Variation in the diagnosis of vesicoureteric reflux using micturating cystourethrography

  Variability in the interpretation of micturating cystourethrography by paediatric radiologists for the diagnosis of vesicoureteric reflux in children was evaluated. All 265 micturating cystourethrograms (MCUs) that were available from 304 consecutive children aged 0.5 – 61 months  –  who were investigated after their first urine infection between 1993 and 1995 as part of a prospective cohort study  –  were selected for interpretation. Three experienced paediatric radiologists from the same department independently interpreted the MCUs according to the grading system of the International Reflux Study in Children, from grades 0 to V, with the presence of intrarenal reflux also noted. Apart from being informed that urine infection was the indication for the MCU, no other clinical information was given to the radiologists. The indices of variability used were the percentage of agreement and the kappa statistic, expressed as a percentage. Both measures were weighted with integers representing the number of categories from perfect agreement. Disagreement was analysed for children and kidneys. For the diagnosis of vesicoureteric reflux in individual patients, including grade, the percentage of agreement was 96% – 97% (kappa 90% – 91%) and the weighted percentage of agreement was 96% – 98% (weighted kappa 93% – 94%). The same high level of agreement was present for individual kidneys, with a percentage of agreement of 97% – 98% (kappa 89% – 92%) and a weighted percentage of agreement of 98% – 99% (kappa 94% – 95%). There was near perfect agreement in the interpretation of radiological micturating cystourethrography among three experienced paediatric radiologists for the diagnosis and grade of vesicoureteric reflux. Any variations in the medical care of children suspected of having vesicoureteric reflux are not explained by differences in the reporting of this diagnostic test. Received June 19, 1996; received in revised form November 1, 1996; accepted December 6, 1996     

Predictors of remission and relapse in idiopathic nephrotic syndrome: a prospective cohort study

Background

Although most children with idiopathic nephrotic syndrome will respond to corticosteroid therapy, 80–90 % suffer one or more relapses.

Methods

Using Cox proportional hazard models, we analyzed predictors of remission and relapse in 1-year follow-up data on children aged below 15 years with new-onset nephrotic syndrome.

Results

Of 129 children, 107 achieved remission with corticosteroid therapy and 86 subsequently relapsed. Boys achieved remission more often than girls (adjusted hazard ratio [AHR] 1.52, 95 % confidence interval (CI) 1.02–2.3). Boys relapsed significantly more frequently than girls (AHR 1.77, 95 % CI 1.11–2.83) and were more likely to have frequently relapsing disease (AHR 3.3, 95 % CI 1.18–9.23). The risk of first relapse increased with the number of days to first remission (AHR 1.02, 95 % CI 1.01–1.04). The risk for a frequently relapsing course increased with a shorter time from remission to first relapse (AHR 0.92, 95 % CI 0.87–0.97).

Conclusions

In idiopathic nephrotic syndrome, boys are more likely to respond initially, more likely to relapse, and to be classified as having frequently relapsing nephrotic syndrome. A decrease in time from remission to first relapse predicts for a frequently relapsing course.     

A reproducible pediatric daytime urinary incontinence questionnaire

PURPOSE: We developed and tested the reliability of a new, structured, parent administered questionnaire to determine the prevalence of and risk factors for daytime urinary incontinence in children. MATERIALS AND METHODS: A new questionnaire was developed and evaluated in a pilot study for ease of understanding and acceptability. It was then tested for reproducibility of responses in a randomly selected sample of new primary school entrants in Western Sydney 4 weeks after baseline data were collected. The questionnaire obtained data on demographics, prevalence of daytime incontinence, family history of incontinence, voiding symptoms and socioeconomic status. Categorical data agreement was assessed using the kappa statistic and continuous data agreement was analyzed using the Bland-Altman method. RESULTS: A total of 166 subjects 3.5 to 7 years old (mean and median ages 5.6 and 5.7, respectively) completed the repeat questionnaire with a 78.5% response rate. Mean agreement of the responses to the first and second questionnaires was 91% (range 83% to 100%, mean kappa = 0.70, range 0.34 to 1.00). For continuous data the 95% confidence limits were narrow (0.3 for birth weight data). CONCLUSIONS: We have developed a new daytime urinary incontinence questionnaire using parent reported data and demonstrated that it is reproducible. We consider it to be a useful instrument for ascertaining information on urinary incontinence and other voiding symptoms.     

The cost of steroid-free protocols in primary cadaver kidney transplantation

Steroid-free immunosuppression regimens have been enjoying recent success in clinical transplantation. The use of antibodies required for such protocols can be an economic burden. We proposed to study their cost in our center. This retrospective study involved 147 consecutive patients subjected to 4 protocols of immunosuppression. The first received triple therapy. The second group received induction with basiliximab, whereas the third received Basiliximab plus cyclosporine (CSA) plus mycophenolate mofetil (MMF), and the fourth received Thymoglobulin plus CSA plus MMF in conjuction with only 4 days of steroid. Rejection episodes were treated with Solumedrol. Six-month charges were obtained from computerized records of the finance department, the in-house laboratories, and the transplantation service registry. All charges were expressed in 2004 dollars. Statistical analyses were obtained using chi-square, analysis of variance (ANOVA) and Kaplan-Meier tests. The 4 groups were similar with regard to donor and/or recipient gender, race, panel reactive antibodies, cold ischemia, dialysis requirements length of stay and readmission, graft survival, and function. Charges were significantly higher in the last 2 groups as compared with triple therapy.     

Interaction between enrofloxacin and monensin in broiler chickens

Enrofloxacin, a fluoroquinolone, and its interaction with monensin, an ionophore drug, was studied to explore the influence of enrofloxacin on drug metabolizing enzymes that can lead to physiological and toxicological consequences upon coadministration with monensin in broiler chickens. Group I, treated with 100 mg monesin/kg feed from 1 d old to 41st d of age, did not show any influence on aniline hydroxylase and cytochrome b5 levels. Group II, treated with 10 mg enrofloxacin/kg body weight per os for three consecutive days on 33rd, 34th, 35th d of age, had a highly significant decrease in aniline hydroxylase on 38th d (ie on 3rd d post-treatment with enrofloxacin); a reversal effect was noticed on the 41st day (ie on 6th d post-treatment with enrofloxacin). There was no alteration in cytochrome b5 level. Group III with monensin and enrofloxacin coadministration 100 mg monensin/kg feed from 1 d old to the 41st day + 10 mg enrofloxacin/kg body weight, per os for 3 consecutive days on the 33rd, 34th, 35th d of age) had a significant decrease in aniline hydroxylase level on the 3rd d post-treatment with enrofloxacin, but an elevation tending to reach normal on the 6th d post-treatment with enrofloxacin. Monensin + enrofloxacin coadministration did not produce any alteration in cytochrome b5 level. Creatine kinase (CK) and alanine amino transferase (ALT) levels significantly increased on the 3rd d post-treatment with enrofloxacin, but on the 6th d post-treatment with enrofloxacin the increase declined. Aspartate amino transferase (AST) significantly increased on the 6th d post enrofloxacin treatment. This study demonstrated the reversible competitive type of inhibition of enrofloxacin on CYP450 enzymes, and with coadministration with monensin produced increased CK, AST and ALT serum enzymes suggesting heart and liver injury. Simultaneous administration of enrofloxacin and monensin even at recommended levels could result in adverse interactions.     

Palliative care in Kerala, India: a model for resource-poor settings

BACKGROUND: The need for palliative care is increasing throughout the world. Developing countries are progressively faced with an ageing population, whose changing health needs require urgent action. Insufficient access to care for both cancer and AIDS patients make palliative care the only humane and feasible response in many contexts. MATERIAL AND METHODS: In order to describe the need for palliative care in Kerala and the development of the new palliative care policy, we have collected and reviewed information from government officials, health professionals involved in cancer care, patients and their families, sponsors, and members of palliative care teams across Kerala. We also collected data on the functioning of the newly established palliative care clinics. RESULTS: The Pain and Palliative Care Society developed in a few years a network of 33 palliative care clinics across Kerala, providing care free of charge to patients in need. Outpatient treatment with a supportive home care service was adopted as the main mode of operation. Trained volunteers from the community assisted in providing care, and family members were empowered to the highest degree in order to ensure continuity of treatment. In 2002 the network of clinics saw about 6,000 new patients, about 25% of incident cancer cases. CONCLUSIONS: The synergistic effect of motivation and knowledge, coupled with the use of local resources, has made possible the development of a network of palliative care services, available for free to terminally ill patients. The challenge of adapting such a model to other developing countries is discussed.     

Colonic mucosa in patients with portal hypertension

BACKGROUND AND AIMS: To do a histomorphometric study of vascular changes in colonic mucosa of patients with portal hypertension (PHT) and to find their association with clinical and upper and lower gastrointestinal endoscopic observations. METHODS: Full length colonoscopy was carried out in 55 patients with portal hypertension and 25 controls. Hemorrhoids, anorectal varices and colopathy were carefully looked for and recorded. Two biopsies each were taken from the caecum, ascending colon, transverse colon, descending colon and rectum. Sections from all the five sites were examined for histopathological changes with special reference to changes in mucosal capillaries. Morphometric assessment of the diameter of the capillary and thickness of the capillary wall was performed. These histomorphometric changes were correlated with clinical parameters and findings of upper and lower gastrointestinal endoscopic findings. RESULTS: Dilated and congested capillaries as well as capillaries with irregular thickening of the wall were seen in a significantly higher number of sections from patients than controls in biopsies from all the five sites from caecum to rectum. On morphometry, the diameter of the capillaries and the thickness of the capillary wall in biopsies from all the five sites in patients was significantly higher than that in the control group. Apart from vascular changes, edema and inflammatory infiltrate in lamina propria were the other significant histological features noted. No significant association between clinical and endoscopic features and histomorphometric assessment was found. CONCLUSION: Dilated tortuous mucosal capillaries with irregular thickening of wall, edema of lamina propria and mild chronic inflammatory infiltrate are the major histopathological changes seen in colonic biopsies of patients with PHT, showing that PHT produces changes in the colonic mucosa similar to those seen in the mucosa of upper GI tract. However, the histological changes had no correlation with the clinical or endoscopic findings except that the thickness of the capillary wall was higher in patients who had undergone endoscopic sclerotherapy as opposed to those who had not received sclerotherapy.