Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation.

AIM: Sphincteroplasty (SP) is used to treat faecal incontinence (FI) in patients with a sphincter defect. Although sacral nerve stimulation (SNS) is used in patients, its outcome in patients with a sphincter defect has not been definitively evaluated. We compared the results of SP and SNS for FI associated with a sphincter defect. METHOD: Patients treated by SNS or SP for FI with an associated sphincter defect were retrospectively identified from an Institutional Review Board approved prospective database. Patients with ultrasound evidence of a sphincter defect were matched by age, gender and body mass index. The main outcome measure was change in the Cleveland Clinic Florida Faecal Incontinence Score (CCF-FIS). RESULTS: Twenty-six female patients with a sphincter defect were included in the study. The 13 patients in each group were similar for age, body mass index, initial CCF-FIS and the duration of follow-up. No differences were observed in parity (P = 1.00), the rate of concomitant urinary incontinence (P = 0.62) or early postoperative complications. Within-group analysis showed a significant reduction of the CCF-FIS among patients having SNS (15.9-8.4; P = 0.003) but not SP (16.9-12.9; P = 0.078). There was a trend towards a more significant improvement in CCF-FIS in the SNS than in the SP group (post-treatment CCF-FIS 8.4 vs 12.9, P = 0.06). Net improvement in CCF-FIS was not significantly different between the groups (P = 0.06). CONCLUSION: Significant improvement in CCF-FIS was observed in patients treated with SNS but not SP patients. A trend towards better results was seen with SNS.

Reference values of exhaled nitric oxide for healthy children 6-15 years old.

Nitric oxide (NO) can be detected in human exhaled air, and its endogenous production is increased in patients with asthma. It may provide a noninvasive means for measuring airway inflammation. The aim of this study was to establish reference values for exhaled NO concentrations in a large number of healthy school-age children. We measured exhaled NO levels in 159 white healthy children (88 girls, 71 boys, age range 6-15 years) recruited from two public schools of Padua, Italy. Exhaled NO levels in exhaled gas were measured by a tidal breathing method with a chemiluminescence analyzer, and NO steady-state levels were recorded. Nasal NO levels were measured by direct sampling from the nose during mouth breathing. The mean concentration of endogenous NO in orally exhaled gas was 8.7 parts per billion (ppb) (95% confidence interval (C.I.), 8.1-9.2 ppb) and sampled data followed a log-normal distribution (Kolmogorov-Smirnov d = 0.77, P > 0.2). No difference was found between boys (mean value, 8.4 ppb; 95% C.I., 7.3-9.4 ppb) and girls (mean value, 8.9 ppb; 95% C.I., 7.9-9.9 ppb). No significant correlation was found between age, height, or spirometric data and exhaled NO levels (r < 0.2). The mean value of nasal NO concentrations was 216 ppb (95% C.I., 204-228 ppb). There was no correlation between exhaled and nasal NO values (r = 0.16, P = ns). In conclusion, this study establishes a reference range for exhaled NO values measured by a tidal breathing method in children between age 6-15 years. The observed levels are independent of age, gender, and lung function, and can be used to monitor airway inflammation in asthmatic children.

[The subject with spina bifida and his family: psychological and social aspects. I]. / Il soggetto affetto da spina bifida e la sua famiglia: aspetti psicologici e sociali. Parte prima.

This paper is to examine the psychological and social effects in spina bifida. In 130 subjects, aged from 4 to 24 years old, the levels of the I.Q. have been studied and they have been distributed into revelant percentual groupings, and the psychologic perception problems of the malformation of the subject have been studied. Finally, dominant psychologic and social problems have also been considered.

[The spina bifida patient and his family: psychologic and social aspects. 2]. / Il soggetto affetto da spinal bifida e la sua famiglia: aspetti psicologici e sociali. Parte seconda.

In the second part of the present work the data which was obtained through questionnaires and interviews with 130 families with children affected by spina bifida is presented. Presented first are the immediate sociopsychological aspects of the family when they are informed about the malformation, the derived psychological effects and the preoccupations relating to the life of their child. Then the aspects of the successive social and psychological problems of these parents are presented, and finally the expectations and demands of the same parents following the psychological operations carried out at the centre to the benefit of the children and their families.

[Sound alarms and conditioning therapy in the treatment of childhood enuresis: a study of 180 cases]. / L'allarme sonoro e la terapia del condizionamento nel trattamento dell'enuresi infantile: uno studio su 180 casi.

The Authors present the study and results in 180 cases of infantile enuresis, treated with a new bell alarm associated to conditioning psychological treatment (toilet training, token economy, motivational counseling, urine stop exercises, etc.). The cases have been subdivided into the type of enuresis, age and sex. 140 (77.8%) subjects aged from 6 years to 16 years with primary enuresis, and 40 (22.2%) aged from 6 years to 15 years with secondary enuresis have been treated. The following results were obtained in the primary enuresis with this type of treatment after a follow-up of 6-12 months: permanent recovery in 85.71% of the cases, relapse after 6 months in 11.42%, improvement in 5% and failures in 9,29% of the cases. In secondary enuresis the following results were obtained: permanent recovery after 12 months in 75% of the cases, relapse after 6 months in 10%, improvement in 7.5% and failures in 17.5% of the cases. The differences in the results between the two types of enuresis with respect to the age of the cases up to 12 years are proved and relatively less with respect to the average time of treatment for the total remission. Regarding the sex of the cases no significant therapeutic answer was noted neither in the final results nor in the time of treatment in both types of enuresis. Finally, it is not the substitution of symptoms which are proved but the benefits of a general and psychological level.

[Biofeedback in asthmatic children]. / Il biofeedback nel bambino asmatico.

This paper reports the results of the treatment of continuous bronchial asthma in children, 7-14 years old, by means of biofeedback and the counter-conditioning. We observed the remission of the symptomatology in all the cases, with a statistical significance.

[Psychological study of adults surgically treated in childhood for hypospadias]. / Rilevazioni psicologiche su soggetti adulti operati in età pediatrica di ipospadia.

The authors present the study and results in 100 subjects operated of hypospadia. They interviewed patients within 15 and 22 years old, in randomized selection and in permanent percent relations as far as: different types of pathology, the age of surgery effected in Vicenza Hospital - Pediatric Surgery Department (1971-1981). Through a structured questionnaire they tried to analyse psychological lived in operated subjects as far as: surgery, convalescence, psychologic problems before and after surgery, way of life when they became adults. Results explain that exist some psychologic problems in operated patients (8.5 years old) before surgery and during convalescence, while there is no problem after surgery. Moreover when these subjects became adults their kind of life (school, profession, sexuality) is without psychopathological problems. This is because of positive attitudes pre-acquired, brief convalescence and above all the high and positive quality of surgery effected.

[Cardiosurgical intervention in extracorporeal circulation and intellectual performance in childhood. Study and follow-up of 20 cases]. / Intervento cardiochirurgico in C.E.C. e performance intellettiva in età pediatrica. Studio e follow-up di 20 casi.

6 and 12 months before and after surgery in E.C.C., twenty subjects, at the age of development between 6 and 14 years, suffering from congenital heart disease, were subjected to psychometric observations with tests of level and others (wisc, raven, pm 38, rey, bender), in order to analyse the intellective level, specific mental capacities and eventual modifications in the mental and cognitive performances of the patients. No psychometric, statistically meaningful variations were generally noticed during the 3 observations. No meaningful correlations resulted between the duration of E.C.C. and psychometric observations. The patients subjected to the E.C.C. longer than the average of the total group generally didn't show any statistically meaningful variations in the scores of the 3 observations. To sum up the authors think that the experimental group showed and maintained before and after the cardiac surgery, a normal developing and maturative level and anyway that after the follow-up, no changes in the several intellective capacities of the patient were noticed.

The Pediatric Bowel Management Clinic in children with severe chronic constipation. Personal experience.

The multifactorial nature of functional constipation in children suggests that a multidisciplinary management approach may be effective and leads to both patients and parents' satisfaction and significant short term improvement. The authors describe their experience with the study and treatment of children with severe chronic constipation in a newly-created Pediatric Bowel Management Clinic (BMC). Further studies will examine the long-term impact of the clinic.

Determinants of on-the-job-barriers in employed persons with multiple sclerosis: the role of disability severity and cognitive indices.

BACKGROUND: Literature has shown that work maintenance is central in order to guarantee participation to persons with disability. Knowledge about potential sources of difficulties and obstacles is then crucial in order to prevent barriers and facilitate work maintenance and career development for persons with disabilities. OBJECTIVE: Studies analyzing on-the-job barriers among employed people with multiple sclerosis (MS) have found evidence for a role of clinical determinants. The aim of this study was to describe in more detail the role of disability severity and of cognitive indices on work barriers. PARTICIPANTS: Thirty-two employed adults with a diagnosis of MS with mild to moderate disability severity were included in the study. They were involved in the descriptive study while attending their planned care in the MS unit. METHODS: Subjects completed neurocognitive tasks, a self-report measure of executive functioning and a face-to-face semi-structured interview exploring their perception of barriers at work. RESULTS: Regression analyses showed a specific role of disability severity on perception of barriers due to physical, cognitive and interpersonal relationships; cognitive indices, on the other hand, predicted barriers ascribed to company policy (cognitive score), to accessibility (planning score) or difficulties in cognitive and task related abilities (self-rated executive functioning). CONCLUSION: These findings underline the relevance of objective tasks and self-report questionnaire, direct and indirect multi-dimensional assessment of functioning for an early intervention planning. An ecological model of career development in adults with disabilities is also supported.

The first 20 minutes after a single dose of inhaled salmeterol in asthmatic children.

Very little is known as yet about the effect of salmeterol in pediatric asthma, so a trial was performed on children with mild asthma to compare salmeterol with salbutamol in terms of how quickly they took effect. The double-blind study involved 11 children (mean age 13.4 years) randomly assigned to inhale salmeterol 50 micrograms, salbutamol 200 micrograms, or a placebo three times on alternate days. Peak expiratory flow (PEF), heart rate, and blood pressure were measured before and 5, 10, 15, and 20 min after administering the medication. With salbutamol, PEF was higher at 5 and 10 min, subsequently dropping off at 15 and 20 min; with salmeterol, PEF was better at 10 and 20 min. Forced expiratory volume at 1 s (FEV1) measurements taken at the baseline and after 10 and 20 min revealed an important and consistent rise in values after salmeterol, whereas salbutamol was more effective after 10 min than after 20 min. No significant changes were recorded in heart rate or blood pressure after salbutamol; after salmeterol, there was a significant increase in heart rate after 5 min, but not at subsequent measurements. In conclusion, salmeterol begins to take effect already within 10 min of a single administration in asthmatic children, although the onset of its effect is slower than with salbutamol.

Interstitial lung disease in children: a multicentre survey on diagnostic approach.

Chronic interstitial lung disease (ILD) is a rare disorder in the paediatric age group, with a poor prognosis. The diagnostic approach to ILD is based on more or less invasive methods. This study was implemented to verify which methods are the most often used in children. Questionnaires (333) were sent to members of the European Respiratory Society Paediatric Assembly belonging to 187 European and non-European centres. Questions concerned the use of noninvasive diagnostic methods, e.g. history taking, physical examination, routine laboratory tests, respiratory function tests and radiology (chest radiography, high-resolution computed tomography (HRCT)), and the use of invasive techniques such as bronchoalveolar lavage (BAL), transbronchial biopsy (TBB), open lung biopsy (OLB), video-assisted thoracoscopic biopsy (VAT) and HRCT with fine-needle aspiration biopsy (FNAB). Thirty eight centres returned the questionnaires and 131 children with ILD were studied. A diagnosis of ILD was achieved in five (3.8%) patients using noninvasive techniques alone. Using the various biopsy methods, histological assessment was performed on a total of 98 (74.8%) children. The most frequently used invasive technique both alone and in combination was BAL (83, 63.3%), followed by OLB (64, 48.8%), TBB (26, 19.8%) and VAT (11, 8.4%); FNAB was used in one patient. In conclusion a diagnosis of interstitial lung disease was reached on the basis of aetiological and/or histological findings in 117 (89%) of the 131 patients studied.

Retrospective study of children with acute pyelonephritis. Evaluation of bacterial etiology, antimicrobial susceptibility, drug management and imaging studies.

The purpose of the study was to investigate the management of pyelonephritis in a large Italian pediatric population. A total of 1,333 patients (36% male) were considered. Escherichia coli was the most frequently isolated agent (89.9%), followed by Proteus mirabilis (3.6%) and Klebsiella oxytoca (2.1%). 27% of microorganisms were resistant to amoxicillin, 4% to amoxicillin/clavulanic acid, 11% to trimethoprim-sulfamethoxazole, 2.4% to gentamicin and less than 2% to ceftazidime. Despite this resistance pattern showing that oral antibiotics, such as amoxicillin/clavulanic acid, are effective in vitro as well as parenteral antimicrobials, a parenteral antibiotic was given initially to 756 (57.2%) children. A prophylactic regimen was started in 922 patients with a rate of reinfection during prophylaxis of 9.5%; a higher rate of reinfection was observed in patients with reflux (25%) compared to children without reflux (3%) (p < 0.0001). Vesicoureteral reflux was demonstrated in 30% of patients. The number of renal abnormalities detected by DMSA in patients with and without reflux was significantly different (p < 0.001). CRP was higher in patients with scars (p < 0.02). In conclusion, pyelonephritis represents a common disease with about 2,500 days of hospitalization per year in the Veneto Region where there is a pediatric population of about 800,000 under 15 years of age. The results of antimicrobial in vitro tests indicate that amoxillicin/clavulanic acid could represent the antibiotic of choice. The high frequency of malformations, observed even in children between 6 and 12 years of age, may suggest the need of an imaging study including DMSA scan and VCUG in all age groups.

Determination of urinary orotate excretion by high-performance liquid chromatography.

A new reversed-phase high-performance liquid chromatographic procedure for the determination of urinary orotate excretion is described. It is a selective, sensitive and rapid method, suitable for the differentiation of inherited metabolic diseases with abnormal orotate metabolism.

Determination of 8-methoxypsoralen in plasma by gas chromatography-mass spectrometry using selected-ion monitoring.

A sensitive and accurate assay was developed for the measurement of 8-methoxypsoralen in plasma using electron-impact positive-ion mass fragmentography. 4,5,8-Trimethylpsoralen was used as an internal standard. Sample preparation consisted of a two-step liquid phase extraction using acetonitrile and methylene chloride. The calibration curve showed a linear relationship between the peak areas of 8-methoxypsoralen and 4,5,8-trimethylpsoralen over a wide range of 8-methoxypsoralen concentrations (1-500 ng/ml). With-in- and between-run precisions, measured at five different drug concentrations, varied from 0.82 to 1.41% and from 0.82 to 1.86%, respectively.

Determination of inulin in plasma and urine by reversed-phase high-performance liquid chromatography.

We report a new HPLC procedure for measuring inulin in plasma and urine. Samples after dilution are boiled in mild acidic conditions and then analyzed on a C18 column. Solvent system A is 3.2 mM HCl, pH 2.5, and B is acetonitrile-3.2 mM HCl (60:40, v/v), pH 2.5. The separation is carried out in 8 min with a flow-rate of 1.0 ml/min and the absorbance monitored at 280 nm. The relationship between inulin and the recorded peak area is linear from 0.2 to 3.2 mg/ml with a correlation coefficient of 0.999 for plasma and 0.999 for urine. Within-run precision, measured at three inulin concentrations, ranged from 0.9 to 1.7% in plasma and from 0.8 to 1.2% in urine. Between-run precision varied in plasma from 2.7 to 3.2% and in urine from 3.0 to 3.3%. Analytical recovery ranged from 102 to 107% in plasma and from 101 to 105% in urine, respectively. The method is sensitive, selective and only 30-microliters samples are required. Therefore, it could be used to evaluate the glomerular filtration rate even in small babies and to perform studies in animals.

Use of the paediatric bronchoscope, flexible and rigid, in 51 European centres.

We have undertaken a survey to establish current practices and differences in the use of bronchoscopes in children in European centres. A questionnaire was sent to all 220 members of the Paediatric Assembly of the European Respiratory Society (ERS). The questions concerned the following points: indications for bronchoscopy; site of bronchoscopy; type of sedation; any oxygen supplementation during the procedure; number of procedures performed in the previous 12 months; number of procedures performed in the neonatal intensive care unit; number of bronchoalveolar lavages (BALs); side-effects during and after the procedures; and diagnostic yield. Fifty one European centres (40.8% of the European centres contacted) took part in the study. A total of 7,446 bronchoscopies had been performed in the last 12 months: 4,587 using the flexible bronchoscope and 2,859 using the rigid bronchoscope. At centres using only the fibreoptic bronchoscope, the most frequent indication was "recurrent/persistent pneumonia" (17%); at centres using only the rigid bronchoscope, it was "foreign body inhalation" (36.7%); at centres using both methods, the most frequent indication was "other indications" (23.9%). In 12 months, 2,231 BALs were performed: 1,419 in immunocompetent children and 812 in immunocompromised patients. In centres using only the fibreoptic bronchoscope, the highest yield was for "stridor" (81%); in centres using only the rigid bronchoscope, the highest yield was for "persistent atelectasis" (68%); and in centres using both instruments, it was for "foreign body inhalation" (93%). The results of the study suggest that bronchoscopy in children is now a well-established procedure at several European centres, while others are just beginning to use this technique.