Top-Down versus Bottom-Up Approach in Children Presenting with Urinary Tract Infection: Comparative Effectiveness Analysis Using RIVUR and CUTIE Data. Reply.

Abstract

surgeons are directed to a hub center for surgery, there was an absence of income level influence on quality of care metrics used in kidney cancer, including the use of nephron-sparing surgery and minimally invasive surgery, and survival outcomes. These findings may suggest a benefit of centralizing cancer care to ensure patients have access to adequate expertise. Importantly, the surgical management of kidney cancer is quite different than prostate cancer and is largely based on the experience and recommendation of the surgeon, including the decision to undergo radical vs partial nephrectomy or open vs minimally invasive surgery. While centralization may improve access to specialized services, it is important to remember that patients often incur additional costs and logistical complexities with this required travel that can be a barrier. 3 In fact, some patients may choose to have treatment closer to home even at the expense of inferior survival outcomes. 4 In the present study, we included patient residence (rural vs urban) as a surrogate for access to care and found that this was not significantly associated with treatment selection. Part of this may be due to the unique preexisting organization of prostate cancer care in our province, whereby the vast majority of patients are treated (with either surgery or radiation) in the capital city. Since treatments are naturally centralized in our jurisdiction, the referral hospital or volume of the center has a null effect. Outside of this unique position, we acknowledge that for specialized cancer care a centralized model of care delivery may work well in a universal health care system; however, we must remain sensitive to the unintended costs and sacrifices that patients are required to make to travel for such care.

Top-Down versus Bottom-Up Approach in Children Presenting with Urinary Tract Infection: Comparative Effectiveness Analysis Using RIVUR and CUTIE Data. Letter.

“…To the Editor: I read with amazement, and some anger, the article by Ryan et al regarding the realworld management of men with metastatic prostate cancer. 1 It was shocking to learn that 38%e48% of men are untreated, 45%e46% receive androgen deprivation therapy alone and only 2%e13% receive multimodal therapy. I am a long-term survivor of metastatic castration-sensitive prostate cancer (polymetastatic) who 9 years ago was treated with androgen deprivation therapy, robot-assisted laparoscopic prostatectomy, docetaxel, enzalutamide and radium-223.…”

“…To the Editor: The authors have submitted a simulated comparative effectiveness analysis using data from the National Institutes of Health-sponsored RIVUR (Randomized Intervention for Children with Vesico-Ureteral Reflux) and CUTIE (Careful Urinary Tract Infection Evaluation) studies comparing the traditional "bottom-up" vs "top-down" approaches to the evaluation of children with their first urinary tract infection (UTI). 1 Both approaches are designed to detect the most common anatomical anomaly in children with UTI, which is vesicoureteral reflux. More specifically, the top-down approach identifies patients with clinically significant dilating vesicoureteral reflux (VUR) who would most benefit from medical or surgical intervention on the basis of renal cortical defects following UTI.…”

“…Its goal is to reduce the number of children undergoing voiding cystourethrogram. 1 Several recent studies have demonstrated sensitivity of the top-down approach as high as 95% for detection of dilating VUR, albeit with lower specificity. 2e4 The top-down approach is predicated on an early dimercaptosuccinic acid (DMSA) scan within the first 2 weeks following a febrile UTI as this represents the time period of maximum sensitivity for the detection of acute pyelonephritic changes.…”

This Month in Pediatric Urology

“…Wang et al (page 1284) from Boston, Massachusetts performed a complex medical version of a Gedankenexperiment, or thought experiment. 2 Using data from the RIVUR (Randomized Intervention for Children with Vesico-Ureteral Reflux) and CUTIE (Careful Urinary Tract Infection Evaluation) trials, they created a pool of patients who had undergone VCUG and a dimercaptosuccinic acid (DMSA) renal scan. Using these patients, parameters were then generated to build 1,000 simulated data sets.…”

“Bottoms Up!”: A Toast to Reexamining the Debate of Top-Down vs Bottom-Up Approach for the Evaluation of Febrile Urinary Tract Infection

“…3,7 In this issue of The Journal (page 1284), Wang et al performed a head-to-head comparison between the traditional bottom-up vs top-down approaches. 8 Using data from the RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux)/ CUTIE (Careful Urinary Tract Infection Evaluation) trials, they simulated 1,000 virtual sets of 500 examining the overall need for VCUG, CAP and number of recurrent UTIs. A potential key point acknowledged in their discussion is that within the RIVUR/CUTIE protocol, DMSA scans were typically not performed during the acute episode (as classically prescribed), which may have decreased overall detection rates for cortical abnormalities and thus subsequent indication for VCUG and detection of dilating VUR.…”