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The diagnosis of urinary tract infections in young children (DUTY): protocol for a diagnostic and prospective observational study to derive and validate a clinical algorithm for the diagnosis of UTI in children presenting to primary care with an acute illness
Bacterial and fungal diseases
Urinary tract infection (UTI) is common in children, and may cause serious illness and recurrent symptoms. However, obtaining a urine sample from young children in primary care is challenging and not feasible for large numbers. Evidence regarding the predictive value of symptoms, signs and urinalysis for UTI in young children is urgently needed to help primary care clinicians better identify children who should be investigated for UTI. This paper describes the protocol for the Diagnosis of Urinary Tract infection in Young children (DUTY) study. The overall study aim is to derive and validate a cost-effective clinical algorithm for the diagnosis of UTI in children presenting to primary care acutely unwell.
DUTY is a multicentre, diagnostic and prospective observational study aiming to recruit at least 7,000 children aged before their fifth birthday, being assessed in primary care for any acute, non-traumatic, illness of ≤ 28 days duration. Urine samples will be obtained from eligible consented children, and data collected on medical history and presenting symptoms and signs. Urine samples will be dipstick tested in general practice and sent for microbiological analysis. All children with culture positive urines and a random sample of children with urine culture results in other, non-positive categories will be followed up to record symptom duration and healthcare resource use. A diagnostic algorithm will be constructed and validated and an economic evaluation conducted.
The primary outcome will be a validated diagnostic algorithm using a reference standard of a pure/predominant growth of at least >103, but usually >105 CFU/mL of one, but no more than two uropathogens.
We will use logistic regression to identify the clinical predictors (i.e. demographic, medical history, presenting signs and symptoms and urine dipstick analysis results) most strongly associated with a positive urine culture result. We will then use economic evaluation to compare the cost effectiveness of the candidate prediction rules.
This study will provide novel, clinically important information on the diagnostic features of childhood UTI and the cost effectiveness of a validated prediction rule, to help primary care clinicians improve the efficiency of their diagnostic strategy for UTI in young children.
Acute illness in young children is one of the commonest reasons for seeking health care worldwide. Reported rates of urinary tract infection (UTI) in children consulting for any acute condition vary widely (from 2% to 20% depending on setting and inclusion criteria) and most of this research has been hospital based
UTI may be missed in as many as 50% of young children presenting to primary care
UTIs in young children may cause acute morbidity and recurrent symptoms that may indicate functional and anatomical abnormalities. In some young children, UTI may lead to renal scarring
Dramatic reductions during the second half of the 1990s and early 2000s in antibiotic prescribing for children with upper respiratory infections
To date there is a lack of evidence as to the clinical predictors of UTI in young children. A meta-analysis
A more recent review of primary care based paediatric studies using urine culture as the reference standard found that no individual symptom or sign, or any combination of symptoms or signs, was sufficient to rule in a diagnosis of UTI, although some (e.g. increased capillary refill time, no fluid intake, and supra-pubic tenderness) appear to warrant urine testing and empirical treatment while awaiting culture confirmation
We found only one clinical algorithm derived from primary research for the diagnosis of UTI in young children. The research included febrile girls aged under two years in one US Emergency Department
An additional issue for the diagnosis of UTI in children is uncertainty as to the best criteria for microbiological diagnosis of UTI in this age group. Historically this has been based on a colony count of bacteria in the urine with a cut-off of ≥105 colony forming units (cfu)/mL of a uropathogen indicating infection. However this was derived from studies in adult women
Additional value of dipstick testing in young children
A 2006 Health Technology Assessment (HTA) review found there was inadequate evidence on the diagnostic performance of dipstick tests for protein or blood for children aged under 5 years old. The combination of a positive test for both nitrite and leucocyte esterase (LE) was most accurate for ruling in UTI (pooled LR + 28.2 (95% CI: 17.3 to 46.0)), and a negative test for both nitrite and LE was most accurate for ruling out UTI (pooled LR- 0.20 (95% CI: 0.16 to 0.26))
Economic impact of UTI
UTI is the fourth most common reason overall for prescribing antibiotics in UK general practice, accounting for approximately 8% of all antibacterial prescriptions . However, UTI is currently infrequently diagnosed in children
The few economic evaluations of methods for diagnosing UTI in young children
Research objectives
In summary, rigorous evidence regarding the predictive value of symptoms, signs and urinalysis for UTI in young children is urgently needed to help primary care clinicians better identify UTI. Furthermore, since obtaining urine samples is especially challenging in children aged before their fifth birthday, the resulting algorithm will be constructed to answer two separate questions: first, which children warrant urine sampling? And second, can point of care dipstick urinalysis help clinicians determine which samples should be sent for laboratory culture? The algorithm will then be the subject of a validation study. Furthermore, since changes in the frequency with which urine samples are requested has implications for parents and for healthcare services, analyses will model the economic impact (from the NHS and societal perspectives) of GP judgement versus diagnostic algorithm guided diagnosis and management with respect to the cost per correctly identified UTI, cost per symptomatic day avoided and the cost per quality adjusted life year.
The Diagnosis of Urinary Tract Infection in Young Children (DUTY) study protocol has the following research objectives:
1. To develop candidate clinical prediction rules that accurately identify children presenting in primary care with an acute illness in whom a urine sample should be obtained, based on socio-demographic factors, medical history, symptoms and signs.
2. To assess whether dipstick urinalysis for nitrite, leukocyte esterase, protein, blood and glucose gives additional diagnostic information to objective (1) in the identification of urine samples that should be sent for laboratory analysis.
3. To model cost-effectiveness from NHS and societal perspectives of the candidate clinical prediction rules.
4. To compare contamination rates for different urine sampling methods.
Ethical and governance approval
Multi-centre approval was granted by the South West Southmead Research Ethics Committee (previously Southmead Research Ethics Committee, then South West 4 REC), Ref #09/H0102/64. Research and Development (R&D) approval has been granted for all sites taking part in the study.
DUTY is a 3-year, multicentre, diagnostic accuracy study to derive and validate a cost effective algorithm for the diagnosis of UTI in children under 5 presenting to primary care with an acute illness.
Children are eligible if they are aged before their fifth birthday and present to primary care with a new acute illness episode of less than or equal to 28 days duration. A Case Report Form (CRF) will be completed for all eligible, consented children and a urine sample obtained. The prevalence of UTI will be determined on laboratory culture. An algorithm will be derived and validated in separate samples of children.
This UK study will be implemented from four research centres at the Universities of Bristol, Cardiff, Southampton and King's College London. Each centre will recruit children from primary care, defined as any NHS facility providing first-point-of-contact face-to-face advice for parents of unwell children (GP practices, Walk-in-Centres (WIC), and Children's Emergency Departments (CED)).
Study procedures
Primary care sites/GP practice recruitment
Primary care sites will be recruited by each study centre covering both urban and rural areas across England and Wales. Two models of recruitment will be offered: (1) Option 1, in which the majority of the recruitment procedures will be undertaken by a dedicated Research Nurse (RN) or Clinical Studies Officer (CSO) external to the site; and (2) Option 2, in which recruitment will be undertaken entirely 'in house' by the primary care site's clinical team. From now on, members of staff taking informed consent for the DUTY study will be referred to as "recruiting clinicians". Dedicated RNs/CSOs providing external support for sites will be referred to as "DUTY recruiters", while members of practice staff involved in option 2 recruitment will be referred to as "site-based recruiters".
Recruiting staff
The study grant will provide full-time equivalent DUTY recruiter posts across all four study centres, which will be supplemented by additional DUTY recruiter posts provided by local Primary Care Research Networks (PCRNs) and Comprehensive Local Research Networks (CLRNs) (in England) and by the National Institute for Social Care and Health Research – Coordinating Research Centre (NISCHR-CRC) (in Wales). These DUTY recruiters will be available to provide Option 1 support to primary care sites, and to support autonomously recruiting Option 2 sites through the provision of expert training, mentoring and problem-solving.
NHS microbiology laboratory recruitment
The participation of any primary care site in recruitment to the study will depend on the support and participation of the local NHS microbiology laboratory to which the site routinely sends urine samples. In each area of recruitment, the local NHS laboratory will be approached and service level agreements put in place prior to involvement in the study.
Participant recruitment
The recruitment process is summarised in
Figure 1
DUTY participant flow diagram
DUTY participant flow diagram.
Registration and consent
Parents and children may be invited to take part in the study in a number of ways:
1. Where possible, primary care sites will mention the study to parents of children under 5 when they phone for an appointment, and ask them to come to the surgery 15 minutes early to receive further information.
2. Where the study was not raised at the time of making the appointment, parents of children already booked in may be phoned and told about the study and invited to attend a little earlier.
3. If they cannot be contacted by telephone, they will be approached on arrival at the site, given information sheets and asked if they would be happy to see a recruiting clinician to discuss participation.
Once the parent has indicated they are happy to discuss the study, the recruiting clinician will explain study participation answer any questions that the parent may have, ensure that they fully understand the implications of participation, and check the child's eligibility. If the child is eligible and the parent agrees to participate, written informed consent will be obtained from the parent. If the parent wishes to see the GP before consenting, the recruiting clinician will arrange for this to happen, with the parent and child returning to the recruiting clinician afterwards to complete recruitment. Where possible the recruiting clinician will recruit the participant while they are waiting to see the GP, in order that the parent and child are not delayed. However, if more practical or convenient, the recruiting clinician may offer, with the parent's permission, to visit the family later the same day at their home to complete recruitment. If the parent is not interested in hearing more about the study, no further approach will be made.
A screening log of all children aged before their fifth birthday, who are attending for care and whose parents are approached by the recruiting clinician to invite participation in the study, will be compiled. Details will be recorded as to their eligibility, whether consent was given or declined, and reason for declining to participate.
Participant eligibility
The study will include parents who speak other (non-English) languages. Parent information sheets and consent forms will be translated into other languages as required by participating GP practices (e.g. Welsh, Polish and Brazilian Portuguese). For languages less commonly spoken in the UK, particularly for those in which oral translation is more useful than written translation (e.g. Somali), translational services will be accessed, where possible, via interpreters employed by recruiting primary care sites to support patient-clinician communications. Where these services are not available, translational services will be provided via Language Line.
Collecting urine samples and dipstick testing
The recruiting clinician will attempt to obtain a urine sample from the children of consenting parents during the recruitment visit. If this is not possible, the recruiting clinician will ask the parent to collect the sample at home, give them the appropriate equipment and explain how to collect it. To minimise contamination, urine samples will be obtained using the 'clean catch' where this is possible. Where this is not possible, the 'nappy pad' method (which involves cleaning the child's perineum and inserting a sterile pad into the nappy to soak up urine, for a maximum period of 1 hour) will be used, as described by Liaw et al.
The recruiting clinician will retrieve the urine sample, test it with a urine dipstick (Siemans/Bayer multistix 8SG) provided by the study and record the urine sampling method and dipstick result on the CRF. The urine sample will then be split, if sufficient quantity is available, with the priority fraction being sent to the local NHS laboratory for routine diagnostic processing, and the second 'research' fraction being sent to the SACU(Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital of Wales) reference laboratory: for more in-depth analysis. As only small volumes of urine (minimum 1 mL) are required for each laboratory, it is expected that for most urine samples, it will be possible to split the urine into the two fractions.
If a sample is not obtained during this visit the parent will be asked if they could obtain one at home, refrigerate it and return it to the primary care site within 24 hours. Where possible, the DUTY recruiter will offer to collect the urine sample from the patient's home.
In a sub-sample of children recruited from a handful of sites linked to the Bristol study centre, we will use time-motion techniques to measure the additional time (parent and healthcare professional) taken to collect the urine sample and to perform dipstick testing during the primary care appointment. These data will be used to inform the economic analysis.
Maximising urine samples
Obtaining the urine samples will be challenging, and a suboptimal return rate will diminish power and increase risk of bias. Therefore: (1) we will monitor the location of urine specimens using a web-based database. Clinical data for recruited children will be logged onto the secure study website. Dipstick urinalysis data may be added after the clinical data and will provide a record of the urine having been obtained. This will allow the research team to identify children for whom urine samples have not been provided, and to check with the relevant recruiter as to whether this should be followed up. Both the Research and NHS laboratories will also record the arrival of, and results from, the specimens on the website; and (2) each centre will provide dedicated DUTY recruiter resource to assist Option 1 practices with obtaining urines.
Laboratory processing of urine samples
The NHS 'clinical' fraction will be labelled with the child's unique DUTY study identification (ID) number on DUTY specific labels as provided in patient packs. Similar DUTY labels will be adhered to the DUTY study specific microbiology form and the sample sent to the local laboratories using the site's normal method of transport. Any samples not collected within 4 hours will be refrigerated at the site and processed within 36 hours. Clinicians will receive and act on reports from their local laboratory as in the course of usual clinical care.
The remaining portion of urine will be decanted into a sterile monovette container containing boric acid. This will be labelled with the child's study ID number and sent by 1st Class Royal Mail using Post Office approved SafeboxesTM to the central research laboratory.
Minimising effects of sample contamination and assessment of asymptomatic bacteriuria
Contamination of urine (a cultured organism from a source other than the urinary tract) can lead to false positives: a potential false positive rate of 7.2% has been identified in one study by comparing pairs of urines from 203 children
Clinicians use the presence of UTI symptoms to help interpret culture positive results but this leads to incorporation bias. In DUTY, we could restrict recruitment to those children with currently recognised symptoms of UTI, but since the purpose of DUTY is to determine the strength of association between currently recognised as well as
Data collection
Unique study identification numbers will be sequentially generated and used on pre-printed consent forms, paper CRFs, urine sample labels and test request forms (for local NHS and central research laboratories).
A CRF will be completed for all consented patients. This will include a short medical history including recent antibiotic use and other potential risk factors for UTIs and resistance, and clinical examination findings. An outline of the domains covered in the CRF can be found below in the next section.
Case report form
The CRF will contain as many of the known and potential features associated with UTI as are feasible without overly compromising the speed and simplicity of completion.
Five sections will facilitate data entry by different personnel (recruiter taking consent or responsible clinician) so as to minimise the burden to healthcare professionals undertaking same day primary care:
1. Eligibility screening and consent (to be completed by recruiting clinician within the recruitment interview with the parent).
2. Registration (to be completed by recruiting clinician as above): Socio-demographic data (to include: date of consultation, name, address, contact telephone number/s, ethnicity
3. Presenting Symptoms and Medical History (to be completed by recruiting clinician as above): child's presenting symptoms will be recorded, along with known previous medical history (e.g. previous UTI, circumcision
4. Clinical Examination and Management (to be completed by child's responsible clinician within a standard consultation): in addition to the 'constitutional' and 'urinary' study eligibility symptoms defined by NICE
Clinicians will be asked to record the child's management, including antibiotic use and immediate referral to secondary care. To assess the diagnostic value of the urine dipstick test, we will ask clinicians to record their working diagnosis before having seen the dipstick results, and to record whether their working diagnosis has changed after they have seen them. Finally, for the economic analysis, we will ask clinicians to state what their management would be if the patient were not enrolled in the DUTY study (e.g. no urine test/not treated for UTI or urine test/treat for UTI). This will provide information on the 'clinician judgement' diagnostic strategy that will be a comparator in the economic evaluation.
5. Urine collection and processing (to be completed by recruiting clinician): Urine sampling method (clean catch or nappy pad) and urinalysis results with date, time of testing, with a prompt to inform the responsible clinician of dipstick result and confirmation that the sample has been sent to the local NHS and central research laboratories.
In addition to the CRF, the study web-based data collection platform will include additional sections to cover data entry for the following: (1) NHS microbiology laboratory microscopy and culture; (2) SACU research laboratory microscopy and culture; (3) patient follow-up at Day 14 following recruitment, and (4) patient notes review at 3 months from recruitment. Further detail of the content of these domains is provided below.
Processing of urine samples by NHS laboratories
NHS laboratories will be informed of the study and the agreement of the lead consultant microbiologist, laboratory manager and the NHS hospital Research and Development approval obtained before patient recruitment begins. The laboratories will be asked to complete the following tasks for DUTY study samples:
1. Log the date and time of specimen arrival on the secure DUTY web-based database.
2. Process the urine and report the result back to the requestor using their own Standard Operating Procedures (SOPs) and Laboratory Information Management Systems (LIMS).
3. Enter the results of urine culture onto the DUTY study web-based database. Since laboratories vary in their SOPs, not all of the following will be available however, microscopy for white and red cells; quantification and purity of bacterial growth; and speciation will be requested. Laboratories will be asked to transcribe this information onto the DUTY web-based database in order to activate laboratory payment.
4. Store any isolates from urines with >105 CFU/mL in pure/predominant ureopathogen growth for referral onto the central research laboratory at the end of the study. These should be stored, ideally on cryogenic beads, at temperatures of -70 C, or on slopes at -20 C if -70 C storage facilities are not available.
Processing of urine samples by the research laboratory
The central research laboratory has experience in supporting other primary care UTI studies and performed a similar role to that described below in the previous EURICA study (Epidemiology of urinary tract infection in children with acute illness in primary care)
1. Urines will be sent overnight by Royal Mail SafeBoxesTM by the participating sites. Boric acid will be used to stabilise bacterial counts.
2. On receipt at the central research laboratory, the urine sample will be spiral-plated on blood agar and UTI Chromogenic agar will be used to quantify bacteria >2x101 CFU/mL and <1010 CFU/mL.
3. The bacteria will be identified to species level and stored on cryogenic beads at −80°C. The urine will be stored frozen.
4. Results will be recorded on a designated laboratory worksheet and entered into the DUTY web-based database.
Where the urine culture result produced by the central research laboratory is positive and the local NHS laboratory result is negative or not processed, and if this discrepancy is considered by the lead SACU microbiologist to be clinically significant, we will inform the child's responsible clinician. This will enable the child's responsible clinician to consider the future management of the child in the light of the additional information arising from the study.
Patient follow-Up
Telephone follow-up at Day 14
Each centre will telephone parents of all children selected for follow-up according to the proportional selection rules in Table
3 Months note review
Each research centre will conduct a primary care notes review for all children who were selected for follow-up. Primary care contacts, medications and secondary care utilisation during the 3 months after study recruitment will be recorded during the review.
Withdrawal & loss to follow-Up
In the majority of cases the only active participation of participants is at the initial consultation, and withdrawal from the study in most cases is unlikely. Attrition in those selected for 14 day follow-up due to the challenges of making contact with busy parents will be minimised by making several attempts to contact parents/guardians by telephone and, if this is unsuccessful, a postal version of the resource use questionnaire will be posted to participants with a stamped addressed envelope for return. Parents will be offered a £5 voucher, by post, on completion of follow-up either by telephone or post.
Electronic data entry
The DUTY data collection process is complex and involves input from a number of different personnel at different sites: (1) CRF data by a combination of study DUTY recruiters, practice nurses, GPs and dedicated staff at recruiting primary care sites; (2) clinical and research urine culture results by laboratory technicians and managers; and (3) follow-up data at Day 14 and 3 months by study centre administrators and research nurses. To optimise the quality of the data entry and to enable effective data collection from multiple sites across England and Wales, we decided to use a secure, web-based electronic data collection platform.
We will use a secure web 2.0 clinical study management system (The electronic Primary Care Research Network (ePCRN)). Hosted by South London and Maudsley (SLAM) NHS Foundation Trust, the ePCRN implementation is of a separate domain and a Citrix farm serving published applications, with a Structured Query Language (SQL) server providing clinical based study application databases. The system avoids potential data loss, duplication and security issues with laptops and portable media and has been approved by ethics and by the SLAM Caldicott and Executive Committees.
Web-forms for data collection will be created in ASP.net (a dynamic web application framework) on top of a dedicated SQL data management server, with data variables forced to comply with entry and validation rules defined in the data element definitions. The SQL data management server will incorporate auditing, backup and recovery facilities. The study workflow and algorithms will be enforced using the same methods, and a visual algorithm on the web pages will guide users. The web-based system will be piloted for ease of use prior to data entry go-live.
Electronic data protection and confidentiality
The ePCRN safeguards the legal and ethic rights of service users through a fully integrated research security management system consisting of two component parts: (1) technical specifications built into the DUTY study database during the development phase, and (2) procedural standards governing the launch and day-to-day use of the application by DUTY study researchers.
Access to users will be provided through study-specific logon points in Citrix Access Gateway Advanced Access Control. Citrix software establishes a secure, encrypted, connection with the user's PC, allowing access from the Internet uniquely to the Citrix Access Gateway and enabling access to identifiable study data for authorized users.
Data entry in primary care sites
In order to maximise the acceptability and ease of use of DUTY data collection tools, clinicians working in settings without web access or whose working practice made web data entry an unwelcome burden, will be able to opt for paper-based data collection with the support of the local study centre in entering data, or making alternative arrangements for data entry, on their behalf.
The web-based data collection system will be presented as the preferred method of data collection, and practice-based recruiting staff will be strongly encouraged and supported to enter CRF data onto the database directly or, if using paper-based CRFs in the recruitment interviews, to retrospectively enter the data in a timely way (consent and registration within 24 hours, and full eCRF data within 5 working days).
Data entry in the local NHS laboratory and central research laboratory
Once in the local NHS and SACU research laboratories, staff will be able to access an anonymised data collection page, where only study numbers and the data collection forms for the urine samples can be seen. Laboratory staff will be asked to log the samples on receipt and enter the results when available.
Follow-up data entry in research centres
At day 14 from recruitment, and at 3 months, research staff will enter symptom duration, healthcare resource utilisation and expenses data from telephone interviews and practice records respectively onto web-based data collection forms.
The overall aim of the analyses is to derive a validated clinical prediction rule for UTI among acutely ill children presenting to primary care.
Sample size calculation
To estimate the required sample size we drew on our experience with the EURICA study, which found a UTI prevalence rate in children aged before their fifth birthday of 4%
Given the complexity of the statistical analyses, large number of possible predictors and the need to account for some missing data in predictor variables, we propose to recruit at least 7000 children in total (two-thirds for algorithm derivation; one-third for validation), in order to maximise the statistical power of the sample).
Statistical analysis
Defining the primary outcome
The first stage of the analysis will investigate the best combination of microbiology data from the local (NHS) laboratories and the central research laboratory that can be used to define urine samples as positive for UTI. We will agree definitions of UTI positivity for data from each laboratory (using culture results and white cell counts) and will cross-tabulate these. Possible disagreements will be examined, and samples classified after discussion as: (1) "Agree UTI negative"; (2) "Agree UTI positive"; (3) "Disagree (CL positive, LL negative)"; (4) "Disagree (CL negative, LL positive)". If overall between-laboratory reliability (classified on kappa statistics) is good, the primary outcome will be defined as positive for samples classified as (2) "Agree UTI positive". If overall agreement is moderate or poor, we will explore reasons for this. We will stratify according to age of the child and method of collection (clean catch or nappy pad), and investigate whether reliability varies between strata. We will also examine the inference of laboratory methods (e.g. whether samples are process in boric acid) and time from sample collection to laboratory processing.
If the best definition of UTI positivity remains unclear, then we will select a small number of signs and symptoms that the literature suggests are clearly associated with presence of a UTI. We will examine associations of UTI positivity with these symptoms, using different definitions of positivity (e.g. based on central or local laboratory, threshold for amount of growth, evidence of growth of other species, method of sample collection. We will select the best definition of microbiological positivity based on the magnitude of associations with the selected signs and symptoms.
Descriptive analyses
We will use methods appropriate for small proportions
We will compare the probability of contamination in samples that are retrieved via a 'clean catch' method with those using nappy pads, controlling for patient and practice factors in a two level random-effects logistic regression model (objective 4). We will examine the impact of timing of sample in relation to the time between obtaining the urine transportation (including day of the week) and laboratory analysis on the rates of positive and contaminated urine samples (e.g. exploring if delayed samples such as those taken after daily laboratory collection have an impact on contamination rates).
The sample will then be sub-divided into algorithm derivation and validation datasets, compromising two-thirds to one-third of the data set, respectively. This will be done by randomly selecting practices: all of their patients will then contribute to one of the two datasets.
Development of clinical prediction rules
We will develop a clinical prediction rule based on the linear predictor in a logistic regression model in which the outcome variable is a culture-positive urine result. Candidate diagnostic variables will be categorised into demographic background and medical history (for example, gender, previous UTI); both specific and general systemic presenting symptoms and signs (for example overall illness severity, fever, vomiting); and results from urine dipstick analysis (nitrite, leukocyte esterase, protein, blood and glucose). Because of concerns that some aspects of medical history or demographics may be associated with asymptomatic carriage rather than active infection, we will also develop a 'signs and symptoms' only prediction rule. Variables will be included in logistic regression models based on an "inclusive" p value threshold of 0.1. We will check for nonlinear effects of continuous variables, and will examine candidate interactions specified
We will begin by examining the predictive value (based on diagnostic odds ratios and C statistics) of the best predictors from each of the three categories (socio-demographic and previous medical history, clinical assessment, and dipstick urinalysis) of variables. We will then examine the additional diagnostic value of presenting signs and symptoms (compared with socio-demographic and medical history alone) and of dipstick results (compared with the other two categories). We will examine whether it is possible to identify subgroups of children in whom dipstick testing is and is not justified based on their signs and symptoms. The final algorithm will be characterised based on its sensitivity and specificity, and positive and negative likelihood ratios.
Validation of clinical prediction rule
Diagnostic models that are developed using
Analyses of follow up data
Children with positive urine cultures ('contaminants' and 'UTIs') who the clinician felt at recruitment had a suspected UTI will be compared to those who the clinician felt there was little probability of a UTI in terms of their subsequent illness course and resource usage over the next three months.
Risk stratification for clinical practice
In the final stages of analysis, we will examine the sensitivity and specificity of the linear predictor, based on a set of chosen thresholds for positivity. This will be used to identify several candidate clinical prediction rules for comparison in the economic evaluation. We will select thresholds that provide a range of clinical prediction rules from high sensitivity/low specificity to low sensitivity/high specificity.
Minimising Bias
The following design and analytic strategies will be employed to minimise bias:
(1) Selection bias: where possible we will recruit consecutive children. We will ask sites to keep a screening log of patients approached but who did not take part in the study and reasons for this;
(2) Index test technology: all tests (symptoms, signs, nappy pads, dipstick tests) will be carried out using standardised equipment and protocols;
(3) Incorporation bias: the reference standard will consist of culture alone and will not incorporate any of the index tests;
(4) Review bias: observers assessing the index tests will differ from and be blind to those assessing the reference standard (and vice versa);
(5) Verification bias: all children who contribute to the study will have a urine sample sent to assess the reference standard. Children in whom it is not possible to obtain a sample will be excluded from the analysis. It is unlikely that reasons for failure to obtain urine samples will be related to the index tests but we will compare children with and without urine cultures;
(6) Disease progression bias: we expect the time between clinical assessment and obtaining the urine samples to be minimal (no more than 24 hours);
(7) Treatment paradox: for most children, antibiotic treatment will be started after the urine sample has been obtained, but we will record where this has not been possible;
(8) Handling of indeterminate or uninterpretable results or withdrawals: these parameters will be measured and considered in the analysis, and;
(9) Appropriateness of the reference standard: use of >103, but usually >105 CFU/mL of one, but no more than two uropathogens is likely to detect the majority of children with UTI, but the second 'research' urine result from the SACU laboratory will allow for sensitivity analyses around different bacterial concentrations. Where possible, we will measure all threats to validity (e.g. time between clinical assessment and obtaining and culturing the urine sample) that could influence results.
Economic analysis
The aim of the economic analysis is to compare candidate clinical prediction rules (CPRs) on: (a) incremental cost per correct diagnosis of bacteruria, b) incremental cost per symptomatic day avoided, and c) incremental lifetime cost per quality adjusted life year, including potential long term complications of UTI from NHS and societal perspectives.
The cost-effectiveness of each candidate prediction rule will be compared to a 'clinical judgement' testing strategy and two 'boundary strategies': 1) Performing a urine test in every child meeting the DUTY eligibility criteria, and 2) No testing, the diagnosis of UTI is made clinically. The two boundary strategies are not intended to reflect clinical reality, but provide a reference point against which other diagnostic strategies can be compared. The cost-effectiveness of each candidate CPR will be assessed against these three strategies using a decision analytical model. The face validity of the model structure will be reviewed by clinicians on the DUTY study team before being finalised.
Cost per correct diagnosis of UTI (diagnostic model)
The diagnostic cost-effectiveness model requires information on cost (cost of sample collection, cost of NHS laboratory testing), probabilities (probability of sample being obtained and probability of sample being contaminated) and diagnostic accuracy parameters (sensitivity and specificity of the various diagnostic strategies). The diagnostic accuracy parameters will be derived directly from the DUTY CRF and the statistical analysis described above. The probability of sample collection and contamination will be observed in the DUTY study. The cost of sample collection and laboratory testing will be derived from a combination of surveys of NHS laboratories and GPs and a time motion study observing primary care clinical staff as they collect and process urine samples. The model will estimate the cost per patient correctly diagnosed. The model will also include diagnostic strategies that incorporate dipstick testing (e.g. in those children thought to be a moderate risk of bacteriuria) with information on a small number of additional parameters (i.e. cost, sensitivity and specificity of dipstick testing).
Cost per symptomatic day avoided (short term model)
The model will then be extended to estimate cost per symptomatic day avoided at day 14. A Markov model will estimate the short-run cost-effectiveness of each diagnostic strategy. This extension will require information on additional parameters including the probabilities of receiving antibiotics and hospital admission in children diagnosed with and without UTI, the cost of antibiotics and hospital admission/testing, and the daily recovery probability for children with bacteriuria treated with antibiotics, children with bacteriuria not treated with antibiotics and children without bacteriuria. The probabilities of antibiotic treatment and hospital admission will be based on 14 day interviews and review of patients' primary care medical notes at 3 months. The daily recovery probabilities will be based on 14 day interviews with parents of children selected for follow-up. As all children in DUTY will receive a urine test, we will not be able to observe the recovery of children with bacteriuria not treated with antibiotics (i.e. false negatives). For this transition probability we will use literature estimates of the effect of antibiotic therapy on symptom duration.
Cost per quality adjusted life year (QALY -long term model)
The structure of the long-run Markov model will be based on the a previously developed model
All analyses will be probabilistic, as all parameters will be entered into the model as distributions. Therefore the results will be presented as cost-effectiveness acceptability curves (CEACs). The CEAC demonstrates which of several testing strategies is most likely to be cost-effective at any fixed willingness to pay for a correct diagnosis. Costs and outcomes occurring after the first year will be discounted at 3.5%. We will use net monetary benefits and cost-effectiveness acceptability curves, at plausible willingness to pay thresholds (e.g. £0 to £50,000 per QALY) to identify the most cost-effective diagnostic strategies. Deterministic sensitivity analyses will also be used to evaluate the impact of key parameters on results and the influence of various CFU/mL thresholds on the choice of clinical prediction rule.
This paper describes a diagnostic and prospective observational study in primary care, that aims to recruit at least 7,000 children aged before their fifth birthday, who are assessed for any acute, non traumatic, illness of ≤ 28 days duration. Urine samples will be obtained from eligible consented children and tested with a dipstick before being sent to a local NHS laboratory and a central research laboratory for microbiological analysis.
This study will provide novel, clinically important information on the diagnostic features of childhood UTI to help primary care clinicians improve their diagnostic efficiency. New insight into the diagnostic value of dipstick urinalysis and urine sampling methods will also be provided.
The observational design of the study will minimise disruption to normal practice and reduce the research burden on healthcare professionals, thereby maximising the applicability and generalisability of findings. In addition, this study will increase awareness of UTI as a possible diagnosis in appropriate children under 5 years old. We will collect full clinical information, including presenting symptoms and signs, medical history and clinical diagnosis; urine dipstick data and culture data from both usual routine local NHS laboratories and central research laboratory. All the above will be utilised for derivation and validation of the diagnostic algorithm. In addition the follow-up data at 14 days and 3 months will allow for full health economic analysis, providing cost effectiveness outcomes. Additional useful information such as the best way of sampling urine from young children in primary care, the species and sensitivities of the infecting organisms, and contamination rates will also inform care in the future.
The main challenge to the DUTY study is the large number of participants and urine samples needed. A substantial number of practices across each of the four centres will need to be recruited, to provide a large enough population of potential participants. In addition to this, parental consent will be required at the same general practice visit when they are invited to participate, meaning there is a reliance on parents being willing and having the time to participate immediately. Despite the dedicated DUTY recruiting staff on the ground, who will provide support to practices, study buy-in is needed from all primary care staff to ensure adequate resources and infrastructure are in place to facilitate the conduct of the study. This will require training of all staff involved at each participating primary care site. A major contribution from NHS microbiology laboratories will also be necessary, for processing the increased number of urine samples received from primary care sites.
This study will rely on sampling methods most commonly used currently in UK primary care, namely nappy pad and clean catch. Suprapubic aspiration and catheterisation methods are neither feasible nor appropriate for primary care. Nappy pad sampling may carry an increased risk of contamination or un-interpretable results. This may lead to the exclusion of some results from the main analysis. However, this will be minimised by obtaining clean catch samples where possible. Lastly, the electronic data capture on the database has been designed to allow for all parties to enter data separately. A challenge will be to ensure all data is entered into the database in a timely way, to allow for both the real time monitoring of recruitment and urine sample location, as well as the conduction of the follow-up interviews within the tight timeframe.
In summary, this will be one of the largest studies of its kind undertaken in primary care, involving obtaining clinical samples from children, and will help guide management of the acutely unwell child, which is a common and important aspect of primary health care delivery. Improved assessment and diagnosis may lead to more appropriate microbiological and point of care testing and more timely treatment and investigation of those children who are most likely to benefit, while reducing unnecessary treatment and investigation among those that are most unlikely to benefit. This is likely to improve outcomes for individual patients and may help prevent long-term sequelae. The overall outcome of the study will be to achieve a more consistent approach in the clinical care of a common condition, based on accurate diagnosis and effective clinical management.
a This paper will use the term 'parent' to refer to the person with legal responsibility for the child, therefore as applied in this paper the term also encompasses carers (foster parents, legal guardians etc.).
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
CCB and ADH are co-chief investigators and act as guarantors of the study in its entirety. CCB and ADH jointly led the development of the research question, study design and implementation of the study protocol, along with KH, JS, WH, PL, BD, RH, MW and AM. HD is Study Manager and coordinated the operational delivery of the study protocol across the UK. ETJ and CAW are study managers at Cardiff, and coordinated the delivery for the study protocol in Wales. PL and BD are principal investigators, responsible for study oversight at Southampton and London, respectively. RH, MW and AM have provided expert microbiology input. HD, ETJ, MG and CAW jointly drafted the manuscript. All authors listed provided critical review and final approval of the manuscript.
In addition to the authors, the DUTY study team comprises: Kate Birnie, Kim Harman, Marilyn Peters, Kate Martinson, Catherine Lisles, Timothy Pickles, Michael Lawton, Jonathan Benger, John Busby, Margaret Fletcher, Jan Dudley, Judith van der Voort, Kathryn O'Brien, Penny Whiting, Catherine Derrick, Steven Beech, Elizabeth Thomas, Victoria Roberts, Lewis Darmanin, Stevo Durbaba, Margaret Hague, Susan George, Teresa Wade, Annie Sadoo, Peter Brindle, Lisa Carver.
The authors would like to acknowledge the funder of this study: National Institute for Health Research Health Technology Assessment (HTA) programme.
The authors would also like to acknowledge the contribution of the Study Steering Committee members, namely Frank Sullivan, Matthew Thompson, Rafael Perera, Cliodna McNulty and Malcolm Coulthard, and the support from the local Primary Care Research Networks (PCRNs), Comprehensive Local Research Networks (CLRNs) and National Institute for Social Care and Health Research – Coordinating Research Centre (NISCHR-CRC).
Prevalence of urinary tract infection in childhood: A meta-analysis
How Best to diagnose urinary tract infection in preschool children in primary care?
Prevalence of urinary tract infection (UTI) in sequential acutely unwell children presenting in primary care; Exploratory study
A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial
Clinical and demographic factors associated with urinary tract infection in young febrile infants
Unexplained extra visits to general practitioners before the diagnosis of first urinary tract infection: a case–control study
The struggle to diagnose UTI in children under two in primary care
Obtaining urine for culture from non-potty-trained children
Prevalence of urinary tract infection in febrile infants
New renal scarring in children who at age 3 and 4 years had had normal scans with dimercaptosuccinic acid: follow up study
Pediatric Uroradiology
Effect of symptomLess bacteriuria in childhood on subsequent pregnancy
Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up
Childhood reflux and urinary infection: a follow-up of 10–41 years in 226 adults
Is reflux nephropathy preventable, and will the NICE childhood UTI guidelines help?
Antibiotic prescribing in general practice and hospital admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children: time trend analysis
Reduced antibiotic prescribing for acute respiratory infections in adults and children
Prognosis and prognostic research: Developing a prognostic model
What do we mean by validating a prognostic model?
Clinical decision rule to identify febrile young girls at risk for urinary tract infection
Validation of a decision rule identifying febrile young girls at high risk for urinary tract infection
Pyelonephritis and bacteriuria. A major problem in preventive medicine
Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months
Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model
Antibacterial prescribing in primary care
Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis
Technical report: urinary tract infections in febrile infants and young children. Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement
Home collection of urine for culture from infants by three methods: survey of parents' preferences and bacterial contamination rates
Redefining urinary tract infections by bacterial colony counts
Epidemiology of bacteriuria during the first year of life
Six year follow up of infants with bacteriuria on screening
Is ritual circumcision a risk factor for neonatal urinary tract infections?
Management of urinary tract infection in children
Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care
Development and psychometric evaluation of the TAPQOL: A health-related quality of life instrument for 1–5 year-old children
Two-sided confidence intervals for the single proportion: comparison of seven methods
Using regression models for prediction: shrinkage and regression to the mean
Pre-publication history
The pre-publication history for this paper can be accessed here:


text:
Toy train videos for children – Train for kids videos – chu chu train
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Learn Colors for Children with Thomas the Train | Colours Painting | Learning Video for Toddlers
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subset: commoncrawl


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We work from home. We get sales calls all the time for one thing or another. They never care that we're working and that they are interrupting us.
Today Steve answered the phone to one…wanting to sell us an extended warranty on a car wehaven't owned in awhile. Here's what happened:
Steve: "OMG! I am so glad you called!"
SalesGuy: "Um, yeah? Me too!"
Steve: "I really think I'm going to be able to help you out today!"
And then he proceeded to give the guy a sales pitch on ExtraHelp.US, our web solution company. The guy kept trying to get a word in, but Steve kept on, telling him all the wonderful things we could do for their company, building them a customized database, a custom web design, logo creation, etc. Finally the guy said,
"Sir! I…this…well, I'm on my employer's business line and I'm not supposed to talk about other business on it."
Steve: "Oh, I'm sorry…it's an inconvenient time for you?"
SalesGuy: "Yes, Sir."
Steve: "And I bet it's not something you need, since you didn't ask me to call you."
SalesGuy: "Um, well, no, Sir."
Steve: "Huh. Now you know how I feel when guys like you call me for things I never requested while I'm trying to work."
SalesGuy: "Uh…I…uh…I'll take you off the list."
Steve: "Thanks." *click*


text:
A New Essay on Green Revolution! The Green Revolution is a success story of post independence period in increasing food production in India. In early fifties, India's food production was about 50 million tonnes annually and the population (in 1951-361) million was increasing at an alarming rate (1.25 percent —Average annual exponential growth rate). Taking […]
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Essay on Green Revolution in India
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Essay on Green Revolution in India! Essay # What is Green Revolution ? The introduction of high-yielding varieties of Indian seeds after 1965 and the increased use of fertilizers and irrigation are known collectively as the Indian Green Revolution. It provided the Increase in production needed to make India self-sufficient in food grains. The programme […]
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Cable Technician Jobs
Browse For Cable Technician Jobs. Find The Job Of Your Dreams On ValleyJobFinder.com Today!
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CABLE TECHNICIANS Immediate Openings for Installers! Will train. $2,000 hiring bonus. Full benefits offered, must have a clean DL. Minimum 21 years old. Bring current DMV report when applying. Call 209-639-3927 to apply More Details


text:
Suffering from Flappy Bird withdrawal? This may help
Digital Reporter
Monday, February 10, 2014, 10:49 AM -
If you have a smartphone, you're probably aware of the wildly popular game "Flappy Bird".
The seemingly impossible to beat game has been downloaded more than 50 million times -- but creator Dong Nguyen decided to removed the app from the Apple and Google mobile stores over the weekend, citing "stress" over the attention he had been receiving.
DOWNLOAD THE WEATHER NETWORK APP: Get hourly forecasts and severe weather alerts delivered right to your phone.
Now, smartphones equipped with the game are popping up on auction sites -- one selling for US $90,200.
If you're suffering from Flappy Bird withdrawal, you're in luck: we've put together a list of real-life flappy birds to cheer you up.


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A Denham Springs contractor on Monday sought to halt the bid process for Livingston Parish's road overlay program, saying the parish's bid documents ran afoul of state law and parish codes and contained numerous errors and omissions.
Earl Price, of Richard Price Contracting, said the Parish Council should put the bidding on hold until the errors are corrected, but Parish President Layton Ricks said the road overlay program is moving forward as scheduled. Bids for the work are due Nov. 12.
The parish's road engineer, Jim Delaune, of Burk-Kleinpeter Inc., said Price's concerns would be addressed through an addendum to the bid packet that would be sent to all participating contractors.
The contractors met with parish officials Monday morning to ask questions about the bid documents, after which Price sent a 10-page email to Ricks and several council members, detailing his concerns.
Price said the bid documents do not include the state's required bid form and seek information not allowed at this stage of bidding, including a list of the contractor's subcontractors and material suppliers. The advertisement for bids itself failed to meet state law requirements for notice of electronic bidding, he said.
The road design plans included in the bid packet also rely on old specifications for asphalt thickness and road bases that the Parish Council overrode in 2009, when parish residents successfully petitioned to improve the parish's road standards, Price said.
"A lot of people worked too hard to put a stop to the 2-inch asphalt roads, and it would be a slap in their face if the parish goes back to that and we wouldn't want any part of it," he said in an email to The Advocate on Monday afternoon.
Price also took issue with some of the roads on the Parish Council's adopted priority list, saying some appear to serve only a few homes and do not appear to meet standards for acceptance into the parish maintenance system.
"But I realize that next year is an election year and this will be the only roads paved under the new administration but that isn't any reason to be wasteful and careless with our road fund money," Price wrote to parish officials.
Ricks said Monday that he believed the parish did everything correctly in its bid process for the overlay work.
"We didn't reinvent the wheel," Ricks said. "As far as I know, we did what we always do."
The parish's road overlay program has been largely dormant since the 2010 work that sparked a legal dispute between the parish and its former road engineering firm, Alvin Fairburn & Associates, where Ricks worked prior to his taking office in 2012.
The parish and Fairburn are embroiled in a pair of lawsuits over the issue: Fairburn sued the parish in April 2012, claiming it terminated the firm without cause; the parish then sued the firm for alleged overbilling.
Ricks sparked an ongoing battle with the Parish Council immediately after taking office when he paid Fairburn for a disputed $453,000 invoice. The council responded by removing all road work funds from the budget for 2013.
The two branches then fought for months over hiring another engineering firm. Ricks signed the Burk-Kleinpeter contract without council approval. The council, in turn, published its own advertisement for the work, receiving only one response, and again omitted road work funds from the 2014 budget.
A compromise was finally struck in December, when Ricks agreed to publish another request for proposals for the engineering work, then selected Burk-Kleinpeter from among the 10 responding firms. The council approved that choice in February.
Follow Heidi R. Kinchen on Twitter, @HeidiRKinchen.


text: Steve Sasco Designs is an American jewelry brand inspired by celebrities. AccessoriesEdit EarringsEdit Life Magazine w/ Swarovski crystalsAnnie Leibovitz (Sep 12, 2011)Add a photo to this galleryLinkEdit Official website Retrieved from "http://ladygaga.wikia.com/wiki/Steve_Sasco?oldid=189239" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected. Categories: Designers Accessories Add category Cancel Save


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|Thanksgiving Day Store Hours
|Black Friday Store Hours
|Regular Store Hours
|Mon-Fri 7:30am – 6:00pm
Saturday 8:00am – 5:00pm
Sunday CLOSED
Advanced Auto Parts is one of those stores that each location will have a slightly varying opening and closing time. That's why we won't be posting the Black Friday hours here because it's just too difficult for us to confirm them at ever one of their locations across the country. So before you step out your front door, it's probably best for you to confirm this 2016 holiday times with a store associate. Or better yet, just shop online this year 🙂
Either way, be sure to take a moment to browse our Advanced Auto Parts Black Friday page where you'll find our ad flyer and a list of the featured deals for 2016.
Are you shopping for some auto parts or are you looking for deals some killer accessories for your ride, like a new a new pair of wheels? Let us know what you will be buying at Advanced Auto Parts this coming Black Friday weekend!


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|Home > Ysmal
♂ Ysmal
What does Ysmal mean?
Ysmal [ys-mal] as a name for boys is of Arabic origin, and the name Ysmal means "God listens". Ysmal is an alternate form of Ismail (Arabic): variant spelling of Ishmael.
ASSOCIATED WITH arabic
VARIANTS Ysmail, Izmail, Ismayl, Ismal, Ismael▲, Ismaal
RELATION VIA ISMAIL IshmaelCREATIVE FORMS
(male) Samal, Yamal, ..
(female) Ysma, Ysmil, .. MIDDLE NAME PAIRINGS
Ysmal Koen (Y.K.), ..
How popular is Ysmal?
Ysmal is a rare given name for males. Ysmal is a rare surname too for both adults and children. (2000 U.S. CENSUS)
Which version is better?with its source form and related boy names. Ismael (#401 VIA LATEST LIST), Ismail (#1173) and Ishmael (#1229) are the prominent alternative forms of Ysmal (OUTSIDE TOP 2000). Other variants, like Ysmail, are seldom used. These forms of Ysmal were favored as birth names 9 years ago (MEDIAN #1068) and have remained as popular to this day (#934, DOWN 4%). Ismael is the most chic name for newborns among these. (TOP BABY NAMES, 2015)
Similar Names
Ysmal is alike in pronunciation to Ysmael. Other recommended names are Akmal, Amal, Aqmal, Gamal, Gemal, Hamal, Jamal▼, Jemal, Jimal, Jomal and Kamal. These names tend to be more commonly used than Ysmal.See names in meaning and etymology.


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Textured Bangle Bracelet Set of Three
This hammered and textured bangle bracelet set is so simple to wear and works well with anything in your wardrobe. Set of three includes bronze, copper, and brass open bangles. These are much more hammered and textured than our other set and catch the light beautifully. They layer perfectly with all of our bangle bracelets.
See our other hammered bangle set.
Adjustable to fit any wrist.
These bracelets are meant to be slipped onto your wrist and not bent open and closed. If you need to open the bracelet more to slip it on, do not pull the end apart but twist one end up, and the other end down.
Be sure to read our blog to ensure the integrity of these bangles: How to Bend Without Breaking: Bangle Bracelets, Nose Rings and More.
Materials: Brass, Bronze and Copper
Your purchase comes in a beautiful glossy silver foiled box that is ready to give as a gift or to keep for yourself.
Please be sure to read our shop policies before purchasing.


text: I would love to add a graphical banner of sorts just under my forums sub title text. It would need to be in the standard theme look and feel and have a graphic and be clickable so I can take users to a forum page about a contest. I think I saw a XenForo demo video that created a cool rotating graphical media area, but that might be only for v1.1 Thanks, Steve


text:
EFFORTS to overhaul a corporate image typically face challenges ranging from entrenched support for the status quo to the fear of selecting a symbol that might be lampooned as abstruse or derivative.
For instance, few in the corporate-identity field can forget how NBC once spent $750,000 on a makeover that included a stylized "N" nearly identical to the symbol created in-house -- for about $100 -- by an educational television network in Nebraska.
But what if the company planning a facelift is owned by a government that has undergone changes as substantial, sudden and startling as those ever experienced by any business? That is a primary reason for the national airline of South Africa, South African Airways, asking an unusual partnership to develop and introduce a revamped look for everything from the logos on the tails of the aircraft to the color scheme of the ticket folders.
The partners tackling that challenging task are Diefenbach Elkins, an American corporate identity consulting company that has worked for marketers like Eastman Kodak and Mastercard International, and Herd Buoys Advertising and Marketing, a South African advertising agency that represents clients like Coca-Cola and Eskom, the South African national broadcaster. The companies formed a joint venture in September 1995 and were awarded the airline assignment three months later; that work is expected to be completed in October.
"We're looking for something that gives us a break with the past and a key to the future," Ian Bromley, senior manager for marketing communications at South African Airways, said in a telephone interview from Johannesburg. "It's a process of revelation."Continue reading the main story
Mr. Bromley likened the new identity program, on which the airline will spend $3 million during a two-year period, to the changing of the South African flag after the white-led apartheid Government was replaced by one representative of the nation's black majority.
"The flag is a combination of images that people have found attractive," he said. "We see ourselves as having the same potential."
Unlike the flag, said Peter Vundla, managing director of Herd Buoys in Sandton, South Africa, the identity project must "reposition the airline not only internally but externally, too," because "the world has suddenly opened up to us after isolation."
"We've just come out from a regimented, divided and polarized society," he added, "and because of apartheid we were never able to develop a common national character or common 'South Africanism.' There's not a single identifiable unifying icon that all segments of the population can identify with."
The elements of the corporate identity program of South African Airways is indicative of that problem. Many black South Africans associate one color the airline uses, orange, with the apartheid regime; tellingly, the new flag omits orange from its six-color palette. And the airline's symbol of a "flying springbok" was derived from the springbok, a small gazelle, that the old Government prized as an icon.
"In World Cup rugby, the South African team was the Springboks, but blacks called it something else," said Tony McKeever, regional director for South Africa at Diefenbach Elkins in New York.
The "seismic changes taking place in South Africa" mandate a rethinking of how the airline presents itself to all constituencies, he added, particularly as competition from other carriers has intensified with the lifting of sanctions against the old Government.
John Diefenbach, chief executive of Diefenbach Elkins, said the new identity could also prove helpful as the South African Government considers a so-called restructuring of state assets -- that is, the sale of stakes in enterprises like South African Airways, Eskom and Telkom, the Government-owned telecommunications company.
Diefenbach Elkins, which has produced identity programs for airlines like Air Canada, and Herd Buoys were selected for the South African Airways assignment from an initial field of 19 contenders that was narrowed to 4 finalists. The partners will work with the airline's advertising agency, Sonnenberg Murphy Leo Burnett in Johannesburg, which is the South African affiliate of the Leo Burnett Company in Chicago.
A team of executives from Diefenbach Elkins and Herd Buoys will soon begin canvassing South African consumers and airline employees as well as reviewing research among fliers in overseas markets. The airline is perhaps best known internationally for a 1994 commercial by Sonnenberg Murphy that showed the birth of a baby aboard a flight.
Mr. Vundla said the team would examine "the flora and fauna" of South Africa for potential icons, adding that the national cricket team has adopted "the protea, a wild flower that grows all over the country."
Mr. Bromley several times mentioned a characterization of the new South Africa by Nelson Mandela, the new President, as "a rainbow nation." So could a rainbow symbolize South African Airways?
"Can you imagine the production costs?" he asked, laughing. "And besides, we have to be able to execute it in monochrome, too."Continue reading the main story


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Doctor insights on:
Itchy White Rectum
I have an itchy rectum ?
Pruritus ani: Pruritus ani is a medical condition that causes an itchy rectum. A number of foods have been associated with this condition: spices, hor sauces, pepper, coffee, tea, carbonated beverages, milk products, tomatoes, tomato products, white bread. You may want to delete some of these foods and see it that helps. Other causes include pinworms, hemorrhoids, psoriasis, diabetes and yeast. ...Read moreSee 1 more doctor answer
Rectum (Definition)
The rectum is the last portion of the GI tract where the colon ends. It is heavily muscled and generally remains contacted to control the colonic contents but is under conscious control when a ...Read more
I have large, itchy, flaking, dark patches on my pubic area and rectum?
Intertrigo: Intertrigo (intertriginous dermatitis) is an inflammatory condition of skin folds, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation. Intertrigo frequently is worsened or colonized by infection, which most commonly is candidal but also may be bacterial, fungal, or viral. Intertrigo commonly affects the axilla, perineum, inframammary creases, abdominal folds. ...Read more
Sudden oneset pinched like itchy feeling inside my rectum behind my anus ring. What could it be?
TimetoStopThDryClean: Could be you're not wiping that area enough after you unload. Try moistening the toilet paper a bit with some water (cold, not hot) and wipe thoroughly; also, try and push inside a bit to clean out that rim. If that doesn't work, keep doing that anyways and get some antifungal cream at the drug store and try using that three times a day for a week and if that doesn't work write back, there's more ...Read more
Itchy rectum, hemorrhoids or worms?
Your physician : Would help you to distinguish the two. ...Read more
Had an itchy rectum on and off for about 5 months, feel constipated and have had swabs taken that show nothing . What could this be?
Possibly hemorrhoids: have a doc take a look inside with a scope ...Read more
My rectum is itchy and I bleed a little when I excrete feces, what do I do?
See below: A common cause of anal itching in adults is called pruritus ani, leaving pinpoint spots of blood on the tissue from superficial skin inflammation. The most common causes are caffeine and excess moisture. Eliminate caffeine and keep the area dry with corn starch powder, not talcum powder. ...Read moreSee 1 more doctor answer
A clear/yellowish, odorless discharge coming from my rectum making it very itchy. What could this be?
Signs of Trouble: This situation, while common, may not lead to a full diagnosis. I would consider food allergies as the most likely cause. If there is any anal sexual history then we can discuss this. If there is redness or skin irritation one may consider yeast infection. ...Read more
I have an itchy rectum for the past few weeks, looked through the mirror in the hole, small tiny white particles like ulcers present ?
See GI specialist: If you truly have ulcers you should see a GI specialist and possibly get a colonoscopy with biopsies looking for inflammatory bowel disease such as Crhns or ulcerative colitis. However, if a lot of itching, may simply have hemorrhoids, worms (can place scotch tape on your rectum at night to look for), etc. ...Read more
Is an itchy anus or rectum also a symptom of an abscess down there?
Usually PAIN: Itchy anus often due to hemorrhoids, can be due to worms, skin irritation, fungal skin infection, psoriasis, lichen planus (skin condition), etc. Anal problems can lead to abscess (pus pocket)-generally very painful, with fever; itching would be the least of it. ...Read more
Nowdays after passing stools. My rectum is really itchy. What can I do to relieve it?
Anti-hemmorhoidals,,: Anti-hemmorhoidal ointment should help this. It has soothing, pain relieving chemicals that stop itching and burning. It is likely best to use this after pasing stools and cleaning yourself. ...Read more


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Chapter 1
It had been a busy few weeks for Sherlock, one of the most complex cases he had encountered yet, and he was glad that it was all over. However, as he was leaving the hospital he could not help feeling a tinge of sadness for he thought he would not have another case as mentally stimulating as this one for a long time. He was wrong.
He stepped out into the heavy rain and rushed across the car park towards the main road. He hailed a passing taxi which then stopped a few metres away.
"Where to?" Asked the driver as Sherlock clambered into the back seat.
"221B Baker Street"
He could not stop a sense of uneasiness running through him as he remembered his first case with Dr John Watson, 'A Study in Pink' as he called it. His thoughts drifted back to the case which he had so cunningly just solved and remained there until the taxi pulled up outside 221B Baker Street. He paid the driver and dashed to the front door, fumbling in his pocket for his key on the way. It wasn't until he was about to push his key into the lock that he noticed a small chip of paint missing from the doorframe, as if it had been forced open. He glanced behind him and saw that the taxi had not yet departed and the driver was watching him intently. He smiled at the driver as if nothing were amiss and turned back to the door, inserting the key into the lock and turning it slowly to prevent it from making a loud click and alerting anyone inside to his presence. He opened the door and went into the hallway as quietly as he could, closing the door softly.
His heart was racing as he glanced around, looking for any evidence of the unexpected visitor that had broken into the flat. He immediately noticed a single set of muddy footprints leading up the stairs into his and John's flat. John. Until that moment it had completely slipped his mind that his flatmate had returned hours earlier and may now be in danger.
"John" he murmured, as he peered up the staircase, listening intently for any sound that might reveal the intruder's whereabouts and, more importantly, if John was alright. He could hear two voices, both male. One he recognised as John, the other he had not heard before. He could not quite make out what they were saying but took reassurance from the fact that John was talking as it meant that he was not unconscious... or worse.
He twisted round and peered through the peep-hole in the door, the taxi was still waiting, the driver watching the door intently. He turned back to the stairs and slowly, silently crept up them, listening to the two men all the while. John and the intruder had suddenly stopped talking and Sherlock heard a thump followed by an agonising groan. He was becoming increasingly concerned towards the health of his friend as he crept ever closer to the door at the top of the stairs, leading into the flat.
He was halfway up the stairs when he spotted something lying on the step in front of him. It was an empty chewing gum packet. He picked it up and slipped it into his pocket, unsure of what it meant or of its relevance to the matter in hand but certain that he would, at some point, need it.
He quickly dashed up the last few steps and stood, silently beside the door, looking for anything that might give him a hint towards the intruder's identity.
"Come in Mr Holmes," the intruder called out brightly "we have been waiting for you to arrive for some time now."
Sherlock didn't reply and remained silent and unmoving beside the door.
"Mr Holmes, if you value you friend's life I suggest you show yourself." this time the voice was much more menacing and Sherlock had no doubt that the intruder would indeed kill John if he so wished. Instead of entering the flat, he called out "John?"
"Run!" was the reply, this time in John's voice, "Run Sherlock, Run! Don't worry about me, just get out of here!"
There was another thump and again John let out a cry of pain. Sherlock needed no more persuading, he reached out his hand and pushed open the door. It creaked on its hinges as it swung open and revealed the horrific sight that greeted him. Sherlock felt all his breath rush out of him as he took in the sight before him.
John sat, almost motionless, tied to his chair next to the fireplace with a thick length of rope. He had been badly beaten, his face was almost unrecognisable under the cuts and bruises. His left leg was bent at a strange angle and Sherlock could tell instantly that it was broken. The pain that he felt for his friend and an intense self-loathing consumed him briefly as he realised that this would not have happened had he allowed John to remain with him at the hospital instead of sending him home to get some rest.
He recovered from this brief lapse of self-control and proceeded to examine the intruder who now stood before him with a menacing smile upon his face and a long metal crow-bar in his hand. The last thing Sherlock saw was the cold, black eyes staring back at him as the crowbar struck his head and everything faded into darkness...


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Garmin Vivoactive Black
- DISPLAY – Ultra-thin, high-resolution, sunlight-readable, color touchscreen display
- GPS-ENABLED – Built-in GPS-enabled running, biking and golfing plus swimming and activity tracking apps let you view your stats-even when away from your phone
- Smart Notifications – Pairs with your smartphone1 to gently vibrate and display alerts for incoming calls, texts, email and calendar items plus notifications from social media and other apps
- BATTERY LIFE – Battery charge lasts through all your activities with up to 3 weeks in watch/activity tracking mode or up to 10 hours using GPS3.
- CONNECT IQ – Free downloads of watch faces, widgets, data fields and apps from our Connect IQ Store
- Ultra-thin, high-resolution, sunlight-readable, color touchscreen display
- Built-in sports apps, including GPS-enabled running, biking and golfing plus swimming and activity tracking, let you view your stats even when away from your phone
- Pairs with your smartphone to gently vibrate and display alerts for incoming calls, texts, emails and calendar items plus notifications from social media and other mobile apps
- Battery charge lasts through all your activities with up to 3 weeks in watch/activity tracking mode or up to 10 hours using GPS
- Customize with free watch face designs, widgets and apps from Connect IQ store
GPS Smartwatch for the Active Lifestyle Ultra-thin GPS smartwatch with a sunlight-readable, high-resolution color touchscreen Built-in sports apps, including GPS-enabled running, biking and golfing plus swimming and activity tracking, let you view your stats even when away from your phone Pairs with your smartphone to gently vibrate and display alerts for incoming calls, texts, emails and calendar items plus notifications from social media and other mobile apps Customize with free watch fac
Garmin Vivoactive Black
3 Responses to Garmin Vivoactive Black
594 of 605 people found the following review helpful
Running with the new Garmin Vivoactive,
March 16, 2015ByThis review is from: Garmin Vivoactive Black (Electronics)
I just finished my second run with the new Vivoactive. Although it's not apparently in stores yet, the Garmin booth at the Gate River Run expo had a few last weekend, so I bought one. I had been limping along with a Nike/TomTom GPS watch, but the non-replaceable band has been disintegrating for months and I had wired it together to get by until the new Vivoactive came out. Even with little time to get acquainted with the Vivoactive, I used it during the 15K the next morning and it performed perfectly.
Over the past ten years or so I've owned GPS watches from Timex, Garmin (twice) and Nike (twice). I've also been occasionally using my Galaxy S5 phone coupled with a Pebble watch and Endomondo for running and biking, so I can make some comparisons.
During the race, I had not yet had time to couple the Vivoactive to my phone, so I was using it merely as a stand-alone GPS watch. It's by far the smallest GPS watch I've owned and is comfortable and light, yet I was able to read the display without any problems. Like most watches in this class you can customize the data displays, but the standard one worked fine. The unit locked in to the satellites more quickly than any of my other watches and accuracy was as expected. At the end of the 15K it read 9.45 miles. That's about 1.3% high over the measured distance, and most runners know that's about right due to not being able to take the shortest route (especially in a race with 15,000 runners) and the small padding added by the certification process. I also wore my Nike watch at the same time, and it registered 9.43 miles.
Speaking of accuracy, I'm lucky to have an accurate, wheel-measured course starting at my driveway. During this morning's workout the watch signaled 1 mile intervals within 5 feet or so of the measured distances at 1, 2 and 3 miles. For some reason my Nike is usually off by about 75
feet at one mile, although it usually gets back on track by 2 or 3 miles. My Nike is also notoriously inaccurate in displaying pace during a run (usually 30 to 45 seconds fast), something that causes real problems for me. So I ran another measured mile this morning, trying to keep a slow,
steady pace to check the Vivoactive pace calculation. I was able to keep the pace display between about 8:55 and 9:35, with most readings between 9:10 and 9:15. After finishing the mile the Vivoactive showed a time of 9:09 for that mile…about as accurate as I could expect and a big improvement over the Nike.
I also sometimes run "Galloway" intervals, and have worn a second watch (Timex Ironman) to measure and display the run/walk intervals. So today I went ahead and set up the Vivoactive to handle that duty as well. It worked flawlessly. At first I thought I couldn't easily see the intervals
being timed (since I was displaying the usual Elapsed Time/Pace/Distance data screen during the run), but then I realized that by merely swiping the display sideways I could get to the data screen with the interval information. So that was a great convenience. I have not yet found a way to easily turn the interval timer on and off during a run though.
Now that I have the Garmin Connect app working on my Galaxy S5 phone, as soon as I got back to the house and picked up my phone all (and I mean ALL) the statistics of my run were displayed on my phone. That part was effortless. And as soon as I sat down at my computer and logged into my Garmin account it was all there as well. Absolutely flawless, with no effort necessary on my part at all.
So as far as an electronic running companion I really can't think of anything more I could ask for. All functions I use are there and work well.
As for the other functions, the watch has all the "activity tracker" functions currently in fashion. If I sit at the computer too long it bugs me to get moving. It measures my steps and compares it to my daily goal. It made a graph of how much I moved while sleeping last night. I'm really not
into all that stuff, so I can't make a real judgement on those features. Also, I don't have any add-on sensors (foot pad, heart monitor, cadence sensor, etc.) so I can't comment on how well those work. Knowing Garmin's extensive experience with those I would expect them all to work well.
I also don't play golf, so I can't vouch for that function. But it does sound like a cool feature.
As a smartwatch I can only compare it to my Pebble. Both watches do a good job of alerting you to any incoming notifications on the phone, and I would say the Vivoactive displays more data on the notification screen. It uses its color display to some advantage with that too.
I set up Pandora as my default music choice, and I would say the Vivoactive controls it more reliably than my Pebble. My one complaint there is that I can't give a "thumbs up" or "thumbs down" from the Vivoactive but I can with…
226 of 227 people found the following review helpful
I don't do many reviews, but I have been waiting for this kind of watch forever and I am VERY PLEASED!,
March 29, 2015ByThis review is from: Garmin Vivoactive Black (Electronics)
I don't do many reviews, but I have been waiting for this watch forever and I am VERY PLEASED!
Still very happy.
See new photos.
Have discovered the watch will charge faster when using a USB 3 port, 29% to 100% in under 90 mins.
Took a little trial and error to work out which cycling data screens to select and use auto scroll while riding.
Auto sync via Nexus 5 to Connect and auto sync to Strava is awesome, much better than using the Edge 500 and having to manually connect and sync.
GPS and battery consumption is exactly as described. After 3 cycling sessions of 4 hours total, 1/2 hour of yard work GPS on, 24 hours of step and sleep tracking battery, lots of screen swiping and backlight use it was down from 100% to 32%. Display while riding was easily readable for the numbers like speed, HR etc, but the text description of the data line was tiny and for me unreadable while riding, luckily I know what they are eg. page 1 = HR, Speed, Distance, page 2 = Time, Elevation, Cadence, but Garmin should make the text bigger.
Just like on the Edge 500, you have to remember to select your activity and also press start. Once you have started an activity, I don't believe you can use any of the watches other functions, so you should add whatever data you need to see to your visible / auto scrolling screens. (like time of day).
I ran multiple comparison cycling GPS sessions with my Edge 500 (when the dodgy button worked) and my Virb Elite which also has GPS and ANT+ sensor recording and they all matched to within the second and a tenth of a mile which was probably down to my button pressing. Strava segment times were identical on every one. (I compared about 30 segment results).
I did notice that after rides the step count had also gone up, not a big issue for me as I got my workout done so the step count was irrelevant, hopefully a software update will fix this.
Reading some of the negative reviews make sure you update the software by registering with Garmin Connect and using the charger in a PC. I think mine went through 2 updates. Also I had installed a IQ watch face app BigTime that made the watch reset multiple times so uninstalled and installed ActiFace Blue which works great. Also make sure your phone is compatible. My Nexus 5 works flawlessly with it.
Display indoors like at work or shopping is easily readable, at home in some of the darker rooms the time is easily readable, the smaller text or numbers on the more complex screens not so good, you have to use the back light. There is only one alarm, which in a dark room without my glasses on is a struggle to see how to turn it off (until it becomes muscle memory), but it does wake me up.
The sleep analysis is only available if you sync to your phone or PC and Connect, the data as usual says I don't sleep enough, I move quite a lot in the night and I get up around 3 am to go to the bathroom ….. getting old sucks.
The vibration alerts are gentle but noticeable, the "Move" vibration nudges are good for me, I sit at a PC a lot at work, so it encourages me to go talk to someone instead of emailing them or Lyncing / texting. The upcoming calendar events only display the current day events. Text, email and phone notifications are discreet, useful when in meetings etc.
I don't really use the music control so no comment but it works with the native music app.
I prefer to use my phone to check the weather, but the display on the watch is fairly good.
Primary goal achieved, I already got rid of that hateful Polar Loop, I have an ALWAYS ON WATCH DISPLAY (after the Loop disaster this was a biggy for me) and can retire the semi broken Garmin Edge 500.
Earlier Review:
I already have a Polar Loop (which I now hate), Garmin Edge 500 (which I messed up the on/off switch and broke the ears off, the reason I wanted this watch) and have a Garmin Virb Elite.
I considered replacing my Edge with a new one but it was too expensive and wanted to reduce the number of gadgets I have (plus I wanted to get rid of the Loop).
IF you are already in the Garmin ecoverse and setup on Garmin Connect already, then getting going with this watch is fairly easy. IF you are NOT then you WILL have a leaning curve just like buying any new gadget.
The transflective display is very good, easily readable in dim light (plus it has a back light)
The functionality in this watch for $249 is very hard to beat. I would recommend everyone read DCrainmaker reviews on this watch.
THE DISPLAY IS GREAT OUTDOORS, exactly what an outdoors person needs, not great indoors, what watch is? There's a backlight for indoors.
There is only a quick start manual with links to websites for the latest setup data, and it was pretty easy to get setup.
Garmin website…
159 of 162 people found the following review helpful
So far so good…screen a bit of a disappointment though.,
March 19, 2015ByJoe T –This review is from: Garmin Vivoactive Black (Electronics)
Out of the box, I've been pretty impressed with this watch. As someone who tried ad returned the Fitbit Surge due to the lack of functionality at that cost, I found this to be a very solid addition. With that said, there are some quirks and improvements to be had.
Activity Tracking – seems solid. When compared with the Fitbit Flex I had, it was pretty much right on with minimal variation. I actually think it calculates more accurate distance in general activity tracking than the Fitbit. This is based on me entering identical stride lengths in each app but Fitbit appearing to show a greater distance despite the calculations not adding up.
GPS/Workouts – only 2 so far but GPS came up quickly and tracked my run very well. The alerts for pace and distance worked well. I like the display that the screen offers and the fact that it can be customized. Does not seem that this supports workouts created on Garmin Connect though (at least for now)…this is one area where Garmin can improve.
Heart Rate monitor – this does not come with a HR monitor but I coupled this with my Schosce Rhythm Plus. This was extremely easy to set up and seemed to work well.
Watch Apps – Major potential here. Not too much Garmin IQ offers right now other than some Watch faces and such but this is where Garmin can really get some traction if they can get solids apps. Right now the ones that came loaded for workouts seem to be adequate…the apps that you can get will supplement the data that you can see (e.g. different ways of displaying heart rate, elevation, etc.). I'm also a fan of the built in Weather widget. It seems very convenient that I can look at my watch and quickly get the current weather as well as the immediate forecast for the coming hours.
Smart Notifications – in addition to Text and Calls (like the Surge) it appears that any notification that comes up on my phone also displays, which is a positive to me.
Screen – this is by far the most disappointing area. In person, the colors are not as vibrant and it is not as bright. Touch sensitivity is solid.
Charging/Battery Life – so far so good. I was playing around a great deal with it right out of the box and it did not seem impact the battery very much. When I did put it on the charger, I was able to get a 20% increase within 30 minutes.
Garmin Connect App – not as strong as Fitbit but I had not problems setting it up and customizing. Does not seem that there are many people using it as of yet though; it does, however, synch well with other tools such as Strava.
It's only been a day but I'm not having that disappointed feeling as I did with the Fitbit Surge. I have enjoyed the few workouts I've done with this and can see myself keeping this for some time. To me, it was worth the wait and for the price, it really does a great deal, especially when you compare it to other watches at the same price point. I will update this as I see fit after some more rigorous use in the coming days/weeks.
UPDATE March 20
Sleep tracking – You do have to turn it on and off. I agree that given what is out there now, auto sleep should have been part of the package…perhaps a firmware update, Garmin? The tricky part is finding where that is. In order to do it, you have to go to the Activity tracking widget screen and then expand the menu by pressing the bottom right of the watch. Once you're in sleep mode, its easy to remember to turn it off since it clearly states you are in SLEEP mode when you look at the watch for the time. If you get up in the middle of the night, I wouldn't bother turning it off and on again. It will just register as "movement" when you look at it on the graph the next day.
Battery life – so I went to bed and my battery dropped significantly last night. I'm wondering if it is b/c the GPS was pretty much on the whole time. By default, the setting appears to be in the ON mode. I just turned if off and verified that when I go into an activity mode (RUN, WALK, etc.), I still get a GPS signal. I'm not clear as to what the purpose of the On/Off setting for GPS is.
Also, the manual is not very helpful at all. Really just gets you through pairing your device. Once you are in that you pretty much have to figure out how to get to different menus and change settings (e.g. alerts while on runs, etc.) on your own.
UPDATE – March 26
Just a quick comment on battery. Apparently there is an issue with Bluetooth where if you are just out of range of your phone for, the battery will drain very quickly. This has been a particular problem for me when I go to sleep as I don't typically bring my phone with me. They way it was explained to me was that when your phone is close enough that the Vivoactive is searching and is just in range that it will connect and disconnect constantly from your phone all night and that is what is draining the…


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Om Katie
I have owned dogs all my life up until I moved back to Stockholm and haven't had the time to have one full time. Along came dog buddy.se and it is perfect for when I have days off and weekends at home where I can take care of a dog for dog owners. I live in a cosy and calm area here in Nacka. There is a lot of nature around here so going out to play and walk is never an issue of course. In the photos I have attached a few pictures of me with dogs I have had before. My sambo is allergic so I can only take dogs of no shedding - minimal. Dog-sitting is an absolute pleasure for me! Your dog will be taken great care of, walked, fed/watered and played with. Welcome!+ Mer
- Boendetyp: Lägenhet
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- Utomhusplats: Balkong, Trädgård