 per 1000 person-years of observation (83 cases up to end of follow-up) in the circumcised cohort and 7.02 per 1000 person-years (247 cases up to end of follow-up) in the uncircumcised cohort (p<0.0001). The estimated relative risk of admission for UTI by first-year follow-up indicated a significantly higher risk for uncircumcised boys than for circumcised boys (3.7 [2.8-4.9]). 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life. INTERPRETATION: Although our findings support the notion that circumcision may protect boys from UTI, the magnitude of this effect may be less than previously estimated.

Circumcision, Male↗
PubMed1998

Is bone marrow aspiration needed in acute childhood idiopathic thrombocytopenic purpura to rule out leukemia?

OBJECTIVE: To assess the prevalence of leukemia in a series of bone marrow aspiration (BMA) samples collected to confirm provisional diagnoses of acute idiopathic thrombocytopenic purpura (ITP) in children. DESIGN: A retrospective cohort. SETTING: All BMA reports at The Hospital for Sick Children, Toronto, Ontario (a tertiary care pediatric hospital), from January 1, 1984, to May 31, 1996, were reviewed. PATIENTS: Included were BMAs performed to confirm provisional diagnoses of ITP in children (6 months to 18 years of age) with "typical" contemporaneous hematologic features of ITP (platelet count, < or =50 x 10(9)/L; hemoglobin level, > or =100 g/L [6-12 months of age] or > or =110 g/L [> 1 year of age]; white blood cell count, > or =5 x 10(9)/L [6 months to 6 years of age] or > or =4 x 10(9)/L [> 6 years of age]; and neutrophil count, > or =1.5 x 10(9)/L [6 months to 6 years of age] or > or =2 x 10(9)/L [> 6 years of age]). Children with chronic ITP, thrombocytopenia-related chronic conditions, or leukemic blasts on peripheral smears were excluded. MAIN OUTCOME MEASURE: The finding of leukemia in the BMA report was chosen a priori as the primary outcome for the yield of BMA. RESULTS: Four hundred eighty-four BMAs were performed to confirm provisional diagnoses of acute childhood ITP. No diagnoses of leukemia were revealed in the 332 children with typical hematologic features of ITP. The risk of missing the diagnosis of leukemia in this setting is less than 1%. CONCLUSIONS: The yield of BMA for leukemia in this setting is low. Routine BMA is not necessary for children with typical acute ITP.

Adolescent↗
PubMed1997

A randomized controlled trial of penicillin vs clindamycin for the treatment of aspiration pneumonia in children.

OBJECTIVE: To compare the effectiveness of intravenous penicillin vs clindamycin for the treatment of aspiration pneumonia. DESIGN: A double-blind, randomized controlled trial. SETTING: A tertiary care pediatric hospital. PATIENTS: We enrolled 42 children, aged 6 months to 18 years, who were admitted to the hospital for the treatment of aspiration pneumonia. All of the children had underlying conditions that predispose to aspiration. INTERVENTION: The patients were randomly assigned to receive intravenous penicillin G sodium, 250,000 U/kg every 24 hours, or intravenous clindamycin phosphate, 30 mg/kg every 24 hours. MAIN OUTCOME MEASURE: The primary outcome measure was "time to ready for discharge" from the hospital. RESULTS: In an effectiveness (intention to treat) analysis, the median time (interquartile range) to ready for discharge from the hospital was 4.9 days (range, 2.8-6.5 days) in the penicillin-treated group and 3.4 days (range, 2.3-6.8 days) in the clindamycin-treated group (P = .66). Results were not markedly altered when adjusted for the age difference of the groups or in the efficacy analysis (after the exclusion of 9 patients who withdrew from the trial). Rates for readmission to the hospital were similar in the 2 groups. CONCLUSION: Penicillin and clindamycin seem to be equally effective for the treatment of aspiration pneumonia in children hospitalized for this illness.

Adolescent↗
PubMed1997

Effectiveness of prophylactic inhaled steroids in childhood asthma: a systemic review of the literature.

BACKGROUND: There has been no systematic appraisal of the evidence regarding the effectiveness of prophylactic inhaled steroids in childhood asthma. OBJECTIVE: We sought to evaluate the effectiveness of prophylactic inhaled steroids in childhood asthma. METHODS: A MEDLINE search from January 1966 through December 1996 was used to identify pertinent English-language publications. All randomized, double-blind, placebo-controlled trials of prophylactic inhaled steroid therapy for childhood asthma that included data on clinical outcomes (symptom scores and concomitant drug use) or laboratory outcomes (peak expiratory flow rate) were included. RESULTS: In total, 24 of 93 studies retrieved met the inclusion criteria. The overall weighted relative improvement in mean total symptom score (inhaled steroid vs placebo) was 50% (95% confidence interval [CI]: 49%, 51%), the overall weighted relative decrease in mean concomitant beta2-agonist use (inhaled steroid vs placebo) was 37% (95% CI: 36%, 38%), and the overall weighted relative decrease in mean concomitant oral steroid use (inhaled steroid vs placebo) was 68% (95% CI: 66%, 70%). The overall weighted absolute improvement in mean peak expiratory flow rate (inhaled steroid vs placebo) was 38 L/min (95% CI: 34.3 L/min, 41.7 L/min). CONCLUSIONS: Prophylactic inhaled steroids are effective, compared with placebo, in improving both clinical and laboratory outcomes in childhood asthma.

Child↗
PubMed1997

Fetal medicine.

Fetal medicine is the practice of medicine where the patient is the fetus. The traditional activities of clinical medicine: prevention, screening, diagnosis, and therapy are directed at decreasing, identifying and treating fetal disease. Examples of successful preventative, screening, diagnostic and therapeutic maneuvers involving the fetus are presented. A plea is made for the systematic evaluation of the new technology being developed in fetal medicine. The same standard of evidence-the randomized, controlled clinical trial-which is more and more applied to traditional medical practice-should also be the gold standard for fetal medicine.

Female↗
PubMed1997

Where do children go? Comparing the after-hours availability of family physicians and primary care pediatricians in four Canadian cities.

OBJECTIVE: To describe and compare family physicians' and pediatricians' after-hours availability for pediatric care in four Canadian cities. DESIGN: Cross-sectional telephone survey. SETTING: Winnipeg, Toronto, Ottawa, and Montreal pediatric and family practices. PARTICIPANTS: All primary care pediatricians and an equal number of family physicians randomly selected from the membership list of the College of Family Physicians of Canada were matched by postal code. Sixty-four (10%) of 282 family physicians and 296 primary care pediatricians were excluded, most because no office telephone number was found. MAIN OUTCOME MEASURES: "After hours" was defined as between 1800 and 0700 hours on weekdays and 0900 to 2400 hours on weekend days. Outcomes included demographics, year of graduation, day of call, time of call, and availability of physician. RESULTS: Availability varied markedly by city rather than by physicians were available after hours: 92.4% in Winnipeg, 56.0% in Toronto, 65.5% in Ottawa, and 26.9% in Montreal. Winnipeg, Toronto, and Montreal showed no significant differences between specialties in availability. Only Ottawa pediatricians were significantly more available than family physicians when age was taken into account (adjusted relative risk = 2.17, 95% confidence interval = 1.51 to 3.12). Stratified analysis showed no differences by day of call, time of call, or physicians' sex. Physicians graduating before 1975 in both groups tended to be more available in all cities than younger physicians. CONCLUSIONS: Regional differences appear to influence after-hours availability more than specialty. Older physicians from both groups were more available than younger physicians.

Child↗
PubMed1996

Variability in physicians' reported ordering and perceived reassurance value of diagnostic tests in children with 'growing pains'.

OBJECTIVES: To determine the variability in the reported ordering of tests and treatment and to determine physicians' perceptions of the reassurance value to families of diagnostic tests in children with "growing pains." DESIGN: Cross-sectional survey using a mailed questionnaire. SETTINGS: Primary care and referral practices in Toronto, Ontario. PARTICIPANTS: University-affiliated primary care pediatricians and family physicians were surveyed, as well as all pediatric orthopedic surgeons and pediatric rheumatologists in Ontario. Pediatric orthopedic surgeons and pediatric rheumatologists were combined into a single group. MAIN OUTCOME MEASURES: Frequency of office visits because of growing pains, frequency of diagnostic testing, management strategies for these children, and physicians' perceptions of the reassurance value of diagnostic tests. RESULTS: Of 205 eligible physicians, 181 (88.3%) responded. The median reported frequency of office visits because of growing pains was 1%. Compared with the other physician groups, family physicians were significantly more likely to order a determination of the hemoglobin level (P = .003), erythrocyte sedimentation rate (P = .01), white blood cell count (P = .01), and differential blood cell count (P = .003), but not imaging tests. Family physicians were also more likely to order diagnostic tests when they were under parental pressure to do so (P = .001) or for the child with repeated visits (P = .02). In total, 86% of pediatric orthopedic surgeons and pediatric rheumatologists, 95% of pediatricians, and 100% of family physicians perceived normal test results to be reassuring to parents. Treatment strategies were similar across the 3 physician groups. CONCLUSIONS: The frequency of diagnostic testing varied among physician groups. Virtually all physicians perceived normal test results to be reassuring to families.

Adult↗
PubMed1996

Routine diagnostic imaging for childhood urinary tract infections: a systematic overview.

OBJECTIVE: To assess the quality of the evidence on which current recommendations for routine diagnostic imaging for childhood urinary tract infection are based. METHODS: A systematic overview of the literature using the MEDLINE database (1966 to October 1994), article bibliographies, and a manual search of current publications using Current Contents, was undertaken. Preset criteria were used to categorize study sample and design, and interrater reliability was assessed with a random sample. RESULTS: A total of 434 publications were evaluated, and 63 studies met the criteria for inclusion. There was 100% interrater agreement on inclusion eligibility and design classification. No controlled trials or analytic studies evaluating routine diagnostic imaging were found. All 63 studies were descriptive, and only 10 were prospective. None of the studies provided evidence of the impact of routine imaging on the development of renal scars and clinical outcomes in children with their first urinary tract infection. CONCLUSION: Methodologically sound, prospective studies are needed to assess whether children with their first urinary tract infection who have routine diagnostic imaging are better off than children who have imaging for specific indications. We conclude that the current recommendations are not based on firm evidence.

Adolescent↗