Eosinophilic cystitis in the pediatric population: a case series and review of the literature.

PURPOSE: Eosinophilic cystitis is a rarely seen condition in the pediatric population with indistinct symptomatology and non-standardized treatment protocols. We review our experience of treating patients with this condition. MATERIALS AND METHODS: We retrospectively reviewed the records of four patients from a single institution who have been diagnosed and treated for eosinophilic cystitis. In addition, the literature was reviewed for cases of pediatric eosinophilic cystitis. Our patients were added and compared to this cohort. RESULTS: Our patients included 3 females and 1 male who range in age from 5 days to 18 years (5 days, 1 month, 7 years, 18 years). Both of the infants presented with a suprapubic mass and bilateral hydroureteronephrosis. The two older patients both had dysuria while the 18 yo also complained of fatigue, flank pain, and hematuria. Only 2 of the 4 patients were found to have significant peripheral eosinophilia and only one patient had eosinophiluria. All of the patients were diagnosed via cystourethroscopy with biopsy. Treatment in each case consisted of a combination of steroids, antihistamines, and antibiotics. CONCLUSIONS: The presentation of eosinophilic cystitis is varied and diagnosis requires a high index of suspicion. Cystourethroscopy with biopsy is essential to establish the diagnosis as there is no typical appearance of the lesions or presenting signs/symptoms. Most cases of eosinophilic cystitis are responsive to medical therapy although in some cases recurrence may be noted.

Interactive computer games for treatment of pelvic floor dysfunction.

PURPOSE: We reviewed our experience with a conservative medical program and computer game assisted pelvic floor muscle retraining in patients with voiding dysfunction to substantiate our previous findings that demonstrated improvement and/or cure in a majority of patients, and identify factors that may be associated with unsuccessful treatment. MATERIALS AND METHODS: All patients presenting with symptoms of dysfunctional voiding enrolled in our pelvic floor muscle retraining were examined. Cases were subjectively evaluated for improvement of nocturnal enuresis, diurnal enuresis, constipation, encopresis and incidence of break through urinary tract infection. Patients in whom our initial conservative approach that included our biofeedback program failed were further treated with medication, and outcomes were reviewed as well. Fisher's exact test was used for statistical analysis to identify factors that may predict failure with our program. RESULTS: During the last 2 years 134 girls and 34 boys were enrolled in the pelvic floor muscle retraining program. Of the patients 160 (95%) were compliant with the program. Mean patient age was 7.6 years (range 4 to 18). The average number of hourly treatment sessions was 4.9 (range 2 to 13). Uroflowmetry and electromyography demonstrated a flattened flow pattern with increased post-void residual volume in 32% of patients, flattened flow pattern with normal post-void residual 47%, staccato flow pattern with increased post-void residual 11% and staccato flow pattern with normal post-void residual 10%. Subjective improvement was demonstrated in 87% (146) of patients, while 13% (22) had no improvement. Statistically significant predictors of failure included bladder capacity less than 60% of predicted volume (p <0.03) and patient noncompliance (p <0.04). Twelve patients who had no improvement with biofeedback were treated with medication and 10 (83%) improved. Multichannel urodynamics or spinal magnetic resonance imaging (MRI) was obtained in only 7 (4%) of our patients with no neurological lesion identified by spinal MRI. CONCLUSIONS: A conservative program combined with computer game assisted pelvic floor muscle retraining improves symptoms in most patients with voiding dysfunction. A majority of patients can be treated without medication. However, in a select population of patients with a small capacity bladder in whom biofeedback fails, anticholinergic medication appears to alleviate symptoms. In our experience almost all patients presenting with symptoms of voiding dysfunction can be treated without multichannel urodynamics, spinal MRI or medication.

Evaluation and follow-up of fetal hydronephrosis.

OBJECTIVE: To determine the antenatal course and neonatal follow-up of isolated fetal hydronephrosis. METHODS: We reviewed our ultrasonography database from January 1989 to June 1999 for all cases of unilateral or bilateral fetal hydronephrosis that had at least 1 follow-up ultrasonographic examination. Cases were defined as mild, moderate, or severe depending on the renal pelvis anteroposterior diameter and gestational age. Data were analyzed using the chi2 test with the Fisher exact test where appropriate. Medical records were reviewed, and telephone interviews were performed to determine which infants received follow-up after birth. RESULTS: Of 57,966 ultrasonographic examinations in 20,049 women during the study period, 393 patients met criteria for evaluation. Of these, 347 (88%) had fetuses with mild hydronephrosis. Most of these had complete resolution during the pregnancy. Forty patients had fetuses classified as having moderate hydronephrosis, and 6 patients had fetuses with severe hydronephrosis. Of those classified as moderate hydronephrosis, 15% resolved, 25% improved, 48% remained unchanged, and 12% worsened during the pregnancy. There were no cases of in utero resolution in the severe group; however, 4 of 6 cases improved to moderate or mild, and 2 cases remained unchanged. Of the cases identified prenatally, 25 received consultation by a pediatric urologist in the newborn period, and 7 of these required surgical intervention. CONCLUSIONS: Our population-based data suggest that most cases of mild hydronephrosis will resolve before delivery. In contrast, cases of moderate or severe hydronephrosis are less likely to have resolution in utero and are more likely to worsen or remain unchanged. Of those fetuses with persistent hydronephrosis, only a small number required some surgical intervention after birth. This information is useful in counseling the patient whose fetus is noted to have isolated hydronephrosis.

Changing concepts concerning the management of vesicoureteral reflux.

PURPOSE: Conservative estimates indicate that up to 54% of patients who present with vesicoureteral reflux have dysfunction voiding. Children with voiding dysfunction and vesicoureteral reflux historically have a high breakthrough infection rate of 34% to 43%. Breakthrough infection represents significant morbidity and it is the most common indication for surgical intervention for vesicoureteral reflux. Voiding dysfunction is present in 79% of patients who proceed to reflux surgery. We evaluated the impact of pelvic floor muscle retraining combined with a medical program in patients with voiding dysfunction and vesicoureteral reflux. MATERIALS AND METHODS: Children with a history consistent with voiding dysfunction and vesicoureteral reflux were screened by uroflowmetry/electromyography, bladder scan for post-void residual urine, renal ultrasound and voiding cystourethrography. Confirmed cases of voiding dysfunction and vesicoureteral reflux were prospectively enrolled in this study. Children participated in an interactive, computer assisted, pelvic floor muscle retraining program that involved a conservative medical regimen and pelvic floor muscle retraining. All patients received prophylactic antibiotics. We evaluated the rate of breakthrough urinary tract infection, reflux outcome and surgical intervention. A literature review with the key words vesicoureteral reflux, voiding dysfunction and urinary tract infection was performed to identify historical control cases for comparison. RESULTS: Study enrollment criteria were fulfilled by 49 girls and 4 boys 4 to 13 years old (average age 8.8), representing 72 units with low grades I to II (48) and high grades III to V (24) reflux. Mean followup was 24 months. Initial uroflowmetry/electromyography and bladder scan revealed a staccato flow pattern and normal post-void residual urine in 11% of cases, staccato flow pattern and elevated post-void residual urine in 10%, flattened flow pattern and normal post-void residual urine in 28%, and flattened flow pattern and elevated post-void residual urine in 51%. Breakthrough infection developed in 5 patients (10%), including 1 in whom reflux had resolved and 1 with grade I reflux who underwent observation. The parents of 2 patients elected to complete biofeedback without surgical intervention and these patients did not have a repeat infection. Reimplantation was performed in 1 case (2%). There was resolution in 18 low and 7 high grade refluxing units, including 2 older patients with a long history of high grade bilateral disease. Average time to resolution was 7.8 months. We noted elevated post-void residual urine in 88% of the patients with high grade reflux. Average age at resolution was 9.2 years. During a 24-month period one of us (P. H. M.) noted a greater than 90% decrease in surgical intervention. CONCLUSIONS: A combined conservative medical and computer game assisted pelvic floor muscle retraining program appears to have decreased the incidence of breakthrough urinary tract infections and facilitated reflux resolution in children with voiding dysfunction and vesicoureteral reflux. Patients with high grade reflux and voiding dysfunction commonly present with elevated post-void residual urine, contraindicating the indiscriminate administration of anticholinergics. Decreasing the rate of urinary tract infections may have a dramatic impact on the need for surgical intervention and enable the reflux resolution rate to approximate that in patients without voiding dysfunction. Prospective controlled trials are needed to determine whether pelvic floor muscle retraining combined with a conservative medical regimen alters the natural history of vesicoureteral reflux in patients with voiding dysfunction.

The Kidney's role in glucose balance following partial hepatectomy.

It has long been believed that the liver is the major contributor to glucose balance during fasting and stressful situations. Recently, investigators have implicated the kidney as having a significant contribution to systemic glucose appearance. We studied the relative contributions of the kidney and liver to glucose homeostasis in fasted nonoperated, sham-operated, and 70% hepatectomized rats. Systemic glucose appearance, renal glucose release and uptake, and hepatic glucose release were determined by glucose balance and isotopic dilution techniques. Systemic glucose appearance remained unchanged following hepatectomy. There was a significant output of glucose by the kidney in all groups, accounting for >50% of total glucose appearance. Despite the kidney's appreciable contribution to circulating glucose in the postabsorptive state, renal glucose release was not increased in the hepatectomized rats compared to controls. Total glucose appearance was maintained following hepatectomy by an increase in hepatic glucogenesis. There was a significant increase in the rate of hepatic glucose release from resected rats when normalized to gram of remaining liver (P < 0.001). Despite the substantial amount of renal glucose output in the postabsorptive state, preservation of glucose balance following 70% hepatectomy is accomplished by adaptation in hepatic glucose output.

Study of a needleless intermittent intravenous-access system for peripheral infusions: analysis of staff, patient, and institutional outcomes.

OBJECTIVE: To assess the effect on staff- and patient-related complications of a needleless intermittent intravenous access system with a reflux valve for peripheral infusions. DESIGN: A 6-month cross-over clinical trial (phase I, 13 weeks; phase II, 12 weeks) of a needleless intermittent intravenous access system (NL; study device) compared to a conventional heparin-lock system (CHL, control device) was performed during 1991 on 16 medical and surgical units. A random selection of patients was assessed for local intravenous-site complications; all patients were assessed for the development of nosocomial bacteremia and device-related complications. Staff were assessed for percutaneous injuries and participated in completion of product evaluations. A cost analysis of the study compared to the control device was performed. SETTING: A 1,100-bed, teaching, referral medical center. PATIENTS AND STAFF PARTICIPANTS: 594 patients during 602 patient admissions, comprising a random sample of all patients with a study or control device inserted within a previous 24-hour period on study and control units, were assessed for local complications. The 16 units included adult inpatient general medicine, surgical, and subspecialty units. Pediatrics, obstetrics-gynecology, and intensive-care units were excluded. All patients on study and control units were assessed for development of nosocomial bacteremia and device-related complications. All staff who utilized, manipulated, or may have been exposed to sharps on study and control units were assessed for percutaneous injuries. Nursing staff completed product evaluations. INTERVENTION: The study device, a needleless intermittent intravenous access system with a reflux valve, was compared to the control device, a conventional heparin lock, for peripheral infusions. RESULTS: During the study, 35 percutaneous injuries were reported. Eight injuries were CHL-related; no NL-related injuries were reported (P=.007). An evaluation of 602 patient admissions, 1,134 intermittent access devices, and 2,268 observed indwelling device days demonstrated more pain at the insertion site for CHL than NL; however, no differences in objective signs of phlebitis were noted. Of 773 episodes of positive blood cultures on study and control units, 6 (0.8%) were device-related (assessed by blinded investigator), with no difference between NL and CHL. Complications, including difficulty with infusion (P<.001) and disconnection of intravenous tubing from device (P<.001), were reported more frequently with CHL than with NL. Of nursing staff responding to a product evaluation survey, 95.2% preferred the study over control device. The projected annual incremental cost to our institution for hospitalwide implementation of NL for intermittent access for peripheral infusions was estimated at $82,845, or $230 per 1,000 patient days. CONCLUSIONS: A needleless intermittent intravenous access system with a reflux valve for peripheral infusions is effective in reducing percutaneous injuries to staff and is not associated with an increase in either insertion-site complications or nosocomial bacteremia. Institutions should consider these data, available institutional resources, and institution-specific data regarding the frequency and risk of intermittent access-device-related injuries and other types of sharps injuries in their staff when selecting the above or other safety devices.