Bladder Bowel Dysfunction Research Articles

430 - A new evaluation method for children with bladder bowel dysfunction: Pelvic floor muscle activity (PFMA)

430 - A new evaluation method for children with bladder bowel dysfunction: Pelvic floor muscle activity (PFMA)

Microsurgical Excision of T12-L1 Pial Arteriovenous Malformation: 3-Dimensional Operative Video.

This 29-yr-old man presented with progressive paraparesis, sensory loss, allodynia, bowel, and bladder dysfunction for 9 mo, acutely exacerbated in the preceding 24 h. Magnetic resonance imaging scan showed multiple dilated vessels involving the thoracic cord. Spinal angiogram revealed a T12-L1 pial arteriovenous malformation (AVM)/arteriovenous fistula on the left side. It was fed by an L1 radicular artery that filled the anterior spinal artery, which in turn had multiple feeders to a pial AVM. Because of the supply from the anterior spinal artery with multiple feeders to the AVM, and the danger of infarction of the conus, embolization was not performed. He underwent T11-L1 laminectomy laterally to the pedicles and excision of AVM. There was one large arterialized vein in the midline that had a fistulous connection with an artery coursing up from inferiorly. Despite occlusion of this fistula, the vein was still arterialized. On further exploration, there was a large artery coming in to the subarachnoid space at the T11 level and coursing inferiorly, and entering the intradural pial AVM with a glomus of vessels located at the T12 level in the left anterolateral subpial aspect of the cord. This major artery as well as multiple smaller vessels going into it were cauterized and divided, and the AVM was totally excised. Postoperative angiogram showed complete excision of the nidus. At 1 mo follow-up, he had complete recovery of motor and bladder functions but bowel dysfunction persisted. He was independent for his daily activities. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Vesicoureteral reflux and recurrent urinary tract infections

Vesicoureteral reflux (VUR) refers to backflow of urine from the bladder into the upper urinary tract. Children with high-grade VUR are at risk of recurrent urinary tract infections (UTIs). It is commonly associated with bladder–bowel dysfunction, necessitating treatment because it further increases the risk of recurrent UTI and results in delayed resolution of VUR. Almost one-third of patients with VUR diagnosed following UTI show renal scarring. It is debated whether scarring in VUR is entirely acquired following UTI or due to dysplasia. The efficacy of antibiotic prophylaxis has been variable for the prevention of UTI in children with VUR. A meta-analysis suggests that it might be of some benefit in preventing UTI, but not renal scarring and at cost of bacterial resistance. Due to questionable efficacy and potential risk, use of antibiotic prophylaxis should be based on risk stratification rather than mere presence of reflux. In view of lack of significant improvement in long-term outcomes with current available interventions, there is ongoing debate on the aggressiveness of algorithms for diagnosing VUR following UTI. Long-term complications of VUR include proteinuria, hypertension, and end-stage renal disease. As opposed to previous assumption, the risk of end-stage renal failure and hypertension is fairly small with scarring following UTI.

Acute meningitis complicated by transverse myelitis: A rare complication

Acute meningitis can be complicated by intracranial complications commonly and rarely by spinal cord dysfunction. The causes of spinal cord dysfunction are cord compression, ischemic infarction of the cord, and acute myelitis. Magnetic resonance imaging (MRI) of the cord is the choice of investigation which not only helps to rule out any compressive lesion but will also confirm the diagnosis of myelitis. The usual findings of myelitis on MRI spine are the hyperintensities in T2-weighted images that predominantly involve the gray matter and usually extend from the cervical to the lumbar cord. Usually, patients are left with some residual deficits including spasticity, weakness, walking difficulties, and bowel–bladder dysfunction. We report a case of acute meningitis which was complicated by acute transverse myelitis.

Encouraging Results of Bowel and Bladder Management in Spina Bifida Aperta in South India with Quality of Life Scores in a Tertiary Care Institution in South India.

Context:It is often a challenge to counsel parents with children operated for spina bifida aperta in developing countries. Data regarding the efficacy of simple measures and preventive are scarce.Aims:The aim of this study is to study such children for the incidence, prevalence of bowel bladder dysfunction, and the quality of life (QOL) in children who are involved with a multidisciplinary team in India.Materials and Methods:All children with spina bifida occulta were followed – QOL questionnaires (PIN Q, modified Barthels activities of daily living , and the visual analog score [VAS]) were used. Interventions, such as clean intermittent catheterization (CIC), bowel enemas, and surgical procedures, were studied.Results:A total of 68 children were assessed. Twenty-nine of these children over five were evaluated with QOL scores. The prevalence of incontinence of bowel and bladder was studied. The primary outcomes included the QOL scores, and the various surgical options help bowel and bladder management. Hydronephrosis in 17.95% of children <5 years and 65.5% of children over 5 years was noted. Nineteen children were socially independent for their bowel management. The Barthel index and PIN-Q showed a poor QOL in 27.6% and the VAS in 34.5% had the same. This translated to an acceptable QOL for over two-thirds of the children.Conclusions:Simple procedures and training for bowel management translate to a significant number of children being able to independently manage bowel care. About 30% of children develop hydronephrosis by 5 years; the decision to teach CIC must be made by then. We believe that positive counseling is given to the parents of children with spina bifida aperta as the children are capable of a reasonable QOL.

Urinary disorders and bladder-bowel dysfunction in children: approaches to diagnosis, treatment and prevention

Pediatric urinary disorders manifested as urinary incontinence, compelling urges to urinate, etc. remain an important problem of contemporary healthcare. In spite of being extensively covered in the literature, urinary disorders, including enuresis, still present a diagnostic challenge to the physicians of primary healthcare facilities. Based on the findings of our retrospective study that revealed discrepancies between referral and final diagnoses of pediatric urinary disorders, we give recommendations to both physicians of primary healthcare facilities and their inpatient care colleagues that will help them to arrive at the correct diagnosis of a urinary disorder or concomitant bladder-bowel dysfunction using the proposed diagnostic algorithm.

Pelvic floor biofeedback therapy in children: Assessment of symptom scores in responders and non-responders.

Pelvic Floor Biofeedback Therapy (PFBT) can be an effective treatment for pediatric lower urinary tract symptoms (LUTS). Due to differing perceptions of efficacy and practice patterns, we sought to further evaluate PFBT in our practice. We hypothesized that PFBT results in quiescence of EMG activity during voiding and improves questionnaire scores in patients with LUTS. We retrospectively reviewed all patients undergoing PFBT and refined the analysis to females ≥6 years old with ≥2 sessions with completed voiding questionnaires pre- and post-treatment, active EMG during voiding, with non-neurogenic urinary tract complaints refractory to standard urotherapy. Validated Bladder Bowel Dysfunction (BBD) questionnaires were collected at each visit. Quiescence of EMG activity and changes in BBD score were the primary outcomes. 229 patients underwent ≥1 PFBT session, of which 64 females ≥6 years of age with ≥2 PFBT sessions and completed pre and post PFBT voiding questionnaires were identified. In this group, mean age at PFBT start was 10.1 (6.2-17.0). Patients completed 3.1 sessions (2-6). No difference was seen in post-void residual (PVR) between first and last session (23.8 vs 22.6 mL, P = 0.55). Median questionnaire score decreased from 18 (4-42) before to 13 (2-28) following PFBT (P < 0.0001). Responders, characterized by silencing of the EMG after PFBT, occurred in 31% (20/64). Non-responders were younger (P = 0.007) with higher pre-PFBT questionnaire scores. The use of PFBT appears to result in a significant reduction in symptom scores, though quiescence of EMG was observed following therapy in less than 1/3 of patients.

The effectiveness of biofeedback therapy in managing Bladder Bowel Dysfunction in children: A systematic review.

The purpose of this study was to examine the effects of biofeedback therapy as a non-invasive intervention to treat Bladder Bowel Dysfunction in pediatrics. Six databases were searched between February 2016 and September 2016. Biofeedback studies for children aged 4-16 with idiopathic urinary or fecal incontinence were included. Articles were excluded on subjects' medical histories, study design, timeline of study, and lacking expert review. Quality was determined using Sackett's Levels of Evidence and the PEDro scale. Twelve articles were included in the review. Quality of evidence was moderate, as the average PEDro score of the selected articles was 5.3. The participants' ages ranged from 4-16 years old. Studies demonstrated that a multifactorial approach consisting of biofeedback therapy and behavioral modification can be successful in resolving Bladder Bowel Dysfunction. Biofeedback is a beneficial treatment for children with dysfunctional voiding and functional fecal incontinence. More conclusive research needs to be completed to explore the effects of biofeedback therapy treatment to make more concrete conclusions. Healthcare professionals should consider biofeedback as an alternative approach in conjunction with traditional treatments. A multidisciplinary approach is best when treating dysfunctional voiding and functional fecal incontinence in the pediatric population.

Clinical Outcomes of Surgical Treatment for Arachnoid Web: A Case Series.

Introduction We describe 5 patients who underwent operative treatment for arachnoid web (AW) and discuss the postoperative clinical outcome in each case. AW is an extremely rare disease that causes cord compression and syringomyelia in the thoracic spine. To date, 14 cases only of AW have been reported, and the effect of surgical intervention on clinical and radiologic outcomes is unknown. Methods Five patients who underwent surgical treatment for AW were retrospectively reviewed. The clinical outcomes were evaluated using the thoracic Japanese Orthopaedic Association (T-JOA) score. Preoperative and postoperative images were reviewed. Results All the patients presented with spastic gait and numbness in the lower extremities. Two patients also presented with bladder-bowel dysfunction (BBD). AW, or the so-called “scalpel” sign, was seen dorsally in the thoracic spine on magnetic resonance imaging in all the patients. Syringomyelia adjacent to the web was observed in 4 patients. Fenestration and web resection without instrumentation was performed in all the cases. Overall, significant improvement was seen in locomotion and the total T-JOA score postoperatively. However, numbness in the lower extremities improved in 2 patients but was unchanged in 3 cases. BBD was ameliorated in 1 patient but remained unchanged in the other patient. Conclusions Our experience suggests that surgical treatment, including the another patient and resection of the web, can correct the flow dynamics of cerebrospinal fluid and allow neurologic recovery, in particular locomotion, in patients with AW.

Bladder-Bowel Dysfunction in Children: Consequences, Risk Factors and Recommendations for Primary Care Interventions

The goals of this paper are to review potential risk factors and emerging insights into nature of bladder-bowel dysfunction (BBD) and highlight a patient-centered approach to management, which can begin in the primary care setting. (1) BBD is documented in about half of patients with vesicoureteral reflux and increases potential for renal scarring. (2) Neurodevelopmental and environmental factors are associated with BBD and greater understanding of a neurocentric basis for BBD is emerging. (3) A patient-centered approach to care is required. The way in which children and adolescents understand their bladder, bowel, or continence problem can influence coping strategies and adherence to treatment. Early identification and treatment of BBD is important to prevent significant medical and social burden. The primary care provider with foundational knowledge of the causes and risk factors for BBD and an established relationship with a patient and family is well suited to identify BBD and begin management.

Robotic-assisted laparoscopic ureteral re-implant (RALUR): Can post-operative urinary retention be predicted?

Urinary retention following robotic-assisted laparoscopic extravesical ureteral reimplantation (RALUR) is proposed to be due to traction or injury of the pelvic parasympathetic nerve plexus during distal ureteral dissection. Nerve-sparing techniques have been employed to avoid injury to the pelvic plexus, either directly or indirectly. This single-center study assessed postoperative urinary retention rates after extravesical RALUR and investigated whether demographic or operative factors could predict this occurrence. All RALUR cases entered into an Institutional Review Board-approved registry were retrospectively reviewed, and the rate of postoperative retention was determined. Postoperative urinary retention was defined as the need for catheterization at any time in the postoperative period during hospital admission or within 1 week after the operation. This included acute urinary retention episodes (AUR) as well as high post-void residuals (>50% of expected bladder capacity). Univariate analysis was performed to analyze for predictors of postoperative retention. Factors assessed included age, gender, clinical presentation, bowel bladder dysfunction (BBD), pre-operative urinary tract infection (UTI), procedure length, grade of vesicoureteral reflux (VUR), and operative laterality. A total of 128 patients underwent extravesical RALUR in 179 ureters during the study period 2012-2016. Male:female ratio was 1:2.6. Median age at surgery was 4 years. Bilateral RALUR was performed in 52 cases (40.6%), and unilateral in 76 (59.4%). Urinary retention requiring catheterization occurred in 11 cases (8.59%). Of these, seven were post-bilateral RALUR, while the remaining four were unilateral. In seven cases, postoperative retention occurred within 24h following RALUR. The remaining four instances occurred within 1 week, despite successful voiding in the immediate postoperative period. Univariate analysis revealed male gender (P=0.009) and operating room time (P=0.029) as predictors of retention. No association was found with age, weight, BBD, pre-operative UTI, grade of VUR, or laterality. Urinary retention after RALUR was an infrequent complication. When it did occur, urinary retention appeared to be secondary to covariates such as male gender and length of surgical time - possibly an indication of technical difficulty - rather than laterality of repair.

Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children's Continence Society.

We present a consensus view from the International Children's Continence Society (ICCS) on the evaluation and management of bladder bowel dysfunction (BBD) in children with urinary tract infection (UTI). The statement aims to highlight the importance of BBD in the development and recurrence of childhood UTI and its management to reduce its associated morbidity and sequelae. A systematic literature search was done on PubMed, Embase, and Scopus databases until August 15, 2016. Relevant publications concerning BBD and its relationship with UTI among children were reviewed and aggregated for statements of recommendation. Discussion by the ICCS Board and a multi-disciplinary core group of authors resulted in a document available on its website for all ICCS members to review. Insights and feedback were considered with consensus and agreement reached to finalize this position statement. BBD in children with UTI is summarized. Details regarding epidemiology, pathophysiology, and recommendations for general and family practitioners and pediatricians relating to the evaluation and management of this condition are presented. This document serves as the position statement from ICCS, based on literature review and expert opinion providing our current understanding of BBD in children with UTI.

Distal Ureteral Diameter Ratio is Predictive of Breakthrough Febrile Urinary Tract Infection.

Distal ureteral diameter ratio is an objective measure that is prognostic of spontaneous resolution of vesicoureteral reflux. Along with likelihood of resolution, improved identification of children at risk for recurrent febrile urinary tract infections may impact management decisions. We evaluated the usefulness of ureteral diameter ratio as a predictive factor for breakthrough febrile urinary tract infections. Children with primary vesicoureteral reflux and detailed voiding cystourethrogram were identified. Ureteral diameter ratio was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1 and L3 vertebral bodies. Demographics, vesicoureteral reflux grade, laterality, presence/absence of bladder-bowel dysfunction, and ureteral diameter ratio were tested in univariate and multivariable analyses. Primary outcome was breakthrough febrile urinary tract infections. We analyzed 112 girls and 28 boys with a mean ± SD age of 2.5 ± 2.3 years at diagnosis. Vesicoureteral reflux was grade 1 to 2 in 64 patients (45.7%), grade 3 in 50 (35.7%), grade 4 in 16 (11.4%) and grade 5 in 10 (7.2%). Mean ± SD followup was 3.2 ± 2.7 years. A total of 40 children (28.6%) experienced breakthrough febrile urinary tract infections. Ureteral diameter ratio was significantly greater in children with (0.36) vs without (0.25) breakthrough febrile infections (p = 0.004). Controlling for vesicoureteral reflux grade, every 0.1 U increase in ureteral diameter ratio resulted in 1.7 times increased odds of breakthrough infection (95% CI 1.24 to 2.26, p <0.0001). Children with increased distal ureteral diameter ratio are at greater risk for breakthrough febrile urinary tract infections independent of reflux grade. Ureteral diameter ratio provides valuable prognostic information about risk of recurrent pyelonephritis and may assist with clinical decision-making.

Controversies Regarding Management of Vesico-ureteric Reflux.

The primary goal in the management of a child with urinary tract infection (UTI) is to prevent recurrence of UTI and acquired renal damage. Approximately 15% of children develop renal scarring after a first episode of febrile UTI. Vesico-ureteric reflux (VUR) is diagnosed in 30-40% of children imaged after first febrile UTI. The 'top-down' approach involving ultrasound and dimercaptosuccinic acid scan (DMSA) first after an appropriate interval following UTI, can help in avoiding voiding cystourethrogram (VCUG), an invasive test with higher radiation exposure. The majority view remains that VCUG should be done after the second attack of UTI in girls and first attack of UTI in boys. Although the evidence in favour of antibiotic prophylaxis remains doubtful in preventing renal scars associated with VUR, it remains the first line treatment for high-grade reflux (grade 3-5) with an aim to prevent UTI and allow spontaneous resolution of VUR. Early identification and appropriate treatment of associated bowel bladder dysfunction is an essential part of successful medical management of VUR. Endoscopic treatment of VUR, using a bulking agent, is useful in grade 3 VUR. The main controversy regarding intervention (endoscopic/open surgical intervention) involves absence of strong evidence for these interventions in reducing renal scarring on randomized controlled trials. However, several recent trials have found the surgical interventions to be effective in reducing recurrent pyelonephritis and repeated hospital admissions.

Role of body mass index in school-aged children with lower urinary tract dysfunction: Does weight classification predict treatment outcome?

Lower urinary tract (LUT) dysfunction comprises a large percentage of pediatric urology referrals. Childhood obesity is a major health concern, and has been associated with voiding symptoms. We assessed the impact of body mass index (BMI) on treatment outcomes of children presenting with LUT or bladder-bowel dysfunction (BBD). Children aged 5-17 years diagnosed with non-neurogenic LUT dysfunction and no prior urologic diagnoses were identified. Patient demographics including BMI, lower urinary tract symptoms, constipation, medical and psychologic comorbidities, imaging, and treatment outcomes were evaluated. BMI was normalized by age and gender according to percentiles: underweight<5th, healthy 5th to <85th, overweight 85th to <95th, and obese>95th percentile. Uni- and multivariate analyses were performed to identify predictors of treatment response. During an 18-month period, 100 children (54 girls, 46 boys) met the inclusion criteria. The mean age at diagnosis was 7.7±2.4 years, and mean length of follow-up 15.3±13.1 months. Sixty-nine patients were a normal weight, 22 were overweight, and nine were obese. Fifteen percent of the children had complete treatment response, 63% partial response, and 22% non-response. On univariate analysis, children with elevated BMI (p=0.04) or history of urinary tract infection (p=0.01) were statistically more likely to not respond to treatment. Controlling for all other variables, children with BMI>85th percentile had 3.1 times (95% CI 1.11-8.64; p=0.03) increased odds of treatment failure (Table). BBD management includes implementation of a bowel program and timed voiding regimen, with additional treatment modalities tailored on the basis of the prevailing symptoms. We observed that school-aged children with a BMI≥85th percentile were over three times more likely to experience treatment failure when controlling for all other patient characteristics including constipation and a history of urinary tract infection. Limitations of the study include the relatively small sample size, lack of uroflow with electromyography to confirm the presence or the absence of detrusor sphincter dyssynergia, and inconsistent anticholinergic dosing. Nearly one-third of school-aged children presenting to our institution with LUT or BBD were overweight or obese when normalized for age and gender. Children with LUT dysfunction and elevated BMI are significantly less likely to experience treatment response.

MP61-11 A REEVALUATION OF THE RIVUR TRIAL WITH A VALIDATED RISK STRATIFICATION MODEL

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2017MP61-11 A REEVALUATION OF THE RIVUR TRIAL WITH A VALIDATED RISK STRATIFICATION MODEL Zhan Tao (Peter) Wang, Yasaman Alam, Irene McAleer, Ahmed Ali, Josh Chamberlin, Guy Hidas, and Antoine Khoury Zhan Tao (Peter) WangZhan Tao (Peter) Wang More articles by this author , Yasaman AlamYasaman Alam More articles by this author , Irene McAleerIrene McAleer More articles by this author , Ahmed AliAhmed Ali More articles by this author , Josh ChamberlinJosh Chamberlin More articles by this author , Guy HidasGuy Hidas More articles by this author , and Antoine KhouryAntoine Khoury More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1869AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial showed a 50% reduction in the risk for recurrent urinary tract infection (UTI) in children who received prophylaxis compared to placebo. This conclusion is heavily debated. We reevaluated the RIVUR data using a validated risk stratification model. METHODS Data from all 607 children were used. We stratified the children into low, intermediate and high risk categories based on gender, circumcision status, VUR grade and bladder bowel dysfunction. Febrile or symptomatic UTI recurrence in our stratified placebo and prophylaxis groups were compared using Fisher's exact test. Kaplan-Meier curves and a log-rank test was used for time-to-event analysis. RESULTS There were 389 (65%), 132 (22%) and 50 (8%) children stratified into low, intermediate and high risk categories. The rate of recurrent UTI was not significantly different in low risk children receiving either placebo or prophylaxis (Table 1). Whereas intermediate risk children receiving prophylaxis had a 20% absolute reduction in recurrence compared to placebo. Similarly, there were half as many recurrent UTIs in high risk children on prophylaxis; however this was not significant due to the small sample size. Time-to-event analysis showed no difference in recurrence between the stratified categories with placebo or prophylaxis (p=0.045). CONCLUSIONS The majority (65%) of the children in the RIVUR trial fell into the low risk category and do not benefit from prophylaxis, while intermediate risk children receiving prophylaxis showed a 20% absolute reduction in recurrence. These results favor an individualized approach for the optimal management of children with vesicoureteral reflux. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e803 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Zhan Tao (Peter) Wang More articles by this author Yasaman Alam More articles by this author Irene McAleer More articles by this author Ahmed Ali More articles by this author Josh Chamberlin More articles by this author Guy Hidas More articles by this author Antoine Khoury More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP61-09 DISTAL URETERAL DIAMETER RATIO IS AN INDEPENDENT RISK FACTOR FOR BREAKTHROUGH FEBRILE URINARY TRACT INFECTION

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2017MP61-09 DISTAL URETERAL DIAMETER RATIO IS AN INDEPENDENT RISK FACTOR FOR BREAKTHROUGH FEBRILE URINARY TRACT INFECTION Angela M. Arlen, Siobhan E. Alexander, Paul J. Guidos, Traci Leong, and Christopher S. Cooper Angela M. ArlenAngela M. Arlen More articles by this author , Siobhan E. AlexanderSiobhan E. Alexander More articles by this author , Paul J. GuidosPaul J. Guidos More articles by this author , Traci LeongTraci Leong More articles by this author , and Christopher S. CooperChristopher S. Cooper More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1867AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previous reports have demonstrated that distal ureteral diameter ratio (UDR) is an objective and reliable measure predictive of spontaneous resolution in children with primary vesicoureteral reflux (VUR). Improved identification of children at risk for recurrent febrile urinary tract infections (fUTI), along with likelihood of spontaneous resolution, may impact management decisions. We evaluated the effect of UDR as a predictive factor for breakthrough fUTI. METHODS Children with primary VUR and detailed voiding cystourethrogram (VCUG) were identified. Children were prescribed daily prophylactic antibiotics and followed with annual cystograms until reflux resolution or operative repair. UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between the L1-L3 vertebral bodies. Demographics, VUR grade, laterality, presence/absence of bladder bowel dysfunction (BBD), and UDR were tested in uni and multivariate analysis. Primary outcome was breakthrough fUTI. RESULTS One hundred and forty children (112 girls, 28 boys) met inclusion criteria. Mean age at diagnosis was 2.5±2.3 years, and mean length of follow-up was 3.2±2.7 years. VUR was grade 1-2 (n = 64, 45.7%), grade 3 (n = 50; 35.7%), grade 4 (n = 16; 11.4%) and grade 5 (n = 10; 7.2%). Forty children (28.6%) experienced breakthrough fUTI events. Children with breakthrough fUTI had significantly higher UDR than those without (0.25 versus 0.36; p = 0.004). Controlling for VUR grade, every 0.1 unit increase in UDR resulted in 1.7 times increased odds of breakthrough fUTI (95% CI 1.24-2.26; p<0.0001). Increased probability of breakthrough fUTI was observed with increased UDR; however increasing grade alone was not [Figure]. Forty-five children (32.1%) experienced spontaneous VUR resolution at a mean of 2.7±2.7 years. Ninety-five patients (67.9%) underwent surgical correction of VUR at a mean of 3.4±2.6 years from initial diagnosis. CONCLUSIONS Children with elevated distal ureteral diameter ratio are at increased risk for breakthrough fUTI independent of reflux grade. UDR was more predictive of breakthrough fUTI than either VUR grade or UDR combined with grade. UDR provides valuable prognostic information about risk of recurrent pyelonephritis and may assist with clinical decision-making. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e802 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Angela M. Arlen More articles by this author Siobhan E. Alexander More articles by this author Paul J. Guidos More articles by this author Traci Leong More articles by this author Christopher S. Cooper More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Risk Factors and Functional Impact of Medical Complications in Stroke.

ObjectiveTo determine the incidence and risk factors for medical complications in Korean patients suffering from stroke and the impact of such complications on post-stroke functional outcomes.MethodsWe assessed patients enrolled in a prospective cohort study. All recruited patients had suffered a first acute stroke episode and been admitted to nine university hospitals in Korea between August 2012 and June 2015. We analyzed patient and stroke characteristics, comorbidities, prevalence of post-stroke medical complications, and functional outcomes at time of discharge and 3, 6, and 12 months after stroke onset.ResultsOf 10,625 patients with acute stroke, 2,210 (20.8%) presented with medical complications including bladder dysfunction, bowel dysfunction, sleep disturbance, pneumonia, and urinary tract infection. In particular, complications occurred more frequently in older patients and in patients with hemorrhagic strokes, more co-morbidities, severe initial motor impairment, or poor swallowing function. In-hospital medical complications were significantly correlated with poor functional outcomes at all time points.ConclusionPost-stroke medical complications affect functional recovery. The majority of complications are preventable and treatable; therefore, the functional outcomes of patients with stroke can be improved by providing timely, appropriate care. Special care should be provided to elderly patients with comorbid risk factors.

Electroneurostimulation for the management of bladder bowel dysfunction in childhood.

Both non-invasive and invasive electroneurostimulation (ENS) modalities for bladder bowel dysfunction have been studied and reported in children. A summary of the proposed mechanism of actions and the more commonly used and recently reported techniques and outcomes are described. This includes transcutaneous electrical nerve stimulation, functional electrical nerve stimulation, intravesical electrical nerve stimulation, percutaneous tibial nerve stimulation and sacral neuromodulation in conditions including overactive bladder, enuresis, dysfunctional voiding, constipation, combined bladder bowel dysfunction and neuropathic bladder and bowel dysfunction. There is a need for further high quality randomised trials as well as long-term outcomes to establish whether ENS is able to alter the long-term trajectory for an individual child with bladder bowel dysfunction.

Computer model predicting breakthrough febrile urinary tract infection in children with primary vesicoureteral reflux

Factors influencing the decision to surgically correct vesicoureteral reflux (VUR) include risk of breakthrough febrile urinary tract infection (fUTI) or renal scarring, and decreased likelihood of spontaneous resolution. Improved identification of children at risk for recurrent fUTI may impact management decisions, and allow for more individualized VUR management. We have developed and investigated the accuracy of a multivariable computational model to predict probability of breakthrough fUTI in children with primary VUR. Children with primary VUR and detailed clinical and voiding cystourethrogram (VCUG) data were identified. Patient demographics, VCUG findings including grade, laterality, and bladder volume at onset of VUR, UTI history, presence of bladder-bowel dysfunction (BBD), and breakthrough fUTI were assessed. The VCUG dataset was randomized into a training set of 288 with a separate representational cross-validation set of 96. Various model types and architectures were investigated using neUROn++, a set of C++ programs. Two hundred fifty-five children (208 girls, 47 boys) diagnosed with primary VUR at a mean age of 3.1 years (±2.6) metall inclusion criteria. A total 384 VCUGs were analyzed. Median follow-up was 24 months (interquartile range 12-52 months). Sixty-eight children (26.7%) experienced 90 breakthrough fUTI events. Dilating VUR, reflux occurring at low bladder volumes, BBD, and history of multiple infections/fUTI were associated with breakthrough fUTI (Table). A 2-hidden node neural network model had the best fit with a receiver operating characteristic curve area of 0.755 for predicting breakthrough fUTI. The risk of recurrent febrile infections, renal parenchymal scarring, and likelihood of spontaneous resolution, as well as parental preference all influence management of primary VUR. The genesis of UTI is multifactorial, making precise prediction of an individual child's risk of breakthrough fUTI challenging. Demonstrated risk factors for UTI include age, gender, VUR grade, reflux at low bladder volume, BBD, and UTI history. We developed a prognostic calculator using a multivariable model with 76% accuracy that can be deployed for availability on the Internet, allowing input variables to be entered to calculate the odds of an individual child developing a breakthrough fUTI. A computational model using multiple variables including bladder volume at onset of VUR provides individualized prediction of children at risk for breakthrough fUTI. A web-based prognostic calculator based on this model will provide a useful tool for assessing personalized risk of breakthrough fUTI in children with primary VUR.