Publication Of New Guidelines Research Articles

The ongoing impact of obesity on childhood hypertension.

Obesity rates among children have been steadily rising over the past several decades. This epidemic has been accompanied by an increase in the prevalence of childhood hypertension, with children in low- and middle-income countries being affected to the same extent as children in high-income countries. This review will examine the trends in childhood blood pressure and the relationship between excess body weight and the development of hypertension. In addition, distinct mechanisms of obesity-related hypertension will be discussed. There will be an emphasis on recent studies conducted since the publication of new guidelines by the American Academy of Pediatrics in 2017 which resulted in the adoption of lower normative blood pressure cutoffs. The overall intent of this review is to provide the reader with an understanding of the ongoing impact, and complexities, of obesity-related hypertension.

Comportment Management in the Hospital: Where Is Patient’s Health Care Station?

This article analyzes the factors that explain the increased use of special reports by hospital facility auditors, such as the structured interview, wondering if they look like evaluation studies. It examines their training, impact, and the institutional use implicit in the performance audit. From an anthropological perspective, the audit could traditionally be considered as “Rituals of Verification,” recognizing the procedure and the evaluation of social effects, in public management. Therefore, sampling represents an effective and efficient tool for carrying out the statutory audit activity in the health care facilities where the coronavirus disease (COVID-19) virus is treated. However, the performance established a regulatory dimension compared to the concept of verification. In addition, auditing practices may often seem “trivial, inevitable part of a bureaucratic process,” but taken together and over time, they are probably part of a distinct cultural artifact. As we have seen, the reasons that justify the activation of a clinical audit can be numerous: patient complaints, occurrence of adverse events such as the case of COVID-19, performance with inadequate results, publication of new guidelines; however, the “bet” is that in the future the awareness that auditing is an irreplaceable part of professional practice will mature among professionals.

Selección de lo mejor del año 2020 sobre el tratamiento antitrombótico para el cardiólogo clínico

In recent months, therapeutic novelties have appeared in the area of antithrombotic treatment with important repercussions for our activity. In the field of anticoagulation of atrial fibrillation, the publication of new guidelines that continue prioritizing the use of direct-acting anticoagulants collide with our clinical practice possibilities, due to the limitations imposed by the approval of these drugs. Regarding chronic coronary syndromes, double antithrombotic treatment will become a preferential option for a high percentage of patients; hence it will be very useful to be able to identify them. In patients with peripheral arterial disease, double antithrombotic treatment will also play a very important role. In heart failure, the results are conflicting and the new studies will help us to choose the best candidate. Percutaneous aortic prostheses is an area in continuous growth, but antithrombotic treatment in these patients has not been clarified and important developments have emerged in recent months. Finally, anticoagulation in cancer patients continues to be a challenge in our clinical practice.

Surgical cancellation rates due to peri‐operative hypertension: implementation of multidisciplinary guidelines across primary and secondary care

Patients with uncontrolled hypertension are at increased risk of complications during general anaesthesia but the number of patients whose surgery is delayed or cancelled due to hypertension remains unknown. Prospective, regional multicentre service evaluations were performed on consecutive patients undergoing elective surgery before and after the publication of new guidelines from the Association of Anaesthetists and the British Hypertensive Society. The aim was to quantify the number of operations cancelled due to hypertension alone and to assess impact of the guidelines on cancellation rates. In October 2013 (before the publication of the guidelines), 1.37% (95%CI 0.69-2.11%) of patients listed for elective surgery were cancelled solely due to raised blood pressure. This reduced significantly to 0.54% (95%CI 0.20-0.92%, p<0.001) in 2018. There was a significant reduction in inappropriate cancellations for stage 1 or 2 hypertension from 2013 to 2018 (72 vs. 14, respectively, p<0.001) in keeping with the recommendations in the guidelines. Furthermore, the number of patients being referred back to primary care for the management of hypertension reduced from 2013 to 2018 (85 vs. 30, respectively, p<0.001). Our data suggest achievement of three major outcomes: reduced surgical cancellations due to hypertension alone; improved detection of significant hypertension before elective surgery; and reduced referral back to primary care from hospital for hypertension management. To the best of our knowledge, this is the first time the successful implementation of guidelines from the Association of Anaesthetists has been assessed on such a broad scale. Our data indicate that these guidelines have been effectively implemented in both primary and secondary care, which is likely to have made a positive psychosocial, physical and economic impact on patients and the NHS.

Otitis media: what is new?

To review the latest literature on otitis media diagnosis, guidelines, treatment, and pathophysiology. Although otitis media remains one of the most common reasons for outpatient visits, antibiotic prescriptions, and surgery in the United States, little progress has been made in terms of developing novel treatments for the prevention and resolution of this condition, indicating the urgent need to continue investigations into the pathophysiology of this disorder. The recent past has seen the publication of new guidelines for the management of both acute otitis media, chronic otitis media and tympanostomy tube placement. Exciting technologies are being investigated into novel means to improve the diagnosis of otitis media, reviewed herein. Advancements in mucosal immunology and genetics have offered clues as to the underlying pathophysiology influencing otitis media propensity. Future research into modifying these pathophysiologic underpinnings, potentially through the usage of transtympanic drug delivery systems, should greatly influence the management of this condition. Research into novel methods for otitis media pathophysiology, diagnosis and treatment has seen great strides in the recent past. Avenues towards markedly altering the evaluation and management of the condition are likely to be adopted into clinical practice over the coming years.

The most recent recommendations for the surgical treatment of inguinal hernia

The publication of new guidelines in recent years shows that surgical treatment of inguinal hernia remains topical. The main goal is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain. The main purpose of this article is to summarize the latest recommendations in surgical treatment of the groin hernias, especially in the case of strangulation. The authors made literature review of all the guidelines published by the hernia societies, including related articles, in the last ten years. The use of the EHS classification system is suggested. In elective operations, mesh repair is recommended. The Lichtenstein technique is the standard in open inguinal hernia repair. Transabdominal preperitoneal and totally extraperitoneal approach have comparable outcomes. Their clear advantages include minimal invasiveness. Mesh repair is recommended also in the case of strangulation, but only in clean and clean-contami-nated operations. Alaparoscopic approach should be considered as well. Inter alia, it allows an assessment of bowel viability during the whole procedure. The need of bowel resection is hence lower compared to open surgery. If it is not possible to use the mesh, the Shouldice method is regarded as the best non-mesh repair technique. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is recommended. Hernioscopy is asimple and safe procedure that uses the hernia sac for insertion of aport following insufflation and diagnostic examination. It requires less advanced laparoscopic skills than does emergency laparoscopic hernia repair. It can be performed even by surgeons who lack sufficient experience with laparoscopy. In elective procedures, the mesh repair is recommended. It is recommended also in the case of strangulation, but not in acontaminated-dirty surgical field. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is needed.

Deactivation of implantable defibrillators at end of life — Can we do better?

IntroductionDying patients with implantable defibrillators (ICD) have a risk of receiving unnecessary shocks before death. The aim of this study was to investigate if deactivation of shock therapy at end-of-life has increased since publication of new guidelines in 2010 on ICD management. Method and resultsThis is a study of two groups of ICD patients who died in hospitals before and after publication of new guidelines. Group 1 consists of 89 patients who died between 2003 and 2010. Group 2 consists of 252 patients, the total number of ICD patients in Sweden who died in hospital during 2014. Data was obtained from the Swedish ICD and Pacemaker Registry, Swedish Tax Agency and patient medical notes. Two-thirds died in wards other than Cardiology. Fifty-four percent in group 1 had a Do-Not-Resuscitate-order (DNR) compared to 73% in group 2. Shock deactivation was present in 52% in group 1 and 67% in group 2. The difference in shock deactivation between group 1 and 2 was only significant (p = 0.014) for DNR-patients treated in Cardiology. A significant difference (p = 0.036) was found in deactivation within group 2 between DNR-patients in Cardiology vs. DNR-patients in Non-Cardiology wards. ConclusionTwo-thirds of ICD patients die in wards other than Cardiology. Since publication of guidelines on ICD management there is a general increase in shock deactivation for DNR-patients, but only significant for patients in Cardiology. This implicate that actions have to be taken for patients treated in Non-Cardiology wards to bridge the gap between guidelines recommendations and clinical practice.

National survey of imaging practice for suspected or confirmed plasma cell malignancies.

Objective:Cross-sectional imaging is now recommended by the National Institute for Health and Care Excellence (NICE) for patients with suspected and newly diagnosed myeloma instead of skeletal survey. The objectives of this study were: (1) To evaluate compliance of current UK imaging practice with reference to National Institute for Health and Care Excellence best-practice clinical guidelines for plasma cell malignancies. (2) To identify factors which may influence diagnostic imaging choices.Methods:We conducted a national online survey to assess compliance with guidelines and to identify challenges to implementation (endorsed by Myeloma UK, UK Myeloma Forum and the British Society of Skeletal Radiologists).Results:Responses were received from 31 district general and 28 teaching hospitals. For suspected and confirmed myeloma, skeletal survey remained the most frequent first-line imaging test (suspected myeloma 44.3%, confirmed myeloma 37.7%). Only 9.8 % of responders offered first-line whole body MRI.Conclusion:Significant challenges remain to standardisation of imaging practice in accordance with national best-practice guidelines.Advances in knowledge:This is the first publication to date evaluating current UK imaging practice for assessing myeloma since the publication of new guidelines recommending use of advanced cross-sectional imaging techniques. Skeletal survey remains the most commonly performed first-line imaging test in patients with suspected or confirmed myeloma and this is largely due to resource limitations within radiology departments.

Cardiac Imaging 2015: A Selection of Topical Issues

This year, developments in cardiac imaging were marked by the publication of new guidelines. The recommendations on cardiac chamber quantification and the consensuses on the assessment of patients with hypertension and patients with cancer reinforced the value of deformation parameters. There were also developments in the role of imaging in endocarditis guidelines, in the assessment of the critically ill patient, and in the recommendations on transesophageal echocardiography and diagnosis of aortic disease. Three-dimensional echocardiography was deemed a key technique in the anatomical and functional quantification of the different cardiac structures. Computed tomography extended its scope from the diagnosis of coronary artery disease to structural intervention. Stress cardiac magnetic resonance imaging was established as an excellent technique for the diagnosis of ischemia. In the field of nuclear medicine, the use of hybrid imaging emerged as an alternative to conventional techniques for the diagnosis of coronary disease and prosthetic valve endocarditis or endocarditis affecting cardiac implantable devices.

High resolution seismic undershooting of platforms – stretching the limits

Undershooting, a technique for acquisition of seismic data beneath areas that are difficult to access at the surface of the Earth, has long been practised in the field of 3D seismic exploration. The publication of new guidelines by the OGP for the Conduct of Offshore Drilling Hazard Site Surveys specifies that seismic data greater than ten years old are no longer valid for this application. Hence, there is a need to be able to use the undershoot technique in the evaluation of shallow sub-sea hazards beneath existing structures such as Production Platforms if new wells are planned to be drilled from these structures. This paper outlines the approach taken using two multi-role site survey vessels to acquire a high-resolution undershoot dataset, with the emphasis being to ensure that this was suitable for shallow geohazard evaluation. We describe the techniques and equipment, including specifically designed in-house navigation software routines, the trials undertaken, and the successful acquisition of a useable dataset. Examples are provided that demonstrate the high quality of the seismic dataset acquired. It was only possible to achieve this using a 3D approach for the binning and processing of the seismic data.

Cervical Cancer Screening Rates in a Chart Review of Adolescent Patients at an Academic Institution before and after the Publication of the 2009 American College of Obstetricians and Gynecologists' Recommendations

ObjectiveEvaluation of compliance with ACOG guidelines against screening for cervical cancer in women before age 21; identification of factors associated with lack of compliance with guidelines. MethodsA review of 799 charts of women age 14-21 seen for care at our institution in 2009-2010 to determine baseline cervical cytology rates, compliance with publication of 2009 ACOG guidelines recommending against testing in this age group. Clinical data was gathered to identify patient and physician characteristics associated with testing. ResultsThe baseline rate of cervical cytology testing for women age 14-21 in our chart review (20%, 2009) dropped significantly (10.8%, 2010, P < .005) after publication of new guidelines. Among those patients tested, factors associated with higher screening rates included: patients seen by obstetrician/gynecologist (59% patients tested 2009/38% 2010), who were sexually active (83%/88%) and seen for routine care (68%/95%). Other associated factors: prior screening (61% all patients tested), hormonal contraceptives (58%), private insurance (72%). Patients with history of previous cervical intraepithelial neoplasia had cytology testing done at high rates (72%). ConclusionThe rate of cervical cytology screening in women ages 14-21 was higher than expected given ACOG recommendations. There was a significant decrease in screening rates after publication of guidelines. Patient and physician characteristics were identified which were associated with an increased screening rate. There are no databases that track cervical cancer testing in this age group. This information can be utilized for physician and patient education in order to improve compliance.

Acute Coronary Syndromes. New Diagnostic Strategies and Treatment

Within its continuing education program, Revista Espanola de Cardiologia launches a new series of Update articles. In recent years, these series have dealt with a range of topics in cardiology. Now, we believe the time has come to update our knowledge of acute coronary syndromes (ACS). Recent changes in the field have led to the publication of new guidelines on both acute ST-segment elevation myocardial infarction and non–ST-segment elevation ACS. The present Update deals with those issues that have changed most, or aroused most controversy, in ACS. In the first article, we review the epidemiological data that are currently most relevant and sketch a view of the future. In the diagnosis and prognosis of ACS, various biomarkers have been studied but none—except troponin—has been introduced into clinical practice. In another article, we will analyze the value of the different troponin biomarkers, along with their potential future applications. The invasive strategy in non–ST-segment elevation ACS will be discussed in another paper, at a time when an invasive strategy with possible drawbacks in some subgroups of patients—particularly those with lower levels of risk—is systematically used. In Spain, regional primary angioplasty programs are being implemented but run into difficulties when faced with the problems of performing reperfusion within an adequate time window. In this context, we will study how to improve these programs and the potential role of fibrinolysis as a reperfusion strategy in acute myocardial infarction. Subsequently, we will look at the clinical reality of damage from reperfusion—much in evidence in experimental models but less so in clinical scenarios—and possible means of protecting the myocardium. New antithrombotic drugs have been introduced in the treatment of ACS. These drugs are more effective, but they are also more expensive and entail a greater bleeding risk. How to use these drugs safely and their cost-efficiency will be analyzed in another article. Clinical practice guidelines generally report recommendations derived from major randomized trials. However, in the ‘‘real world’’, we treat patients who would be excluded from these trials and yet we apply guideline recommendations to them. We will devote one article to ACS treatment in these ‘‘special’’ patients represented by populations of advanced age and/or with comorbidities. There have been significant developments in imaging tests

Changes in the Use of the Methylprednisolone Protocol for Traumatic Spinal Cord Injury in Switzerland

A retrospective cohort study. To examine the differences in the use of the methylprednisolone protocol for traumatic spinal cord injury before and after the publication of new guidelines in Switzerland. The use of the methylprednisolone protocol for traumatic spinal cord injury changed after the publication of new guidelines. The rate of physicians prescribing high-dose methylprednisolone for patients with acute spinal cord injury was studied. Two intervals, each comprising 24 months before and after the publication of the consensus article in Switzerland, were compared. As a secondary parameter, the neurological development during the rehabilitation period was compared. The charts of all adult patients who were referred for treatment of a spine or spinal cord injury during the periods from April 2001 to March 2003 and from April 2008 to March 2010 were retrospectively reviewed for demographic and medical details, the application of methylprednisolone within the first 48 hours after the injury, the diagnoses at the time of their referral, and the diagnosis at the time of hospital discharge. Classification of traumatic spinal cord injury was made according to the guidelines of the American Spinal Injury Association. Neurological improvement concerning the level of injury was defined as a change of this segment to a more caudal one or a complete normalization of sensory and motor function. During the 2 study periods, 110 patients (2001-2003) and 116 patients (2008-2010) were included. Between 2001 and 2003, 96% of patients with a neurological deficit after spinal cord injury were treated with high-dose methylprednisolone, whereas this rate dropped to 23% during the second time interval. In both treatment periods, neurological improvement during the rehabilitation period (mean: 6 mo) did not differ significantly. Pooled data of all patients with a neurological deficit in both study periods (n = 159) showed improved neurological levels in 32% of patients treated with methylprednisolone and 28% of patients without this therapy, without a statistical difference between the groups. In Switzerland, the acceptance of the guidelines for treating traumatic spinal cord injury with high-dose methylprednisolone has been extremely high in the past. The use of high-dose methylprednisolone has decreased to a much lower level in Switzerland after the publication of new guidelines, which is comparable to various other countries. Despite these changes, no differences in the neurological outcome were detected between the observed patient populations.

Annual Report on Health Care for Children and Youth in the United States: Focus on Trends in Hospital Use and Quality

Objective The aim of this study was to describe selected trends in hospital inpatient care for children between 2000 and 2007. Study Design Analysis was conducted of administrative data from annual nationwide databases of hospital discharges from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project, along with survey data from a nationally representative random sample of children from the Medical Expenditure Panel Survey. Hospital utilization rates and expenses, risk-adjusted rates of potentially avoidable hospitalization, and safety indicators in the hospital are calculated and tracked with established and downloadable software. Results The rate of hospital discharges for children aged 15 to 17 years declined significantly, mainly due to fewer maternity-related discharges. The leading principal conditions by age group were similar to the report for 1995 to 2000; however, the rate of admissions for skin infections doubled to 9 per 10 000. Hospital cost per discharge increased by an annual average of 4.5% per year compared with 2.6% annual growth in the gross domestic product deflator. Medicaid is increasingly important relative to private insurance as a payer for hospital care for children. The rate of potentially preventable hospitalizations for both acute and chronic conditions declined substantially (18%, adjusted for age and gender). Several measures of patient safety improved—the rates of postoperative sepsis, iatrogenic pneumothorax, and selected infections due to medical care declined by 14.2%, 17.8%, and 23.5%, respectively. However, the rate of accidental punctures and lacerations and the rate of decubitus ulcer increased by 25.6% and 34.5%, respectively. The trends in safety indicators varied somewhat by age group, income quartile of zip codes, insurance, region, and type of location without a consistent pattern. Conclusions/Implications Although teenage pregnancy rates were declining, there was a worsening trend in skin infections. The latter may eventually be impacted by recent publication of new guidelines for treatment by office-based physicians. A gradually increasing role of Medicaid as a payer for hospital care for children will likely put an increasing strain on public resources in advance of the full implementation of the health insurance reforms recently enacted. The decline in potentially avoidable admissions reduces the use of the most expensive resources. For asthma and diabetes, children in the lowest income zip codes had persistently higher rates of admission, but the rate fell by one third during the period. Children in the South and West regions had substantial and significant declines in preventable admissions. Particular indicators of safety were improving, whereas others were worsening. Trends were not the same in all types of hospitals, all regions, and income categories. This is already a rich area for further research on the impact of quality improvement strategies; however, attention is needed to developing more tools to more thoroughly track quality of care for children.

Betting on Biomarkers

In this issue, Johnson and colleagues (1) report on a study of ondansetron, a serotonin receptor antagonist, for alcohol-dependent patients. Had they conducted a standard randomized placebo-controlled trial, they would have found no statistically significant difference between treatment groups on the primary outcome measure and stopped there. That is, on average, their study participants were not significantly less likely to drink if they received ondansetron than if they received placebo.

Hormonal Contraception and Thrombotic Risk: A Multidisciplinary Approach

Heightened publicity about hormonal contraception and thrombosis risk and the publication of new guidelines by the World Health Organization in 2009 and the Centers for Disease Control and Prevention in 2010 addressing this complex issue have led to multidisciplinary discussions on the special issues of adolescents cared for at our pediatric hospital. In this review of the literature and new guidelines, we have outlined our approach to the complex patients referred to our center. The relative risk of thrombosis on combined oral contraception is three- to fivefold, whereas the absolute risk for a healthy adolescent on this therapy is only 0.05% per year. This thrombotic risk is affected by estrogen dose, type of progestin, mechanism of delivery, and length of therapy. Oral progestin-only contraceptives and transdermal estradiol used for hormone replacement carry minimal or no thrombotic risk. Transdermal, vaginal, or intrauterine contraceptives and injectable progestins need further study. A personal history of thrombosis, persistent or inherited thrombophilia, and numerous lifestyle choices also influence thrombotic risk. In this summary of one hospital's approach to hormone therapies and thrombosis risk, we review relative-risk data and discuss the application of absolute risk to individual patient counseling. We outline our approach to challenging patients with a history of thrombosis, known thrombophilia, current anticoagulation, or family history of thrombosis or thrombophilia. Our multidisciplinary group has found that knowledge of the guidelines and individualized management plans have been particularly useful for informing discussions about hormonal and nonhormonal options across varied indications.

A call for better implementation of European resuscitation council guidelines in primary care

Purpose: To investigate the attitude towards and knowledge of the 2005 European Resuscitation Council (ERC) guidelines on basic life support among physicians in primary care. Methods: Questionnaires were distributed among physicians at an annual national meeting for general practitioners in November 2008. The questionnaire was designed to investigate the attitude towards and the knowledge of basic life support guidelines. Results: A total of 72 questionnaires were included in the study. The majority of respondents stated that they are able to perform chest compressions and ventilations (96%), and are willing to perform mouth-to-mouth ventilation (85%). Only 19% were aware that unresponsiveness and absence of normal breathing are the two recommended criteria for diagnosing cardiac arrest. A minority were able to state the recommended chest compression depth (32%), frequency of chest compressions (31%) and compression–ventilation ratio (39%). Overall, 5% knew both how to diagnose cardiac arrest, the recommended depth, frequency of chest compressions and the compression–ventilation ratio. The majority aimed at updating their knowledge on resuscitation (61%), primarily by attending courses (47%) and by reading national medical journals (24%). At the time of the study, the 2005 ERC Guidelines had not yet been published in national medical journals. The majority (83%) stated that more training in resuscitation is needed in primary care. Conclusion: Physicians in primary care are willing to perform basic life support including mouth-to-mouth ventilation. The knowledge of the 2005 ERC Guidelines was limited three years after their release. This calls for a faster and better implementation of resuscitation guidelines. Expedited publication of new guidelines in national medical journals and improved basic life support training in primary care is recommended.

Réanimation du nouveau-né en salle de naissance : faut-il encore utiliser de l’oxygène pur ?

Most of the contemporary guidelines on newborn resuscitation are based on experience but lack scientific evidence. The use of 100% oxygen is one of the more evident. Today, these practices are questioned, particularly for the resuscitation of moderately depressed full-term or near-term newborns. Results of recent meta-analysis of trials that compared ventilation with room air versus pure oxygen at birth suggest current practices should be revisited. On the basis of these data, air can be the initial gas to use for these babies. Large-scale trials, including preterm and cause and/or severity of initial asphyxia, must now be undertaken before the publication of new guidelines for these populations.

New Hypertension Guidelines from the National Institute for Health and Clinical Excellence and the British Hypertension Society

A joint initiative between the National Institute for Health and Clinical Excellence (NICE) and the British Hypertension Society (BHS) has led to the publication of new guidelines for the management of hypertension in the community. Recent trial evidence highlighting the increased incidence of new-onset diabetes in those exposed to beta-blocker-based treatment regimens, with or without diuretics, compared with those based on calcium channel blockers (CCBs) or angiotensin-converting enzyme (ACE-Is) inhibitors has led to a recommendation that in the uncomplicated patient, beta-blockers are no longer considered suitable options for first-line therapy. Together with mounting evidence that age and ethnicity dictate blood pressure (BP) responsiveness to different classes of antihypertensive drugs, the ACD algorithm is now proposed (formerly ABCD), with ACE inhibitors (ACE-Is) (or angiotensin receptor blockers [ARBs] when ACE-Is are poorly tolerated) preferred in younger patients and CCBs or diuretics preferred for older patients and in black patients of any age. Pathophysiological considerations have influenced proposals for combination therapies with CCBs or diuretics added to ACE-Is in younger patients and vice versa in older patients. Health economic analyses have clearly indicated the cost effectiveness of CCBs which are now elevated to equal standing with diuretics in older patients.

De diagnostiek en behandeling van latente tuberculose-infectie in kinderen

More often than active tuberculosis disease children have latent tuberculosis infection (ltbi), which can occur after contact with a patient suffering from smear-positive pulmonary tuberculosis, usually an adult household member. In young children the infection is almost always recently acquired. Compared to adults, infected children, especially children with an immune disorder, have an increased risk of progression to active tuberculosis disease, and will more frequently develop severe manifestations of tuberculosis, such as tuberculous meningitis or miliary tuberculosis. Treatment of ltbi considerably reduces the risk of progression to active disease. Most infected children are identified during contact investigations or immigration screening and treated by the Department of Tuberculosis Control of the Municipal Health Service. The tuberculin skin test is not always a reliable method to diagnose ltbi, particularly in children with a previous bcg vaccination or in children with a reduced immune response. Recently developed interferon-? tests may contribute to improved diagnosis of ltbi in the future. On account of the publication of new guidelines for diagnosis and treatment of ltbi in children in the United States as well as in the Netherlands, the policies and developments in the Netherlands are discussed.