Is there a benefit from routine voiding cystourethrography after ureterocystoneostomy?

Surgical repair such as ureterocystoneostomy (UCN) for vesicoureteral reflux (VUR) or primary obstructive megaureter (POM) is the treatment of choice after the failure of conservative therapy. To document the postoperative outcome, a voiding cystourethrography is routinely performed to exclude persisting reflux. Our aim was to evaluate the benefit of voiding cystoureterography (VCUG) in our patients with respect to radiation, discomfort to the child and costs. The medical records of all patients who underwent an ureterocystoneostomy at the Department of Paediatric Surgery in St. Gallen, Switzerland, between January 1, 1995 and December 31, 2000 were reviewed in terms of the pre- and postoperative clinical course, type of surgical procedure and radiographic examinations performed. During this period, 126 renal units were operated in 81 patients. The surgical technique employed was Cohen's procedure in 121 (96 %) renal units and a Leadbetter-Politano procedure in 5 (4 %) renal units. Mean postoperative follow-up was 42 months (6 - 84). All patients had an ultrasonographic follow-up. 77 (95 %) patients underwent a VCUG with normal results one year postoperatively. VUR was found in 4 patients, 3 of them were asymptomatic one year postoperatively, one had a complication of a fistula with reflux and required reoperation 2 months after operation. The VCUG was performed earlier because of clinical und ultrasonographic findings. None of the routinely performed VCUGs led to a change of procedure. All pathologies had already been detected by clinical or ultrasonographic findings. We recommend clinical and ultrasonographic follow-up after an UCN and performance of a VCUG only when problems appear to be present.

The Yentl syndrome in childhood asthma: risk factors for undertreatment in Swiss children.

Recent prevalence data for childhood asthma in Switzerland suggest a substantial underdiagnosis which seems to be more pronounced in girls. We further analysed our data trying to specify risk factors for underdiagnosis and undertreatment. Our special interest was focused on female sex as there is evidence for a sex-dependent diagnosis and treatment of chronic disease in adults, called the Yentl syndrome. The data are derived from a parent completed questionnaire survey of a stratified cluster sample of schoolchildren aged 7, 12, and 15 years. Besides the 12 months prevalence of asthma symptoms and bronchodilator treatment, the lifetime prevalence of an asthma diagnosis was noted. With a response rate of 97%, a total of 4353 completed questionnaires were analysed. While age was not associated with undertreatment (except for exercise-induced symptoms in adolescents), the lack of a formal diagnosis of asthma and atypical asthma symptoms other than wheeze such as chronic night cough were confirmed as significant risk factors for undertreatment. Of all boys reporting asthma symptoms 31% received bronchodilator treatment compared with only 15% of the symptom-reporting girls (P < 0.001). For all particular asthma-related symptoms (except wheeze), significantly more boys than girls (approximately double) received treatment. The physiological and psychological bases for these findings are discussed and suggest that gender is an important risk factor for underdiagnosis and undertreatment of asthma. Our research indicates that the Yentl syndrome may exist for childhood asthma.

Prevalence of respiratory symptoms in Swiss children: is bronchial asthma really more prevalent in boys?

Precise epidemiological data for the prevalence of childhood asthma were lacking for Switzerland until recently. In 1990 we performed a stratified cluster sampling of schoolchildren (aged 7, 12, and 15 years), using a parent completed questionnaire to obtain data for the 12 months prevalence of asthma symptoms and the lifetime prevalence of asthma diagnosis. A response rate of 97.5% enabled us to analyse 4,353 completed questionnaires. The prevalence of any asthma symptom during the last 12 months was 17.5% while only 4.8% of the children reported the diagnostic label "asthma". The 12 months prevalence of chronic night cough was 12% and is comparable to other European data. Wheeze (5.9%) was reported less often in Switzerland than in England. At the age of 7 years asthma symptoms such as wheeze, morning tightness, and allergen-induced symptoms were reported more often in boys than in girls; at the age of 12 and 15 the male preponderance was no more evident. For all asthma symptoms the male-female ratio decreased with increasing age of the children, while independently of age twice as many boys than girls reported the diagnostic label "asthma." We conclude that asthma symptom prevalence in Swiss schoolchildren is within the lower range of European data. Chronic night cough might be a more appropriate variable to compare prevalence rates between regions with different cultural and linguistic backgrounds that the symptom of wheeze. Evidence exists for a substantial underdiagnosis of bronchial asthma in Swiss children, especially in girls. Further evaluation is needed to define risk factors for underdiagnosis and the associated risk for undertreatment.

International comparison of asthma prevalence in children: Australia, Switzerland, Chile.

The aim of the study was to determine if the prevalence of symptoms suggestive of asthma in school-age children was similar in three countries with differing language and culture. To answer this question, we used the same instrument, translated appropriately, for schoolchildren in Melbourne, Australia, St. Gallen, Switzerland, and La Serena, Chile. A three page respiratory symptoms questionnaire was issued to schools for distribution to children for completion by parents and return to the school. Three age groups were selected for study, based on the average age of the school grade. Grades were used with average ages of 7, 12, and 15 years, respectively. A total of 26,628 questionnaires were issued to parents (Australia, 10,981; Switzerland, 4,464; Chile, 11,183). The response rates for each country were 89% for Australia, 97.5% for Switzerland, and 71% for Chile. The prevalence of wheezing in the last 12 months for 7 year olds was 23.1% in Melbourne, 7.4% in St. Gallen, and 26.5% in La Serena; for 12 year olds it was 20.9% in Melbourne, 6.0% in St. Gallen, and 21.1% in La Serena; for 15 year olds it was 18.6% in Melbourne, 4.5% in St. Gallen, and 17.7% in La Serene. A history of wheezing was more common in boys than girls at age 7 in Melbourne and St. Gallen, but not La Serena. This difference was less at age 12 and was not seen at age 15. Among those who had reported wheezing in the last 12 months, bronchodilator use was reported by 83% (1,611/1,948) from Melbourne, 46% (118/259) from St. Gallen, and 47% (538/1,140) from La Serena.(ABSTRACT TRUNCATED AT 250 WORDS)

Family history of atopy and clinical course of RSV infection in ambulatory and hospitalized infants.

Respiratory syncytial virus (RSV) infection can be severe in pediatric patients. Risk factors for severe disease include age less than 6 months, prematurity, preexisting heart or lung disease or malformations, gastroesophageal reflux, and immunodeficiency. The aim of the present study was to investigate the influence of family history of allergy on the clinical course of RSV infection in ambulatory and hospitalized infants. In a retrospective study, 172 patients younger than 12 months of age (99 inpatients and 73 outpatients) were enrolled. Information was obtained from hospital charts and from questionnaires sent to pediatricians. Inpatients had a significantly higher rate of atopy in their family history than outpatients, 62% and 29%, respectively (P < 0.001). Bronchiolitis was diagnosed more frequently in patients with an atopic burden than those without, 89% versus 74%, respectively (P < 0.02). Inpatients with an atopic family history had a significantly longer hospital stay than those without such a history, 7.4 +/- 3.7 days and 6.1 +/- 2.3 days, respectively (P < 0.04). Factors other than age that are considered a risk for severe infection with RSV (prematurity, preexisting heart or lung disease or malformation, and gastroesophageal reflux) were not confirmed in the present study. We conclude that infants with a family history of atopy are at increased risk for severe RSV infection as indicated by higher rates of hospitalization, longer hospital stay, and more frequent occurrence of bronchiolitis.

Comparison of responses to an asthma symptom questionnaire (ISAAC core questions) completed by adolescents and their parents. SCARPOL-Team. Swiss Study on Childhood Allergy and Respiratory Symptoms with respect to Air Pollution.

The primary objective of the study was to determine the impact of the identity of the respondent (parents versus adolescents) on prevalence estimates of asthma symptoms in Swiss adolescents. In addition, factors influencing agreement between parents' and adolescents' responses to the same questions were analysed. One thousand three hundred and seventy-four (78.4%) adolescents, aged 14 years, self-completed a questionnaire at school based on the International Study of Asthma and Allergy in Childhood (ISAAC) core questions on wheezing and asthma. The same questions were incorporated into a questionnaire to be completed by the parents at home. The adolescents' self-reported prevalence rates of current asthma symptoms and "asthma ever" were significantly higher than those obtained from the parental questionnaires. 856 (62.6%) parental questionnaires were filled in by parents without the help of the adolescents, 460 (37.4%) were completed by parents and adolescents and 51 (3.7%) were completed by the adolescents without the parents. Prevalence rates were higher when parents and adolescents completed the questionnaire jointly than when questionnaires were completed by parents alone. The level of agreement between parental and self-completed questionnaires was moderate to low (kappa coefficients 0.22-0.68). Agreement between parental and adolescents reports of asthma symptoms was best when questionnaires were completed jointly by parents and adolescents, when the adolescent was a girl, when a family history of asthma was recorded, when the adolescent was a non-smoker, and when the parental education was high. We conclude that the higher reporting of prevalence rates of current asthma symptoms by adolescents compared to reporting by their parents demonstrates the need to take the respondent to a questionnaire into account when comparisons are made between prevalence studies. The results also suggest that factors related to the family milieu influence symptom reporting.

Factors affecting the efficiency of aerosol therapy with pressurised metered-dose inhalers through plastic spacers.

AIM: The main objective of this study was to compare the in vitro delivery of salbutamol from a chlorofluorocarbon(CFC)-propelled pressurised metered-dose inhaler (pMDI) versus a newly developed hydrofluoroalkane(HFA)-propelled pMDI through various spacers. In addition, we aimed to study the effect on bronchodilator response when using an optimal pMDI/spacer combination for aerosol delivery compared to a suboptimal combination. METHODS: Particle size distribution and output from salbutamol pMDIs containing either CFC propellants (Ventolin) or HFA propellants (Airomir) were measured using a multistage liquid impinger (MSLI) and compared to that through both detergent-coated (non-static) or untreated (static) large volume (Nebuhaler, Volumatic) and small volume (Aerochamber) plastic spacers. Flow-volume curves (FEV1) were obtained from twelve asthmatic children with known significant bronchodilator response (8 males), aged 13-17 years, randomly inhaling salbutamol from a CFC-pMDI through a static spacer (Nebuhaler) and from an HFA-pMDI through a non-static spacer (Nebuhaler). RESULTS: In vitro output of particles in the respirable range (< 6.8 microns) from HFA-pMDIs was significantly higher than that from CFC-pMDIs using various spacers. Removal of electrostatic charge increased output from CFC- and HFA-pMDIs through all spacers by 17-82%. The mean (SD) bronchodilator response after inhalation of salbutamol from a CFC-pMDI through a static spacer was 7.1% (6.3%) compared to 17.5% (7.9%) after inhalation from an HFA-pMDI through a non-static spacer (p = 0.002). CONCLUSIONS: Use of a newly developed HFA-propelled pMDI greatly improves drug delivery through spacers compared to a CFC-propelled pMDI. However, electrostatic charge in plastic spacers remains the key determinant limiting delivery of salbutamol from a pMDI through spacers, and can be reduced by soaking the spacer in a household detergent. Using an optimal pMDI/spacer combination leads to a significantly improved bronchodilator response.

Wearing a noseclip improves nebulised aerosol delivery.

OBJECTIVE: The efficiency of nebulised aerosol delivery is limited due to drug retained within the nebuliser, and due to a poor ratio between inspiratory drug delivery and expiratory drug loss. Several technical approaches have improved the ratio between inspiratory aerosol delivery and expiratory aerosol loss. In our pilot study we aimed to investigate if wearing a noseclip during inhalation therapy improves the inspiratory versus expiratory ratio and hence, improves nebulised aerosol delivery. METHODS: Drug delivery was measured in thirteen subjects (7 males; age range 23-36 years) inhaling in random order nebulised aerosol through a mouthpiece once while wearing a noseclip and once without. RESULTS: Wearing a noseclip leads to an increase of 113% (SEM 23.5) in drug delivery and improves the inspiratory versus expiratory ratio (ratio 2.07 versus 0.75). CONCLUSIONS: We have shown that aerosol delivery is increased due to an improved inspiratory versus expiratory ratio when wearing a noseclip.

Improvement of walking abilities after robotic-assisted locomotion training in children with cerebral palsy.

OBJECTIVE: To measure functional gait improvements of robotic-assisted locomotion training in children with cerebral palsy (CP). DESIGN: Single-case experimental A-B design. SETTINGS: Rehabilitation Centre Affoltern am Albis, Children's University Hospital Zurich, Switzerland (inpatient group) and Neurology Department of the Dr von Haunersches Children's Hospital Munich, Germany (outpatient group). PARTICIPANTS: 22 children (mean age 8.6 years, range 4.6-11.7) with CP and a Gross Motor Function Classification System level II to IV. INTERVENTIONS: 3 to 5 sessions of 45-60 minutes/week during a 3-5-week period of driven gait orthosis training. MAIN OUTCOME MEASURES: 10-metre walk test (10MWT), 6-minute walk test (6MinWT), Gross Motor Function Measure (GMFM-66) dimension D (standing) and dimension E (walking), and Functional Ambulation Categories (FAC). RESULTS: The mean (SD) maximum gait speed (0.78 (0.57) to 0.91 (0.61) m/s; p<0.01) as well as the mean (SD) dimension D of the GMFM-66 (40.3% (31.3%) to 46.6% (28.7%); p<0.05) improved significantly after the intervention period. The mean (SD) 6MinWT (176.3 (141.8) to 199.5 (157.7) m), the mean FAC (2.6 (1.7) to 3.0 (1.6)) and the mean (SD) dimension E of the GMFM-66 (29.5% (30.3%) to 31.6% (29.2%)) also showed an increase, but did not reach a statistically significant level. CONCLUSION: These results suggest that children with CP benefit from robotic-assisted gait training in improving functional gait parameters.

Feasibility of robotic-assisted locomotor training in children with central gait impairment.

Intensive, task-specific training enabled by a driven gait orthosis (DGO) may be a cost-effective means of improving walking performance in children. A paediatric DGO has recently been developed. This study was the first paediatric trial aimed to determine the feasibility of robotic-assisted treadmill training in children with central gait impairment (n=26; 11 females, 15 males; mean age 10 y 1 mo [SD 4 y]; range 5 y 2 mo-19 y 5 mo). Diagnoses of the study group included cerebral palsy (n=19; Gross Motor Function Classification System Levels I-IV), traumatic brain injury (n=1), Guillain-Barré syndrome (n=2), incomplete paraplegia (n=2), and haemorrhagic shock (n=1), and encephalopathy (n=1). Sixteen children were in-patients and 10 were outpatients. Twenty-four of the 26 patients completed the training which consisted of a mean of 19 sessions (SD 2.2; range 13-21) in the in-patient group and 12 sessions (SD 1.0; range 10-13) in the outpatient group. Gait speed and 6-Minute Walking Test increased significantly (p<0.01). Functional Ambulation Categories and Standing dimension (in-patient group p<0.01; outpatient group p<0.05) of the Gross Motor Function Measure improved significantly. DGO training was successfully integrated into the rehabilitation programme and findings suggest an improvement of locomotor performance.

Trends in prevalence of asthma, allergic rhinitis and atopic dermatitis in 5-7-year old Swiss children from 1992 to 2001.

BACKGROUND: Changing occurrence rates of asthma, allergic rhinitis and atopic dermatitis are of public health concern and require surveillance. Changes in prevalence rates of these atopic diseases were monitored during 10 years and their trend with time was determined taking into account the influence of personal and environmental risk factors. METHODS: Four cross-sectional surveys in 5-7-year old children were performed in seven different communities in Switzerland between 1992 and 2001. Prevalence of respiratory and allergic symptoms and of affecting risk factors including parental environmental concern were assessed using a standardized parental questionnaire. RESULTS: A total of 988 (74.1%), 1778 (79.0%), 1406 (82.6%) and 1274 (78.9%) children participated, respectively, in the 1992, 1995, 1998 and 2001 surveys. Prevalence rates of asthma and hay fever symptoms remained quite stable over time (wheeze/past year: 8.8%, 7.8%, 6.4% and 7.4%, sneezing attack during pollen season: 5.0%, 5.6%, 5.4% and 4.6%). Rates of reported atopic dermatitis symptoms (specific skin rash/past year: 4.6%, 6.5%,7.4% and 7.6%) showed an increase over time, but those of diagnosis of eczema did not show a clear pattern (18.4%, 15.7%, 14.0% and 15.2%). Stratified analysis by parental environmental concern and by parental atopy showed similar trends. Rates of atopic dermatitis symptoms showed significant increase in girls but stayed stable in boys. CONCLUSION: Results of these four consecutive surveys suggest that the increase in prevalence of asthma and hay fever in 5-7-year old children living in Switzerland may have ceased. However, symptoms of atopic dermatitis may still be on the rise, especially among girls.

Mastitis in early infancy.

AIM: To evaluate the clinical features and microbiological findings in young infants with mastitis. METHODS: Retrospective review of medical records of 18 infants with breast inflammation during the first 3 mo of life seen in the paediatric emergency department between 1992 and 2002. RESULTS: All were full-term infants with female-male ratio of 3.5:1. The age ranged from 12 to 45 d, with a peak in the 4th and 5th weeks of life. Only five patients had systemic manifestations, and five were pretreated with oral antibiotics (amoxicillin-clavulanic acid). The latter as well as seven additional cases required incision and drainage due to abscess formation. Bacterial cultures grew Staphylococcus aureus in 10 cases including all pretreated infants. In four of these cases, Gram stain showed the pathogen. After antimicrobial treatment, no recurrence was observed in any of the patients. CONCLUSIONS: These findings suggest that mastitis in early infancy should be treated with parenteral antibiotics guided by Gram stain when available and informative. Otherwise, beta-lactamase-resistant antibiotics are a reasonable empirical initial treatment pending culture results. Optimizing the management of infants with mastitis is important especially since abscess formation requiring incision may be detrimental for later breast development.

The effect of montelukast on lung function and exhaled nitric oxide in infants with early childhood asthma.

Effective treatment of respiratory symptoms, airway inflammation and impairment of lung function is the goal of any asthma therapy. Although montelukast has been shown to be a possible add-on therapy for anti-inflammatory treatment in older children, its efficacy in infants and young children is not well known. The aim of this study was to investigate its effect in infants and young children with early childhood asthma. In a prospective randomised double-blind placebo-controlled study, 24 young children (10-26 months) with wheeze, allergy and a positive family history of asthma consistent with the diagnosis of early childhood asthma were randomised to receive montelukast 4 mg or placebo. The forced expiratory volume in 0.5 seconds (FEV0.5) was measured using the raised volume rapid thoracic compression technique, and fractional exhaled nitric oxide (FeNO) and symptom scores were determined. No change was noted in FEV0.5, FeNO or symptom score in the placebo group following the treatment period. In contrast, significant improvements in mean+/-SD FEV0.5 (189.0+/-37.8 and 214.4+/-44.9 mL before and after treatment, respectively), FeNO (29.8+/-10.0 and 19.0+/-8.5 ppb) and median symptom score (5.5 and 1.5) were noted following treatment with montelukast. In conclusion, montelukast has a positive effect on lung function, airway inflammation and symptom scores in very young children with early childhood asthma.

[Benefits and risks of topical steroids in childhood]. / Nutzen und Risiko topischer Steroide im Kindesalter.

Inhaled glucocorticosteroids have become the cornerstone mode of anti-inflammatory treatment in children, especially with bronchial asthma. Many publications document the clinical efficacy of inhaled steroids and an increasing number of authors point out the possible systemic effects of topical steroids, such as effects on growth, impaired bone metabolism and adrenal suppression. The goal of this review article is to summarize published data. The author stresses possible relevant side effects in relation to dose and inhalation technique and focuses on the most appropriate indications and therapeutic modalities of inhaled steroids. The article yields valuable information for both practitioners and clinicians which will assist them in administering inhaled steroids and in discussing questions of safety with medical professionals and laymen.

[Prevalence of bronchial asthma in childhood in Switzerland: significance of symptoms and diagnosis]. / Prävalenz des Asthma bronchiale im Kindesalter in der Schweiz: Die Bedeutung von Symptomatik und Diagnose.

The prevalence of bronchial asthma has been studied prospectively for the first time in Swiss children. In August 1990 approximately 4900 children were issued with questionnaires to be completed by parents. Overall response rate was 85% and data of 4156 children were available for further analysis. The 12 month period prevalence for wheeze and/or asthma was 9.1% (boys 10.2%, girls 7.8%; p = 0.005). The lifetime prevalence of wheeze in this survey was 16.5%. Overall, only 34% of those reporting wheeze also reported a history of bronchial asthma. Nighttime symptoms such as irritant cough, tightness in the chest and wheezing were reported significantly more often in households with smokers than in families without smokers (p = 0.025). Living in a metropolitan area seems to be a risk factor for asthma symptoms at night when compared with families living in the country (p = 0.005). The current prevalence of asthmatic symptoms in Swiss children is a high as reported in other countries of the northern hemisphere. Our data disclosed a substantial proportion of underdiagnosis of asthma in Swiss children. We speculate that underdiagnosis is a risk factor for undertreatment of childhood asthma.

Prevalence of childhood asthma: facts, tendencies and interpretations.

Questionnaire surveys are an appropriate instrument to assess epidemiologic data on respiratory ill health, to analyse influences of environmental factors on respiratory morbidity and to evaluate treatment strategies. To investigate the prevalence rates of asthma and symptoms suggestive of asthma we performed population surveys in Swiss school children. Special attention is drawn to particular aspects such as atypical symptoms, underdiagnosis and undertreatment of asthma.

Pressure flow characteristics of the valve in spacer devices.

The valve system in the mouth piece of two spacer devices was analysed. Pressures required to open and close the non-rebreathing valve were very low (less than 0.1 kPa). Inspiratory flow requirements were within physiological limits for infants' normal tidal breathing. Expiratory flow requirements varied significantly, and the flow required to prevent rebreathing from the chamber may exceed the physiological flow limits for normal tidal breathing.