Clinical phenotyping of children with nocturnal enuresis: A key classification to improve the approach.

INTRODUCTION: The literature shows that nocturnal enuresis is not an isolated phenomenon of urinary loss during sleep, but encompasses a set of systemic clinical manifestations that significantly influence children's quality of life and development. However, the understanding of the clinical and physiological relationship of these systemic manifestations remains a clinical challenge. The recognition of these manifestations and their subsequent categorisation, may provide better insights into integrated clinical manifestations, facilitating the understanding of pathophysiological mechanisms, and promote increased assertiveness in the assessment and the selection of appropriate therapies. OBJECTIVE: The aim of this study is to develop a phenotyping model for children with nocturnal enuresis based on evidence. METHODS: This study presents a clinical phenotyping model for children with nocturnal enuresis based on an analytical and methodological review of the literature, about nocturnal enuresis and its associated clinical manifestations. There was a bibliometric analysis carried out to better analyse outcomes. After reading and analysing the literature, the clinical manifestations were categorised into domains and submitted to the validation of an expert committee with extensive experience in their specific area of expertise. A visual representation of the categorised model was developed to make the phenotyping concept easily understandable to all professionals. RESULTS: The clinical manifestations related to nocturnal enuresis have been categorised according to frequency and relation found in the literature and validation by an expert committee and the development of the phenotyping model for children with nocturnal enuresis was completed. CONCLUSION: The present study developed an evidence-based phenotyping model for children with nocturnal enuresis.

Management and treatment of nocturnal enuresis-an updated standardization document from the International Children's Continence Society.

BACKGROUND: Enuresis is an extremely common condition, which, although somatically benign, poses long-term psychosocial risks if untreated. There are still many misconceptions regarding the proper management of these children. AIM: A cross-professional team of experts affiliated with the International Children's Continence Society (ICCS) undertook to update the previous guidelines for the evaluation and treatment of children with enuresis. METHODS: The document used the globally accepted ICCS terminology. Evidence-based literature served as the basis, but in areas lacking in primary evidence, expert consensus was used. Before submission, a full draft was made available to all ICCS members for additional comments. RESULTS: The enuretic child does, in the absence of certain warning signs (i.e., voiding difficulties, excessive thirst), not need blood tests, radiology or urodynamic assessment. Active therapy is recommended from the age of 6 years. The most important comorbid conditions to take into account are psychiatric disorders, constipation, urinary tract infections and snoring or sleep apneas. Constipation and daytime incontinence, if present, should be treated. In nonmonosymptomatic enuresis, it is recommended that basic advice regarding voiding and drinking habits be provided. In monosymptomatic enuresis, or if the above strategy did not make the child dry, the first-line treatment modalities are desmopressin or the enuresis alarm. If both these therapies fail alone or in combination, anticholinergic treatment is a possible next step. If the child is unresponsive to initial therapy, antidepressant treatment may be considered by the expert. Children with concomitant sleep disordered breathing may become dry if the airway obstruction is removed.

Study of transcranial therapy 904 nm in experimental model of stroke.

Cerebrovascular accidents (CVAs), commonly known as strokes, can damage the brain through vascular injuries caused by either blood vessel blockages (ischemic stroke) or ruptures (hemorrhagic stroke) which disrupt regular brain blood supply and can cause severe damage to the individual. The objective of the present study was to evaluate the effects of photobiomodulation with a light-emitting diode (LED) device (904 nm, 110 mW, 7 J/cm2) on neurogenesis, muscle resistance, and motor behavior in animals submitted to an experimental model of hemiplegia. The sample consisted of 30 Wistar rats, divided into two groups: control group (GC) and 904-nm LED-treated group (TG). All animals underwent stereotactic surgery for electrode implant and subsequent electrolytic injury to induce an ischemic stroke. TG was subjected to daily LED irradiation (904 nm, 110 mW, 7 J/cm2) for 63 s. Suspension test results indicate an improvement of TG muscle resistance when compared with baseline evaluation (BLT); a reduction in open-field freezing time and the number of fecal bolus pellets suggest diminished anxiety induced by 904-nm LED treatment on treatment days 7 and 21 (TG7 and TG21) compared with the baseline results; and lastly, histological analysis showed important signs of neurogenesis in TG in comparison to CG, especially on treatment days 7 and 21 (TG7 and TG21). In conclusion, the present study suggests that 904-nm LED irradiation may beneficially affect neurogenesis, muscle resistance, and animal motor behavior following ischemic CVA.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Diastasis of the rectus abdominis muscle prevalence in postpartum / Prevalência de diástase do músculo reto abdominal em puérperas

Abstract Introduction: Diastasis of the rectus abdominis muscle (DRAM) is characterized by the separation of the rectus abdominis muscles beams, caused by enlargement of the linea alba, a common condition during pregnancy. Physical therapy has been shown necessary in women health, to help them adjust the physical changes throughout the pregnancy and puerperium. Objectives: To verify the DRAM prevalence in the immediate puerperium in a sample of women attended by the Unified Health System in Guarapuava, PR, Brazil, and investigate possible correlations between the DRAM presence and the delivery type, pregnancies number, maternal age, pregnancy type and weight gain during pregnancy. Materials and Methods: This is a transversal study, that included 88 samples of women in the immediately puerperium. It was realized a specific assessment and verified the DRAM presence and its measures. The checkpoints were in the umbilical, 4.5 cm above and below this point. It was considered present and relevant when there was any separation from the linea alba. Results: The study showed 61.36% DRAM prevalence. Its averages were 0.88 cm supra-umbilical, 1.23 cm umbilical and 0.3 cm infra-umbilical. Puerperium women who had DRAM, 31.5% were primiparous and 68.5% multiparous. Conclusion: The DRAM prevalence was considered high and relevant. The DRAM measure was higher in the umbilical region compared with infra and supra-umbilical. The multiparous women had a higher correlation with the DRAM than the primiparous.

Resumo Introdução: Diástase do músculo reto abdominal (DRAM) caracteriza-se pela separação dos feixes do músculo reto abdominal, causada pelo alargamento da linha alba, condição comum durante a gestação. A fisioterapia tem se mostrado necessária na saúde da mulher, para auxiliá-las a se ajustarem às mudanças físicas do começo ao fim da gravidez e no puerpério. Objetivos: Verificar a prevalência de DMRA no puerpério imediato em uma amostra de mulheres atendidas pelo Sistema Único de Saúde no município de Guarapuava-PR, Brasil, e investigar possíveis relações entre a presença de DMRA e o número de gestações, tipo de gestação e ganho de peso durante a gestação. Materiais e Métodos: Estudo transversal, que incluiu amostra de 88 mulheres no puerpério imediato. Foi realizada uma avaliação específica e verificada a presença de DRMA e suas medidas. Os pontos de medida foram na cicatriz umbilical e 4,5 cm acima e abaixo da mesma. Considerou-se presente e relevante quando houvesse qualquer afastamento da linha alba. Resultados: O estudo mostrou uma prevalência da DRAM de 61,36%. As médias de DRAM foram 0,88 cm supraumbilical, 1,23 cm umbilical e 0,3 cm infraumbilical. Das puérperas que apresentaram DRMA, 31,5% eram primíparas e 68,5% multíparas. Conclusão: A prevalência de DRMA foi considerada alta e relevante. A medida da DRMA foi maior na região umbilical quando comparada com infra e supra-umbilical. As mulheres multíparas tiveram maior correlação com a presença de DRMA que as primíparas.

Avaliação urodinâmica não invasiva / Non-invasive urodynamic evaluation

Revisão dos conceitos atuais sobre a avaliação urodinâmica não invasiva em Pediatria, compreendendo a anamnese adequada de pais e pacientes, exame físico completo e mapa de frequência e volume urinários, associado ao diário miccional. Aborda a seguir os exames subsidiários, a saber, ultrassonografia do trato urinário e urofluxometria. Neste particular, analisa a técnica do exame e as características do estudo do fluxo urinário. Descreve a medida do resíduo pós-miccional e a eletromiografia do assoalho pélvico, finalizando com as indicações da urodinâmica invasiva...

Dysfunction elimination syndrome: is age at toilet training a determinant?

PURPOSE: To study the relationship between the age of completion of toilet training during daytime and the onset of dysfunctional elimination syndrome (DES). METHODS: The present study was designed as a case-control study. A total of 80 patients with DES were allocated to the case group and 80 patients age- and gender-matched without DES were allocated to the control group. The patients with DES were seen in a tertiary center and the control patients were seen in a primary care center. Early completion of toilet training was considered to be before 24 months. RESULTS: Patients were aged 3-17 years (mean: 7.55); 24 were male (30%) and 56 female (70%). The most frequent lower urinary tract symptoms were: urgency (77%), incontinence (75%), holding maneuvers (30%), high urinary frequency (61%) and low urinary frequency (16%). There was a history of urinary tract infection (UTI) in 62% of the DES group. The first UTI episode was before toilet training in 40%. The completion of toilet training was before the age of 2 years in 48% of DES patients and in 50% of the control group (p = 0.752) [odds ratio (OR) 0.91, 95% confidence interval (CI) 0.49-1.62]. CONCLUSION: The completion of toilet training before 24 months of age was not associated with DES. Some patients had DES symptoms such as UTI, infrequent voiding and constipation before toilet training. These findings suggest that DES may precede toilet training and this possibility should be confirmed in further studies.

Lower urinary tract symptoms in enuretic and nonenuretic children.

PURPOSE: We determined the prevalence of lower urinary tract symptoms in enuretic and nonenuretic children and adolescents in an urban community. MATERIAL AND METHODS: We performed a cross-sectional survey including 296 children and adolescents in a small urban community. Trained medical students visited all homes and interviewed the parents or guardians. There were no refusals to participate. Results were analyzed using chi-square and McNemar statistics. RESULTS: The enuresis rate was 10%, including 16.6% and 3.9% in children 5 to 10 years old and adolescents, respectively. The monosymptomatic enuresis rate was only 1.34%. Of those with vs without enuresis lower urinary tract symptoms were present in 86.7% vs 26.8% (p <0.001). In the nonenuretic group lower urinary tract symptoms were associated with nocturia (p = 0.008). The most common daytime urinary symptoms were urgency in 38.2% of cases, holding maneuvers in 30.4% and daytime incontinence in 27.5%. The prevalence rate decreased with age in the nonenuretic group (p = 0.013). CONCLUSIONS: The prevalence of lower urinary tract symptoms was high. Nonmonosymptomatic enuresis was common and monosymptomatic enuresis was rare in this population based survey. In nonenuretic cases daytime symptoms were associated with nocturia, suggesting decreased bladder capacity with a mature arousal reaction.

A enurese em criancas e seus significados para suas famílias: abordagem qualitativa sobre uma intervencão profissional em saúde / Child enuresis and parental meanings: a qualitative perspective for healthcare professionals

OBJETIVOS: discutir as percepcões e significados atribuídos pelas famílias acerca da enurese vivida por seus filhos, através de uma perspectiva socio-antropológica que problematiza as mesmas no contexto das questões identificadas no interior do campo dos modelos explicativos da doenca. MÉTODOS: relato de experiência, baseado em entrevistas semi-estruturadas, realizadas junto a 24 (vinte e quatro) familiares/cuidadores de criancas com quadros de enurese. RESULTADOS: as famílias de pacientes com enurese demonstram a necessidade de definir a doenca de maneira subjetiva, entendendo-a através dos sentimentos que a mesma desencadeia, das mudancas comportamentais e das diferencas encontradas no relacionamento com as outras pessoas devido à mesma. Observa-se que os significados da enurese se organizam em dois campos que se cruzam: a responsabilizacão da própria crianca por sua enurese e os fatores externos, como o ambiente familiar e a situacão econômica e social. CONCLUSÕES: recomenda-se que profissionais de saúde estejam atentos aos perigos da normatividade biomédica de seu discurso, já que o mesmo dificulta a compreensão e elaboracão dos tratamentos necessários. Profissionais de saúde devem estar informados sobre o risco de maustratos relacionados à enurese, o que justifica a discussão acerca de possíveis estratégias de enfretamento dessa realidade na acão profissional junto a essa clientela.

[Clinical diagnosis of bladder dysfunction in enuretic children and adolescents]. / Diagnóstico clínico de disfunção miccional em crianças e adolescentes enuréticos.

OBJECTIVES: To estimate the predictive value of diurnal voiding symptoms for the diagnosis of bladder dysfunction in enuretic children and teenagers receiving care at Fernandes Figueira Institute (Rio de Janeiro, Brazil). METHODS: From June 1999 to May 2002, 91 patients (aged 5-17 years) with enuresis, both monosymptomatic and polysymptomatic, were assessed based on medical history, voiding chart, physical examination, and urodynamic studies. The medical history was investigated for detection of diurnal voiding symptoms. The predictive value of these symptoms for the diagnosis of bladder dysfunction was estimated. RESULTS: Bladder dysfunction was observed in 94.5% of the children and teenagers with enuresis. Medical history identified 97.3% of patients with diurnal voiding symptoms. Increased discharge of urine was detected exclusively by voiding chart in only 2.7% of the patients. The positive predictive value of diurnal voiding symptoms for bladder dysfunction was 98.6%. There was a statistically significant association between diurnal voiding symptoms and bladder dysfunction (p < 0.005). The risk for bladder dysfunction was approximately 20 times higher in presence of these symptoms. CONCLUSIONS: The presence of diurnal voiding symptoms was a strong predictor of bladder dysfunction. Medical history was a useful instrument for detecting diurnal voiding symptoms and establishing the diagnosis of bladder dysfunction.

Diagnóstico clínico de disfunção miccional em crianças e adolescentes enuréticos / Clinical diagnosis of bladder dysfunction in enuretic children and adolescents

OBJETIVO: Estimar o valor preditivo da presença de sintomas urinários diurnos para o diagnóstico de disfunção miccional em crianças e adolescentes enuréticos atendidos no Ambulatório de Urodinâmica do Instituto Fernandes Figueira. MÉTODOS: De junho de 1999 a maio de 2002, foram avaliados 91 pacientes, entre 5 e 17 anos de idade, portadores de enurese, mono ou polissintomática, através de anamnese, mapa da micção, exame físico e estudo urodinâmico. A anamnese baseou-se em um modelo desenvolvido para detecção de sintomas urinários diurnos. O valor preditivo da presença destes sintomas para o diagnóstico de disfunção miccional foi estimado neste grupo. RESULTADOS: O percentual de disfunção miccional entre as crianças e adolescentes atendidos por enurese no Ambulatório de Urodinâmica do Instituto Fernandes Figueira foi de 94,5 por cento. A anamnese identificou 97,3 por cento dos pacientes com sintomas urinários diurnos. Apenas 2,7 por cento dos pacientes apresentaram aumento da freqüência urinária detectado apenas pelo mapa da micção. O valor preditivo positivo da presença de sintomas urinários diurnos para o diagnóstico de disfunção miccional foi de 98,6 por cento. Houve associação, estatisticamente significante, entre sintomas urinários diurnos e disfunção miccional (p < 0,005), e o risco de a urodinâmica estar alterada foi de cerca de 20 vezes maior na presença destes. CONCLUSÕES: A presença de sintomas urinários diurnos apresentou um elevado valor preditivo positivo para disfunção miccional. A anamnese foi um instrumento útil para a detecção dos sintomas urinários diurnos, contribuindo para o diagnóstico de disfunção miccional.

Condiloma acuminado gigante(tumor de Buschke-Lowerstein) / Giant condyloma acuminatum, Buschke-Lowerstein tumor, human papilomavirus

O condiloma acuminado gigante, ou tumor de Buschke-Lowerstein, é uma forma rara de apresentação da infecção pelo papiplomavírus humano (HPV), caracterizado por um crescimento exuberante da lesão verrucosa típica do HPV, diferenciando do condiloma simples por seu caráter invasivo, embora benigno do ponto de vista metastático, sendo, pro isso considerado por muitos como uma patologia intermediária entre o condiloma simples e o carcinoma verrucoso. Os autores apresentam uma forma rara de apresentação do tumor de Buschken-Lowerstein, de localização anorretal, confirmando através de técnica de imunoistoquimica os tipos 11 e 16 do vírus HPV. Discutem ainda os principais aspectos clínicos, histopatológicos e terapêuticos, com ampla revisão da literatura mundial.

A visão da pediatria acerca da gravidez na adolescência: um estudo bibliográfico / A pediatric view on pregnancy among adolescents: a bibliographical study

O artigo objetiva analisar o conteúdo da producão bibliográfica, em três periódicos nacionais de Pediatria, no período de 1990 a 1999, acerca da gravidez na adolescência, identificando as explicacões para a ocorrência desse tipo de gravidez e encaminhamentos sugeridos para a temática. As variáveis do estudo (periódico; ano de publicacão; formacão e atuacão dos autores; palavras-chave; idéias associadas ao tema e metodologia utilizada) foram investigadas através de freqüências e cruzamentos. Na abordagem qualitativa, procurou-se analisar as explicacões e as recomendacões da Pediatria sobre o assunto. Dos 1437 artigos, apenas 1,1 por cento relacionavam-se ao tema. Controvérsias sobre o predomínio do risco biológico foram observadas nos artigos. Dentre as conclusões, aponta-se a necessidade da perspectiva interdisciplinar na abordagem do tema, considerando a complexidade dos aspectos que envolvem a gravidez na adolescência

[The pediatrics point of view regarding pregnancy in adolescence: a bibliographical study]. / A visão da pediatria acerca da gravidez na adolescência: um estudo bibliográfico.

This study analyzes the content of the scientific production of three national pediatric journals from 1990 to 1999, concerning pregnancy among adolescents and identifies the justifications for this occurrence and the follow-up suggested. The following variables were investigated according to their frequency: journal; year of publication; authors background; keywords; ideas associated with the subject in question; methodology. A qualitative approach enabled an analysis of the pediatric explanations and recommendations concerning this theme. Among 1437 papers, only 1.1% were related to the subject. Controversies regarding the importance of the biological risk involving the adolescents' lives were observed in the papers. In sum, the authors point out the need for an interdisciplinary perspective in approaching this theme, considering the complexity of the aspects involved in the pregnancy among adolescents.

Morbi-mortalidade nos acidentes de trânsito no Brasil / Morbidity and mortality in the traffic accidents in Brazil

Os acidentes de trânsito continuam a representar importante causa de morbi-mortalidade no mundo. Para que medidas preventivas, eficazes, possam ser adotadas, o conhecimento das características mais frequentes dos acidentes se faz necessário. Em nosso trabalho, levantamos os dados envolvendo 120.594 acidentes de trânsito no Brasil, no ano de 1998, no Ministério da Justiça - Departamento da Polícia Rodoviária Federal - Coordenação Geral de Operações, Setor de Estatística e Transitometria. Assim, concluímos que os acidentes de trânsito ocorreram, na maioria das vezes, de dia, com tempo bom, nas vias retas, frequentemente por desatenção, velocidade incompatível, desobediência à sinalização e ultrapassagem indevida. Estas conclusões nos permitem afirmar que os principais responsáveis são os motoristas, sendo necessária a sua conscientização no sentido de respeitar as leis, as sinalizações, o uso do cinto de segurança e a disposição adequada das crianças nos veículos