LAUSR

We have all heard the mantra of the physician’s role attributed to Hippocrates: “First, do no harm.” This quotation is often thought to come directly from the Hippocratic Oath. It actually originates from another work attributed to Hippocrates, Of the Epidemics. I find that the entire quotation from this work is worth reading: “The physician must be able to tell the antecedents, know the present, and foretell the future [emphasis added]dmust mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.” I had never thought of my practice in these terms, but as physicians we are asked to have great powers of omniscience! If we break it down, it takes me back to some of the basic tenets that we all learned in medical school. Hippocrates tells us we must 1) tell the antecedentsdtake a thorough history, 2) know the presentdassess the patient now, do a physical examination, evaluate appropriate imaging and laboratory tests, and 3) foretell the futuredwhat will happen if we do nothing and what will happen with various treatments/interventions. The first 2 tasks are fairly straightforward. Understanding the patient’s past and the present condition is a matter of taking the time to do your homework and focus on the individual in front of you. The final task, and the one I find more daunting, is to foretell the future. Who will get sick? Who will get better? Is there a treatment or intervention that will prevent my patient from becoming worse? This issue becomes particularly challenging in conditions where there is a broad spectrum of disease, such as spina bifida. However, if we know the past and carefully follow the present, we can follow trends and use them to try to predict, and alter, outcomes. This is the rationale for surveillance. The primary goal of urological management in patients with spina bifida is preservation of renal function. Interventions to improve quality of life cannot supersede this primary goal. We collect data in the present and compare them to past data points, looking for trends that will give us a glimpse into the future. In this issue of The Journal Chu et al (page 578) examine just how closely we are following kidney function in spina bifida clinics around the country. Based on guidelines from a number of societies, the authors used renal ultrasound and serum creatinine (Cr) as markers of kidney function surveillance. Using the National Spina Bifida Patient Registry, they examined more than 5,000 patients across 23 clinics and found that only 62% had undergone both a renal ultrasound and serum Cr testing during 2 years of followup. The range among clinics was 6% to 100%, and on multivariable analysis clinic site was found to be significantly associated with surveillance rate. Clinics did much better at performing renal ultrasound alone, with 93% of patients undergoing imaging during a 2-year window. It must be acknowledged that our tools for surveillance are not perfect. The quality of ultrasound imaging can vary greatly depending on the sonographer performing the study, the equipment employed and the body habitus of the patient. While serum Cr has been used as a marker for estimating renal function, it may not be reliable in patients with low muscle mass, such as those with spina bifida, and the authors acknowledge that some centers may be drawing cystatin C levels instead of serum Cr. Finally, many urologists also rely on urodynamic data to help determine which patients are at increased risk for upper tract deterioration. However, we have found that variability in the interpretation of urodynamic tracings even among experienced pediatric urologists makes this test imperfect. Even if our tools for surveillance were perfect, the authors make it clear that there is no consensus among current guidelines as to how frequently surveillance should be performed in order to be cost-effective and capture the data needed. Ultimately it is up to the clinician to decide how to use the data collected. Those who prefer expectant