Detection Of Reflux Research Articles

Comparing methods for detection of gastro-oesophageal reflux in anaesthetized dogs

ObjectiveTo compare the sensitivity and specificity of pH with multichannel intraluminal impedance (pH-MII), pH-metry (pH) alone and MII alone to direct observation of GOR by endoscopy in anaesthetized dogs. Study designA prospective comparative trial in a live canine model. AnimalsA group of 35 (22 females, 13 males) dogs of various breeds. The mean (range) body weight and age were 31.9 (14–40) kg and 5.6 (0.75–12) years, respectively. MethodsAll dogs were premedicated with medetomidine and morphine, anaesthesia was induced with propofol and maintained on isoflurane in oxygen. A monitoring assembly consisting of an endoscopy camera, endotracheal tube and a disposable flexible pH-MII catheter was used to measure oesophageal pH, MII and directly visualize reflux. Visual reflux score was (0–3) and pH was recorded on a data capture sheet. Reflux was considered to have occurred whenever oesophageal pH was < 4.0 or > 7.5, device software analysing MII data detected fluid or a visual reflux score of 2 or 3 were assigned. Receiver operator curves (ROC) analysis was used to determine sensitivity and specificity for each monitoring method to detect GOR. ResultsEndoscopy identified GOR in 20 dogs (57%), pH-MII in 19 dogs (54%), pH alone in 13 dogs (37%) and MII alone in 12 dogs (24%). ROC analysis showed fair accuracy for pH-MII and pH alone, whereas MII demonstrated low accuracy. Conclusions and clinical relevanceIn conclusion, pH-MII is a reliable method for detecting GOR and emerges as a promising tool for future research. Endoscopy is reliable and provides the ability to subjectively quantify the volume of reflux; however, it lacks the ability to discern the pH of refluxate. pH alone misses reflux events with intermediate pH (4.1–7.4). Incorporation of impedance addresses some of the limitations associated with pH alone and enhances diagnostic accuracy.

Application of the ankle pump method in a sitting position to evaluate calf perforating veins by color Doppler ultrasound

ObjectiveWe investigated the feasibility and efficacy of assessing calf perforating veins (PVs) using the ankle pump in a sitting position (AP-sit) method by color Doppler ultrasound. MethodsWe performed a multicenter prospective clinical trial between November 2022 and October 2023. Eligible patients with chronic venous disease and healthy controls were enrolled. The calf PVs were assessed using three different methods: manual compression in a standing position, manual compression in a sitting position, and AP-sit method. The reflux durations and detection rate of incompetent PVs (IPVs) were compared among the three methods. The number and diameter of calf PVs and distribution of IPVs were analyzed. ResultsA total of 50 patients with chronic venous disease and 50 healthy controls were included. There were 173 calves analyzed, including 97 healthy calves and 76 calves with chronic venous disease. The number of PVs per calf was higher in the diseased calves (median, 7.0; interquartile range [IQR], 6.0-8.0) than in the healthy calves (median, 5.0; IQR, 3.0-6.0; P < .001). The diameter of IPVs (median, 2.3 mm; IQR, 2.0-3.1 mm) was larger than that of competent PVs (median, 1.4 mm; IQR, 1.2-1.7 mm). Most of the IPVs (78.8%) were located in the medial and posterior middle of the calf. The reflux duration induced by the AP-sit method was greater than that induced by the manual compression methods (P < .001). Although the AP-sit method had a higher detection rate (92.0%) of IPVs than the manual compression methods (71.7% and 74.3% for standing and sitting, respectively; P < .001), especially in the distal lower leg, the manual compression methods found IPVs not found using the AP-sit method. ConclusionsDiseased calves with chronic venous disease have more PVs than do healthy calves. IPVs are commonly larger than competent PVs, with most IPVs located in the medial and posterior middle of the calf. Most importantly, the AP-sit method provides a convenient and effective approach for assessing the calf PVs, especially those located in the distal calf, as an alternative or complementary method to traditional manual compression, which is valuable in the daily practice of sonographers.

Comparison of contrast-enhanced voiding urosonography using second-generation contrast agents and voiding cystourethrogram

Voiding cystourethrogram (VCUG) has been considered the gold standard for detecting and evaluating vesicoureteral reflux (VUR) among children. However, ionizing radiation exposure is a concern for this diagnostic modality. Contrast-enhanced voiding urosonography (ceVUS) is an alternative technique for the detection of vesicoureteral reflux (VUR) using ultrasound and intravesical administration of an ultrasound (US) contrast agent. ceVUS is a radiation-free, effective, and safe method for identifying and grading VUR. We performed a study specifically for our hospital. The purpose of this study was to evaluate the diagnostic accuracy of contrast-enhanced voiding urosonography (ceVUS) in the detection of vesicoureteral reflux and its grading in children, compared to voiding cystourethrogram (VCUG). If we consider VCUG as the gold standard, the sensitivity of ceVUS in our study was 83%, specificity was 100% and accuracy was 94%. Our positive cases had Grade II to V reflux on ceVUS and Grade I to V reflux on VCUG. In our small sample of 18 patients, the detection of vesicoureteral reflux by ceVUS was comparable to that of VCUG. ceVUS can be used as a radiation-free alternative to VCUG for the detection of VUR in children. A benefit of ceVUS is the ability to do cyclical assessment without the fear of increasing radiation dose, as you would with VCUG.

Comparison of voiding vesicoureteral urosonography with fluoroscopic voiding cystourethrography in children with vesicoureteral reflux.

To evaluate the value and compliance rate of voiding vesicoureteral urosonography in pediatric vesicoureteral reflux (VUR). This is a retrospective study. A total of 80 children with high-risk VUR admitted to Children's Hospital affiliated to Capital Medical University from December 2018 to December 2020 were selected. All patients underwent voiding urosonography (VUS) and fluoroscopic voiding cystourethrography (VCUG). The sensitivity and compliance of voiding vesicoureteral urosonography were compared, and its application value was evaluated. A total of 160 PUUs were examined, and all cases were normal. Among them, 56 PUUs had reflux (35.00%, 56/160), 46 PUUs had reflux under both examination methods (28.75%, 46/160), and 10 PUUs were only detected under VUS (6.25%, 10/160). Thirty-four cases of VUR (42.50%, 34/80) were diagnosed by VUS, among which 15 cases were bilateral reflux and 4 cases were unilateral reflux. Twenty-five cases (35.00%, 25/80) were diagnosed by VCUG, among which 10 cases were bilateral regurgitation and five cases were unilateral regurgitation. No significant difference was observed in the detection rate of reflux between the two methods (P=0.432). A total of 146 PUUs were found to be consistent between the two methods (91.25%, 160), including 2 Grade-I reflux, 6 Grade-II reflux, 14 Grade-III reflux, 12 Grade-IV reflux, eight Grade-V reflux, and 104 without reflux, demonstrating SATISFACTORY consistency between the two groups (Kappa=0.885). Voiding vesicoureteral urosonography has a high coincidence rate in the detection of vesicoureteral reflux in children.

Sources of error in direct radionuclide cystography in children and the need for a standardized, manometric apparatus.

Direct radionuclide cystography (DRC) is a safe and reliable method for the detection and follow-up of vesico-ureteral reflux (VUR). Since the first DRC was performed, during the early 60s, the method has undergone many refinements. Themanometric approach, which was first introduced in 1984, provides a correlation between the bladder pressure and VUR visualization. In this study the sources of error that may alter the results of DRC are discussed and a novel, standardized low costmanometric apparatus is suggested.

Comparison between contrast enhanced voiding urosonography (CEVUS) with standard cystography under fluoroscopy (VCUG) for detection of vesicoureteral reflux in pediatric patients

Comparison between contrast enhanced voiding urosonography (CEVUS) with standard cystography under fluoroscopy (VCUG) for detection of vesicoureteral reflux in pediatric patients

Variability and accuracy of multiple saliva pepsin measurements in laryngopharyngeal reflux patients

ObjectiveTo study the variability and diagnostic value of multiple salivary pepsin measurements in the detection of laryngopharyngeal reflux (LPR).MethodsPatients with LPR symptoms were consecutively recruited from December 2019 to Augustus 2022. Twenty-one asymptomatic individuals completed the study. The diagnostic was confirmed with hypopharyngeal–esophageal impedance-pH monitoring (HEMII-pH). Patients collected three saliva samples during the 24-h testing period. Symptoms and findings were studied with reflux symptom score-12 and reflux sign assessment. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of pepsin measurements were calculated considering morning, post-lunch and post-dinner samples. The consistency and relationship between HEMII-pH, pepsin measurements, and clinical features were investigated.ResultsMorning, post-lunch and post-dinner saliva pepsin concentrations were measured in 42 patients. Pepsin measurements were 64.9%, 59.5%, and 59.0% sensitive for morning, post-lunch and post-dinner collections at cutoff ≥ 16 ng/mL. Considering the highest concentration of the three pepsin saliva collections, the accuracy, sensitivity, specificity and PPV were 70.5%, 73.0%; 66.7% and 78.9%, respectively. Morning pepsin measurements reported higher consistency, sensitivity, and specificity than post-dinner and post-lunch pepsin measurements.ConclusionThe collection of several saliva pepsin samples improves the detection rate of LPR. In case of high clinical LPR suspicion and negative pepsin test, a HEMII-pH study could provide further diagnostic information.

Color Doppler Ultrasound's Utility in Detecting Vesicoureteral Reflux Using the Ureteral Jet Angle.

This study hypothesizes using color Doppler ultrasound to measure ureteral jet angles (UJA) as a diagnostic screening tool for reflux. The present prospective cohort study included 122 patients and 238 renal unit pediatric patients suspected of VUR who presented to our hospital between 2019 and 2021. All patients underwent ultrasonography and VCUG, and the UJA was measured color Doppler evaluation of the ureteral jet. The UJA was compared with the VCUG findings in patients with and without reflux. SPSS 26 was used to analyze the data. A total of 96 patients and 139 renal units exhibited reflux. The mean ureteral jet angle in refluxing units was 60.47 + 16.66 degrees, whereas, it was 42.59 + 13.26 degrees in non-refluxing units, a significant difference between the two groups (P < .001). The mean ureteral jet angle was 42.59, 45.89, 60.32, 68.23, and 56.16, for reflux grading from 0 to 5 (except grade 1), respectively. The angle value in each reflux grade increased significantly except for grade 5. For reflux detection (grade I-V), a cut-off angle of 50 degrees was associated with sensitivity and specificity of 70 and 79, respectively. Grade IV/V reflux can be diagnosed with a sensitivity of 70% and specificity of 84% using a cut-off angle of 68 degrees or greater. UJA detection via color Doppler ultrasound demonstrates high accuracy, is non-invasive method can be utilized as an alternative primary diagnostic tool or in follow-up cases of VUR in children.

Detection of gastroesophageal reflux by multichannel intraluminal impedance technology during mechanical ventilation: the first case series

<h2>Summary</h2><h3>Background & Aims</h3> Gastroesophageal reflux (GER) is a common event among mechanically ventilated and tube-fed critically ill patients and it is associated with an increased risk of ventilator-associated pneumonia. Most of the available tools for the detection of GER are experimental and not available bedside. Intraluminal impedance was suggested as a technique for real-time detection and quantification of GER. This study aimed to evaluate the frequency and duration of GER events in mechanically ventilated and tube-fed patients and to determine their correlation with routine procedures performed during patient care. <h3>Methods</h3> This was a prospective observational study of 20 critically ill patients hospitalized in a university hospital general intensive care unit. We included adult, mechanically ventilated patients receiving continuous enteral feeding by feeding tube (FT). A FT with multichannel intraluminal impedance sensors capable of detecting movement of gastro-esophageal content above the lower esophageal sphincter was used for GER detection. The frequency, duration, and association with routine procedures (position change, suction, and fluid bolus administration) were evaluated. <h3>Results</h3> During the median monitoring time of 2.9 days (IQR 2.8–3) per patient, a median number of 2.7 (IQR 2.1–3.8) GER events were detected every hour. 61% of GERs lasted 10–30 seconds. Position changes, endotracheal suctions, and fluid bolus administrations were associated with a high frequency of GERs. <h3>Conclusions</h3> Multichannel impedance sensors embedded on a FT enable real-time bedside detection of GER. This technology provides an opportunity for the development of new strategies aimed to decrease GER prevalence and prevent aspiration. <h3>Registration</h3> The study was registered at http://www.clinicaltrials.gov (NCT02705781).

Correlation of Renal Scarring to Urinary Tract Infections and Vesicoureteral Reflux in Children.

Objective To study the association of the grade of vesicoureteral reflux (VUR) and urinary tract infections (UTI) with renal scarring at the first clinical presentation of patients who underwent antireflux surgery. Materials and methods. Between 2015 and 2020, 150 patients (194 units) who underwent antireflux surgery had dimercaptosuccinic acid (DMSA) renal scans preoperatively. Patients were classified into the nonscar and scar groups according to DMSA scan results. Moreover, cases were classified into afebrile UTI, febrile UTI, and antenatal hydronephrosis (ANH) according to the mode of presentation. We correlated the mode of presentation and the grade of VUR to the presence/absence of renal scars in both groups. Results The mean follow-up was 45 months preoperatively. The mode of presentation was afebrile, febrile UTIs, and antenatal hydronephrosis in (50, 14), (20, 46), and (10, 10) patients in the nonscar and scar groups, respectively. Of the 20 patients who presented ANH, 10 (50%) had scars. Clinical presentation was correlated to the presence of renal scarring and its degree. The scar group had significantly higher grades of VUR than the nonscar group (grades I–II (50 units versus 10 units), grade III (28 units versus 40 units), and grade IV–V (22 units versus 44 units) for the nonscar versus scar groups, respectively (pvalue <0.001). Conclusion Renal scarring is associated with higher grades of reflux and urinary tract infections. We advocate further research investigating infants who had UTIs with or without fever for early detection of reflux.

Another indication for voiding cystourography?

Voiding cystourethrograms (VCUG) are often considered in the evaluation of infants with febrile urinary tract infection (UTI), but there are few additional clear indications for performing them outside of recurrent febrile UTI itself. Hydronephrosis and scarring on kidney ultrasound (US) are included in several guidelines from consensus organizations, including those from the American Academy of Pediatrics (AAP), National Institute for Clinical Excellence (NICE) and the Italian Societies of Pediatric Nephrology and Pediatric Infectivology. The Italian guideline goes further to include other kidney/bladder anomalies and increased kidney echogenicity on US as additional rationale for obtaining a VCUG. In this volume of The Journal, Mohammad et al present retrospective data from their center that would seem to lend additional support to abnormal echogenicity on US as an indication to obtain a VCUG. The presence of increased echogenicity on US in their hands had a low sensitivity for detection of any vesicoureteral reflux (VUR) but was highly specific. Performance of increased echogenicity as a screening test for VUR improved if the analysis was limited to patients with high-grade VUR only (grades 3-5). Similarly, the overall positive predictive value of increased echogenicity for VUR was low (24-44%), but the negative predictive value was good. (77-80%). Although these data ideally require confirmation in a prospective, multicenter study, they do appear to support more detailed analysis of US findings when considering which infant with a febrile UTI requires a voiding cystourethrogram. Article page 201 ▸ Kidney Echogenicity and Vesicoureteral Reflux in Children with Febrile Urinary Tract InfectionThe Journal of PediatricsVol. 242PreviewTo evaluate increased kidney echogenicity as a predictor of vesicoureteral reflux (VUR) in young children with first febrile urinary tract infection (UTI). Full-Text PDF

The role of MR venography with time-resolved imaging in diagnosis of pelvic congestion syndrome

BackgroundPelvic congestion syndrome (PCS) represents a diagnostic challenge due to its variable clinical presentation, complex anatomy, and pathophysiology. Accurate delineation of the venous anatomy, detection of venous reflux or obstruction, its extent will enable interventional radiologists to successfully treat such patients and to avoid recurrence. Magnetic resonance imaging (MRI) allows a noninvasive examination of the anatomy and flow inside the pelvic veins in addition to its excellent soft-tissue contrast allowing evaluation of the pelvic organs. Our study is aiming to investigate the role and accuracy of MR venography with time-resolved imaging (TR-MRV) as a diagnostic tool for pretreatment planning of PCS.ResultsOur study included 25 female patients with mean age 48 ± 12.34, who were referred to the radiology department in the period from April/2019 to April/2020 with clinical and ultrasound features suggesting PCS. TR-MRV was performed and interpreted in a blind fashion evaluating the vascular anatomy, venous dilatation, and reflux. The results were compared to conventional venography as a reference. The sensitivity, specificity, and accuracy of TR-MRV in the detection of ovarian vein reflux were 87%, 80%, and 84%, respectively, versus 75%, 53%, and 72% in internal iliac vein reflux and 92%, 69%, and 64% for pelvic venous plexus reflux. Demonstration of the venous anatomy was excellent in 68% of the patients and was sufficient in 32%. Ovarian vein dilatation was detected in 16 patients by venography and in 10 patients by TR-MRV. The weighted k-values (Cohen's Kappa coefficient statistics) indicated excellent agreement between the two observers for identifying all the refluxing veins by TRI in each patient (k = 0.78).ConclusionMRI with TR imaging has shown high diagnostic accuracy when compared to conventional venography in evaluating pelvic congestion syndrome before endovascular treatment and thus facilitating treatment planning.

Starting a pediatric contrast ultrasound service: made simple!

The addition of contrast US to an existing pediatric US service requires several preparatory steps. This overview provides a guide to simplify the process. Initially, it is important to communicate to all stakeholders the justifications for pediatric contrast US, including (1) its comparable or better diagnostic results relative to other modalities; (2) its reduction in procedural sedation or anesthesia by avoiding MRI or CT; (3) its reduction or elimination of radiation exposure by not having to perform fluoroscopy or CT; (4) the higher safety profile of US contrast agents (UCA) compared to other contrast agents; (5) the improved exam comfort and ease inherent to US, leading to better patient and family experience, including bedside US exams for children who cannot be transported; (6) the need for another diagnostic option in light of increasing demand by parents and providers; and (7) its status as an approved and reimbursable exam. It is necessary to have an UCA incorporated into the pharmacy formulary noting that only SonoVue/Lumason is currently approved for pediatric use. In the United States this UCA is approved for intravenous administration for cardiac and liver imaging and for vesicoureteric reflux detection with intravesical application. In Europe and China it is only approved for the intravesical use in children. All other applications are off-label. The US scanner needs to be equipped with contrast-specific software. The UCA has to be prepared just before the exam and it is important to strictly follow the steps as outlined in the packaging inserts in order to prevent premature destruction of the microbubbles. The initial training in contrast US is best focused on the frontline staff actually performing the US studies; these might be sonographers, pediatric or interventional radiologists, or trainees. It is important from the outset to educate the referring physicians about contrast US. It is helpful to participate in existing contrast US courses, particularly those with hands-on components.

VENOUS HEMODYNAMICS IN ACUTE VARICOTHROMBOPHLEBITIS IN THE GREAT SAPHENOUS VEIN BASIN

Abstract. Objective. To evaluate the influence of venous hemodynamics in acute varicothrombophlebitis in the basin of the great saphenous vein on the spread of the thrombotic process.&#x0D; Materials and methods. The analysis of venous hemodynamic disorders in 245 patients with acute varicothrombophlebitis in the basin of the great saphenous vein was performed. The age of patients participating in the study ranged from 19 to 82 years (mean age 52±2,7 years). There were 93 men (38.0%) and 152 women (62.0%). The laboratory and instrumental methods were used for all the patients. They included doppler ultrasound and ultrasound duplex scanning. («ULTIMA PRO–30, zone Ultra», ZONARE Medical Systems Inc., USA).&#x0D; Results. When AVTF occurred in the GSV basin, all patients showed reflux in the superficial veins of the lower extremities. The ultrasound scanning was performed at the initial examination and immediately before urgent surgery for AVTF. The data of color duplex mapping allowed to reveal certain regularities of venous blood flow disturbance in AVTF and divided patients depending on the state of venous blood flow in the GSV basin into 5 groups. Each of these groups of patients, depending on the prevalence of venous reflux in the GSV pool, was divided into two subgroups: local and widespread reflux. It should be noted, that the conditions for the detection of total reflux in ATVF, with the involvement of GSV in the pathological process, were not due to thrombotic lesions of the latter. When venous reflux was detected, the elasticity and extensibility of the vein wall at the apex of thrombotic masses were evaluated. The ratio of the diameters of the GSV in these positions and the assessment of the "degree of elasticity" by Schwalb PG (2005), which indirectly characterized the state of venous tone were calculated. Venous reflux was assessed on a Valsalva test in vertical and horizontal positions. Venous reflux of blood in the femoral veins was found in 134 (54.7%) patients. At the same time, local reflux was found in 38 (15.5%), and widespread - in 96 (39.2%) patients. It should be noted that the prevalence of venous reflux was directly proportional to its power. Among all groups of patients with acute varicothrombophlebitis, 176 (71.8%) had widespread reflux in the great saphenous vein and 96 (39.2%) in the femoral vein. In 37 (15.1%) patients with acute varicothrombophlebitis revealed a combined nature of reflux, ie the spread of reflux from the superficial venous system not only to the apex of thrombotic masses, but also to the site of horizontal perforation, and reflux from the deep venous system spread through failed perineal veins in the great saphenous vein. Thus, widespread venous reflux was found in 87.3% of patients. In the absence of vertical reflux through the sapheno-femoral cochlea and the presence of an ascending process of thrombosis, it is necessary to identify another source of reflux.&#x0D; Conclusions. It is proved that the process of thrombosis in acute varicothrombophlebitis depends on the power of venous reflux, the severity of venous discharge through the communicating veins, the state of collateral venous blood flow in venous shunts and basins of large and small subcutaneous venous blood vessels. Venous reflux in the trunk of the great saphenous vein to some extent determines the embolism of the thrombus and participates in its development. Varicose veins of the great saphenous vein and the discharge of blood through incapable permeable veins reduce the power of reflux through the sapheno-femoral cochlea and reduce the rate of thrombosis in the main trunk.

Comparison of Urinary Tract Dilatation and Society of Fetal Urology systems in the detection of vesicourethral reflux and renal scar.

PurposeThe presence and degree of hydronephrosis is very important in the management of many diseases of the urinary tract. In this study, we aim to compare the sensitivity and specificity of 2 classification systems that are used for hydro-nephrosis grading in ultrasound, for reflux and scar detection. The classification systems were the Society of Fetal Urology (SFU) and Urinary Tract Dilatation (UTD).Material and methodsUltrasounds and dimercaptosuccinic acid scintigraphies (DMSA) of all patients who underwent voiding cystourethrogram (VCUG) due to urinary tract infection were examined retrospectively. DMSA was accepted for scar detection and VCUG for reflux detection as reference methods. SFU classification was used for hydronephrosis in ultrasound reports, and UTD classification was made over the reports. Sensitivity, specificity, and positive and negative predictive values of UTD and SFU classification systems for reflux and scar detection were calculated, and these 2 systems were compared.Results103 (39%) of the patients were male and 162 (61%) were female. Pathologies were detected in 192 (35%) of 530 kidneys in ultrasound. In 110 (42%) of the children, reflux was detected in VCUG. Scars in DMSA were detected in only 16% (44) of 266 kidneys. Sensitivity, positive and negative predictive values of the UTD classification system were statistically significantly higher than the SFU system for scar and reflux detection (p < 0.01).ConclusionsIf we use the UTD system in ultrasounds of patients with urinary tract infections, children reported as UTD 0 may not need VCUG, which reduces radiation exposure to children and the cost of the diagnostic interventions.

Radionuclide techniques for the detection of vesicoureteral reflux and their clinical significance.

We discuss and try to evaluate the detection of vesicoureteral reflux (VUR) by radionuclide techniques and especially direct radionuclide cystography (DRC). Direct radionuclide cystography is applied for more than half a century mainly in children. Vesicoureteral reflux has a complex pathology not yet completely understood and is often related to urinary tract infection (UTI) and renal parenchyma scarring that can lead to long-term renal function impairment. Since there is no consensus on the optimal imaging algorithm after the first febrile urinary tract infection, many imaging strategies have been proposed for VUR detection in the last decade, including or not DRC. Views opposing or accepting its use are also presented.

Optimization of impedance-measured reflux events in GORD utilizing acid exposure time

BackgroundCombining impedance with pH monitoring improves the detection and characterization of gastro-oesophageal reflux (GOR), yet the two modalities frequently differ in GOR quantification. Ambulatory 24-h pH-impedance monitoring often reveals more significant oesophageal acid exposure than impedance-measured reflux activity in patients with symptomatic gastro-oesophageal reflux disease (GORD). The purpose of this study is to elucidate the discrepancies between these modalities by assessing the predictive accuracy of impedance compared to acid exposure standards.MethodsA single-institution, retrospective review of sequential 24-h pH-impedance results of 72 patients with symptomatic GOR off anti-secretory therapy was conducted. Reflux events measured by impedance were stratified by patient position and compared to oesophageal acid exposure time (AET). Oesophageal AET limits for GORD detection were utilized as gold standards to generate serial receiver operator characteristics (ROC) curves to assess the sensitivity and specificity of current impedance GORD detection limits and identify optimized impedance standards based on area under the curve (AUC) analysis.ResultsMean total AET time was 10.5% (± 9.9%), and 63.8% of patients had elevated AET. By impedance, median GOR frequency was 43 (IQR 21–68), and 22.2% exceeded conventional GOR frequency limits of normal. ROC curve analysis revealed the current impedance standard of > 73 GOR events has a sensitivity of 32.6% and specificity of 96.5% (AUC 0.74) for GORD detection. By AUC analysis, an impedance threshold of > 41 GOR events is optimal for GORD detection (sensitivity 69.6%, specificity 80.7%, AUC 0.83).ConclusionConventional impedance standards for abnormal GOR frequency are weakly sensitive for the detection of GORD, providing a possible explanation to discrepancies in AET and impedance interpretation. Lowering impedance-measured GOR frequency limits to > 41 optimizes sensitivity and specificity while increasing congruence between pH and impedance metrics.

Targeted Indication of Imaging for Detection of Vesicoureteric Reflux after Pediatric Febrile Urinary Tract Infections Based on a Multiparametric Computational Tool.

Diagnostic workup after febrile urinary tract infections (fUTIs) in children remains a matter of debate. The authors aimed to evaluate multiple parameters in order to design a predictive tool enabling a targeted indication of voiding cystourethrography (VCUG). Records of 383 consecutive children who underwent a VCUG as well as a dimercaptosuccinic-acid (DMSA) scan after febrile urinary tract infections (fUTIs) at a single institution between 04/2009 and 06/2014 were reviewed. Twenty parameters were recorded. After regression analysis, 6 parameters were incorporated into a computational tool aiming at a targeted indication of an eventual VCUG. The performance of the tool was prospectively tested on 100 patients. Postpyelonephritic alterations on DMSA, duplex systems, age 1-3 y, duration of fever >3 d, >2 fUTIs before VCUG and abnormal sonography findings were identified as significant predictors (p< 0.05 each); the presence of bladder and bowel dysfunction (BBD) was negatively associated with vesicoureteric reflux (VUR). The resulting computational tool achieved an Area under the curve (AUC) of 0.686 (CI 0.633-0.740). Prospective evaluation (100 new patients) revealed a sensitivity of 85.1%, a specificity of 49.1%, a positive predictive value of 59.7% and a negative predictive value of 78.7%. The differentiated indication of a VCUG based on the use of a tool was efficient in optimizing the specificity of the diagnostic algorithm after fUTIs. The tool outperformed other common clinical approaches in terms of VUR detection and VCUG frequency. After validation and further refinement in a multicentric approach, this strategy could significantly enhance VUR detection whilst reducing the number of VCUGs.

Ultrasound in Hospitalized Children With First Febrile UTI: What Exactly Are We Looking For?

Detection of genitourinary abnormalities and vesicoureteral reflux (VUR) in young children who present with a febrile urinary tract infection (UTI) is important because severe VUR may predispose to renal scar formation, which may lead to hypertension and impaired kidney function. In this issue of Hospital Pediatrics , Wallace et al1 attempt to identify clinical factors that could be used to predict which hospitalized children 0 to 24 months of age with first febrile UTI are likely to have an abnormal renal bladder ultrasound (RBUS). The authors were not able to determine any clinical factors (other than known genitourinary tract abnormalities) that could be used to guide selective RBUS screening. The authors conclude that selective screening cannot be applied and recommend screening all young children at the time of first febrile UTI. Screening for genitourinary abnormalities technically precedes UTI in most children because severe genitourinary abnormalities and clinically significant hydronephrosis may be noted on a prenatal ultrasound. One study of 4586 children revealed that a prenatal ultrasound identified severe genitourinary tract abnormalities requiring immediate intervention with a negative predictive value of 99.9%.2 In a prescreened population, we would not expect an ultrasound at the time of first UTI to detect prenatally missed posterior urethral valves or high-grade obstruction. The population in this study was a prescreened population in which all patients had a normal prenatal ultrasound, and all patients with …

HIDA and Seek: Challenges of Scintigraphy to Diagnose Bile Reflux Post-Bariatric Surgery.

Oesophageal bile reflux after bariatric surgery may trigger development of Barrett's oesophagus. Gastro-oesophageal reflux of bile is captured by hepatobiliary iminodiacetic acid (HIDA) scintigraphy; however, anatomical and physiological changes after bariatric surgery warrant protocol modifications to optimise bile reflux detection. HIDA scintigraphy occurred 6months after either sleeve gastrectomy, Roux-en-Y gastric bypass or one-anastomosis gastric bypass. Standard HIDA scanning involves (i) 6-h fast and 24-h abstinence from opioids; (ii) IV administration of 99mTc di-isopropyl iminodiacetic acid; and (iii) dual anterior/posterior 60-min dynamic scanning of the duodenum, stomach and oesophagus. Three challenges were identified, and modifications were implemented, namely, (1) anatomical localisation of refluxed bile on planar scintigraphy was improved by adding a SPECT/CT for 3D imaging; (2) impaired cholecystokinin-controlled gallbladder emptying, following bypassed duodenum, was addressed by ingestion of a 'fatty meal'; and (3) intestinal hypomotility after gastric bypass was counteracted by longer scan duration (75-90min) to allow bile to pass beyond the gastro-jejunal anastomosis. HIDA scan was undertaken in 18 patients, 13 of whom underwent the modified protocol. The tailored protocol ameliorated issues identified with the standard HIDA scan protocol; thus, accurate anatomical localisation was achieved in all patients, no delayed gallbladder emptying was observed, and bile was observed beyond the gastro-jejunal anastomosis in all gastric bypass patients. The modified technique was well tolerated by patients. A tailored HIDA scan protocol with addition of a SPECT-CT scan, ingestion of a fatty meal and prolonged scanning duration results in enhanced bile reflux detection in post-bariatric surgical patients.