Standards of proficiency for registered nurses-To what end? A critical analysis of contemporary mental health nursing within the United Kingdom context.

Against the backdrop of cultural and political ideals, this article highlights both the significance of mental health nursing in meeting population needs and the regulatory barriers that may be impeding its ability to adequately do so. Specifically, we consider how ambiguous notions of 'proficiency' in nurse education-prescribed by the regulator-impact the development of future mental health nurses and their mental health nursing identity. A key tension in mental health practice is the ethical-legal challenges posed by sanctioned powers to restrict patients' freedom at the same time as the desire (and obligation) to promote patients' self-determined recovery. The genericism of the UK's Future Nurse Standards do little to prepare mental health nurses to navigate the tensions that ensue. This has consequences for nurses and patients alike, as both risk experiencing the distress and dissonance that attends giving or receiving poor care. We argue that more needs to be done to enable mental health nurses to define and articulate the nuances of the profession as part of becoming critical, thoughtful and confident practitioners. Educators can contribute to this mission by aligning curriculum, pedagogy and assessment to create meaningful opportunities for mental health nursing students to engage with the complexities of mental health nursing practice. Without this, the credibility of the profession will continue to be questioned; its future uncertain.

Laparoscopic versus open pyeloplasty in paediatric pelvi-ureteric junction obstruction.

AIM: Compared to open pyeloplasty (OP), we hypothesised that laparoscopic pyeloplasty (LP) is associated with early recovery, a shorter length of stay (LOS) and less analgesia requirement. METHODS: Between 2011 and 2016, 146 dismembered pyeloplasty cases were reviewed, of which 113 were in the OP group and 33 were in the LP group. We evaluated both groups regarding operative time, LOS, success rate, complications rate and analgesia requirement. Subgroup analysis was done for patients above the age of 5 years, and within the OP group (dorsal lumbotomy (DL) vs. loin incision (LI)). RESULTS: The success rate was 96% in the open group and 97% in the laparoscopic group. The median operative time was significantly shorter in the open group for the entire cohort (127 vs. 200 min; P < 0.05), and in children older than 5 years (n = 41, 134 vs. 225 min; P < 0.05). Other parameters were similar in both groups. The median LOS was significantly shorter (2 vs. 4 days; P < 0.05), and the median analgesia requirement was less (0.44 vs. 0.64 mg/kg morphine; P < 0.05) in the DL (n = 60) compared to LI (n = 53). CONCLUSION: Both OP and LP dismembered approaches are equally effective in treating pelvi-ureteric junction obstruction. Overall, the LOS, complications rate and analgesia requirement were not significantly different; however, the operative time was significantly longer in LP.

Parental decision regret in childhood hypospadias surgery: A systematic review.

We conducted a systematic review of the literature to establish the prevalence of and predictive factors for parental decision regret in hypospadias surgery. A search strategy without language restrictions was developed with expert help, and two reviewers undertook independent study selection. Five studies were included in this review (four for quantitative analysis) with a total of 783 participants. The mean overall prevalence of parental decision regret was 65.2% (moderate to severe - 20.3%). Although significant predictors of regret were identified (post-operative complications, small size glans, meatal location, decision conflict between parents, parental educational level and others), they had unexplained discordance between studies. Parental decision regret after proximal hypospadias surgery and refusing surgery was inadequately reported. In conclusion, even though the prevalence of parental decision regret after consenting for the hypospadias repair appears to be high, risk factors associated with it were discordant suggesting imprecision in estimates due to unknown confounders.

Prolonged urinary retention can and does occur after any type of ureteral reimplantantion.

OBJECTIVE: Transient urinary retention has been recognized as a complication of bilateral ureteroneocystostomy (UNC), when performed extravesically. The objective of this study was to review a collective surgeons' experiences of unilateral extra- and unilateral and/or bilateral intra-vesical ureteral reimplanation, where urinary retention greater than 6 weeks, or what we have termed, "prolonged urinary retention" (PUR), occurred. MATERIALS AND METHODS: We retrospectively reviewed charts to identify PUR after any open or robotic reimplant, other than bilateral extravesical, between 1998 and 2015 as reported by five surgeons. RESULTS: During the review period, ten cases were documented where PUR was encountered. Bilateral Cohen reimplants (5), unilateral extravesical open reimplant with ureteral tapering (3), unilateral Cohen reimplant (1) and unilateral extravesical robotic reimplant with tapering (1) were associated with PUR. Younger males predominated (70%). The mean age at operation of the patients was 3.1 years. Eventually 7/10 patients were able to void normally, with periods ranging from 6 weeks to 8 years. The remaining three patients are still unable to void more than 5 years after UNC. A majority of the samples (6/10) were suspected to have bowel and bladder dysfunction (BBD), but neurologically all were normal. CONCLUSION: PUR can occur as a potential complication following any type of UNC and is associated with the risk of significant morbidity, including permanent urinary retention. Patients and caregivers should be counseled accordingly.

Rehabilitation for Survivors of the 1994 Genocide in Rwanda: What Are the Lessons Learned?

Rehabilitation remains a significant concern among survivors of the 1994 genocide in Rwanda. Rehabilitation falls under tertiary prevention, which is a core function of public health. Despite efforts to introduce various rehabilitation programmes for genocide survivors in Rwanda, these initiatives have often proved inadequate in meeting their long-term needs. The failure of the Rwandan Government, international community, United Nations, and other Non-Government Organisations (NGOs) calls into serious question their commitment to international human rights laws. Rehabilitation should be regarded as a free-standing human right for genocide survivors and a human rights-based approach to the rehabilitative process should incorporate measurable outcomes based on an agreed ethical framework. The author calls upon the international community to reiterate its concerns about genocide survivors and reaffirm its commitments to human rights. The main issues discussed in this article are: the long-term needs of survivors of the 1994 genocide; what is already provided, and the gaps; how Stucki's Rehabilitation Cycle framework (a problem-solving tool) can help improve current provision; the role of the international community, NGOs, and genocide survivors' organisations in advancing rehabilitation; and the need for a human rights-based approach to rehabilitation. A strong recognition of the right to rehabilitation is crucial. An ethical framework related to the human rights-based approach should also assist in setting outcomes that can be measured against agreed standards, ensuring: rights that have been violated are identified; the accountability of each service provider in promoting rehabilitation; rehabilitation which is inclusive and non-discriminatory; participation by encouraging collaboration with survivors rather than doing things for them; and empowerment by enabling survivors to understand their rights and have the confidence to challenge or question when their rights have been violated.

Early mercaptoacetyltriglycine(MAG-3) diuretic renography results after pyeloplasty.

OBJECTIVE: To describe the drainage and functional outcome of paediatric pyeloplasty, 1 week after stent removal 7-9 weeks after pyeloplasty using diuretic renography. PATIENTS AND METHODS: Between 2009 and 2014, we assessed the functional and drainage outcomes according to mercaptoacetyltriglycine MAG-3 diuretic renograms from 66 children (69 kidneys) who underwent modified dismembered Anderson-Hynes pyeloplasty for pelvi-ureteric junction (PUJ) obstruction. Stents were left in place for 6-8 weeks and postoperative renal units were evaluated with MAG-3 renogram 1 week after stent removal. Surgical success was defined by improvement of drainage (half clearance time [T/2] < 20 min), stable or improved function on the postoperative MAG-3 renogram and by decreased pyelocaliceal dilatation on ultrasonography (US) at 1 year. RESULTS: Of the 69 kidneys with a preoperative median range T/2 of 33.4 (7.6-200) min, 60 (87%) had improved drainage curves, with a median (range) T/2 of 6.9 (1.6-19) min. Thirteen percent (9/69) had persistent impaired drainage, with a median (range) T/2 of 36 (24-108) min. Of these nine children, one girl was found to have a persistent obstructive pattern (T/2 = 30 min) associated with a decreased split renal function (SRF; from 42 to 33%) and persistent hydronephrosis (at 28 mm). Redo pyeloplasty was performed 2 months after the initial procedure (and 18 days after stent removal) and renal function recovered to 47%. The remaining eight patients were free of symptoms; hydronephrosis improved at 1 year (anteroposterior diameter decreased from 28 to 18.5 mm; P = 1.94) and SRF remained stable (44.5 vs 48.5% after repair; P = nonsignificant). In the 29% of kidneys (20/69) that had preoperative impaired SRF, postoperative renal function improved in 75% (from 27.5 to 43%; P < 0.001), remained unchanged in 2% and one kidney (0.2%) deteriorated. The median (range) postoperative follow-up was 18 (12-90) months. CONCLUSIONS: There is no agreement regarding the 'gold standard' investigation to use after pyeloplasty for PUJ obstruction. Improvement in hydronephrosis on US is slow and often takes > 12 months. Based on animal studies, it is possible that missed recurrent obstruction will cause irreversible loss of renal function after 6 weeks; therefore, early postoperative assessment is desirable, but there have been few reports on urinary drainage changes with early diuretic renography after pyeloplasty. Most of the renal units had improved drainage on diuretic renography 7 weeks after pyeloplasty and 1 week after stent removal. An early diuretic renogram is a reliable method of documenting surgical success after pyeloplasty.

Urethrocutaneous fistulae after hypospadias repair: When do they occur?

AIM: The aim is to determine the incidence and timing of urethrocutaneous fistula diagnosis after hypospadias surgery. METHODS: A retrospective review of all patients who had both initial hypospadias surgery and subsequent fistula repair from 1995 to 2012. A comparison was made between patients who had an initial onlay island flap procedure and those who had a tubularised incised plate repair. RESULTS: Patient age at initial surgery ranged from 6 months to 16 years of age. The median time to fistula presentation was 8.5 months with a range of less than 1 month to 13.9 years post-hypospadias surgery. The median time to fistula repair was 17 months. The overall fistula rate was 8%. There was no significant difference between the rates of fistulae for onlay island flap (9%) versus tubularised incised plate procedure (7%). CONCLUSIONS: Urethrocutaneous fistulae can present many years after the original hypospadias repair. The majority are diagnosed within the first year after surgery. Rates of fistulae are probably underreported due to short follow-up, but more importantly, due to patients transferring to other surgeons for fistula repair.

Testicular microlithiasis: the importance of self-examination.

AIM: To explore the issue of appropriate management of testicular microlithiasis. We report the third ever case of tumour arising from a testis previously known to have microlithiasis in childhood and review the literature to provide an evidence-based approach to management of testicular microlithiasis. METHODS: Case report and review of previous literature. RESULTS AND CONCLUSIONS: Although there is a strong association between testicular microlithiasis and testicular malignancy at diagnosis, there are only three reported cases of subsequent tumour development in childhood. Testicular microlithiasis is an increasingly recognised entity. There is insufficient evidence in the current literature to support any regime of clinical surveillance. Self-examination is the most important factor in the early detection of testicular malignancy.

Facilitating Access to Mental Health Services: A Stakeholder-Driven Improvement of the Children and Young People (CYP) as One Referral Platform.

(1) Background: Pre-pandemic, child and adolescent mental health service (CAMHS) referrals were paper based in Liverpool and Sefton (England, United Kingdom), causing delays in waiting times. The "CYP as One" online mental health referral platform was co-created to overcome these challenges. (2) Methods: This study aims to improve "CYP as One" accessibility and usability and, subsequently, support CAMHS to improve waiting times. The current study utilised the Living Lab approach. We conducted content analysis on completed online referrals extracted from the "CYP as One" platform. These findings were supplemented by seven online focus groups, with 16-19-year-old young people, parents of children under 16, and health service providers. Thematic analysis was conducted on all data. (3) Results: The thematic analysis returned seven themes, namely (i) "CYP as One" vs. Traditional Referrals, (ii) Gender and Language Dynamics, (iii) Digital Empathy in Action, (iv) the Influence of the Provider Perspective, (v) Age and Social Sensitivity, (vi) Enhancing Access to Information, and (vii) Boosting Admin and Clinical Efficiency. (4) Conclusions: Digital content that seeks to replace in-person referrals can provide adequate support to children and young people who have faced difficulties accessing mental health services.

Reduction of Urinary Tract Infection in Pediatric Surgical Patients Using NSQIP-P and Quality Improvement Methodology.

BACKGROUND: Hospital-acquired urinary tract infections (UTIs) have a detrimental effect on patients, families, and hospital resources. The Sydney Children's Hospital Network (SCHN) participates in the NSQIP-Pediatric (NSQIP-P) to monitor postoperative complications. NSQIP-P data revealed that the median UTI rate at SCHN was 1.75% in 2019, 3.5 times higher than the NSQIP-P target rate of 0.5%. Over three quarters of the NSQIP-P identified patients with UTI also had a urinary catheterization performed intraoperatively. A quality improvement project was conducted between mid-2018 and 2021 to minimize catheter-associated UTIs (CAUTIs) at SCHN. STUDY DESIGN: NSQIP-P samples include pediatric (younger than 18 years) surgical patients from an 8-day cycle operative log. NSQIP-P data are statistically analyzed by the American College of Surgeons and provide biannual internationally benchmarked reports. The project used clinical redesign methodology with a 6-phase process for quality improvement projects. RESULTS: The objectives of the project were to reduce urinary catheter duration of use, educate parents or carers, and improve catheter care and insertion technique by health staff. The duration of a urinary catheter in situ reduced from a median of 4.5 to 3 days from 2017 to 2021. The median NSQIP-P UTI rate at SCHN was reduced by 47.4% from 1.75% in 2019 to 0.9% in 2022. CONCLUSIONS: A multifactorial approach in quality improvement has been shown to be an effective strategy to reduce UTI rates at SCHN, and patient outcomes were improved within a 3-year timeframe. Although this project has reduced UTI rates at SCHN, there remain opportunities for further improvement.

Antibiotic prophylaxis and recurrent urinary tract infection in children.

BACKGROUND: Antibiotics are widely administered to children with the intention of preventing urinary tract infection, but adequately powered, placebo-controlled trials regarding efficacy are lacking. This study from four Australian centers examined whether low-dose, continuous oral antibiotic therapy prevents urinary tract infection in predisposed children. METHODS: We randomly assigned children under the age of 18 years who had had one or more microbiologically proven urinary tract infections to receive either daily trimethoprim-sulfamethoxazole suspension (as 2 mg of trimethoprim plus 10 mg of sulfamethoxazole per kilogram of body weight) or placebo for 12 months. The primary outcome was microbiologically confirmed symptomatic urinary tract infection. Intention-to-treat analyses were performed with the use of time-to-event data. RESULTS: From December 1998 to March 2007, a total of 576 children (of 780 planned) underwent randomization. The median age at entry was 14 months; 64% of the patients were girls, 42% had known vesicoureteral reflux (at least grade III in 53% of these patients), and 71% were enrolled after the first diagnosis of urinary tract infection. During the study, urinary tract infection developed in 36 of 288 patients (13%) in the group receiving trimethoprim-sulfamethoxazole (antibiotic group) and in 55 of 288 patients (19%) in the placebo group (hazard ratio in the antibiotic group, 0.61; 95% confidence interval, 0.40 to 0.93; P = 0.02 by the log-rank test). In the antibiotic group, the reduction in the absolute risk of urinary tract infection (6 percentage points) appeared to be consistent across all subgroups of patients (P > or = 0.20 for all interactions). CONCLUSIONS: Long-term, low-dose trimethoprim-sulfamethoxazole was associated with a decreased number of urinary tract infections in predisposed children. The treatment effect appeared to be consistent but modest across subgroups. (Australian New Zealand Clinical Trials Registry number, ACTRN12608000470392.)

Ambulatory urodynamic studies (UDS) in children using a Bluetooth-enabled device.

OBJECTIVES: • To report the early observations of using ambulatory urodynamic studies (UDS) using a Bluetooth-enabled device in children • To evaluate the incremental value of ambulatory over conventional UDS. PATIENTS AND METHODS: • Ambulatory UDS were performed in selected children with voiding dysfunction between August 2009 and October 2010. • Conventional UDS were concurrently performed wherever possible. • The test results and treatment consequences of the two tests were compared. RESULTS: • In all, 12 ambulatory and seven conventional UDS were performed on 10 children (five boys, median [range] age 7 [4-16] years). • Six of the seven children had a normal conventional UDS. Ambulatory UDS detected phasic detrusor overactivity (DO) in five children and generalised DO in one. • Direct correlation of symptoms to DO was possible in two children during ambulatory UDS. Pressure rise during filling, seen in two children on conventional UDS, was not seen during ambulatory UDS. • Five children showed clinical improvement when therapy was guided by ambulatory UDS results. • Ambulatory UDS was generally well tolerated in eight children, with two complaining of discomfort. Inadequate information was obtained in two children who underwent ambulatory UDS due to technical problems in one and distress induced by the UDS in the other. CONCLUSIONS: • Ambulatory UDS provides useful additional information over conventional UDS and can be used to guide further therapy in selected children with voiding dysfunction. • It is safe and well tolerated in children. • There is a need for explicit guidance for the technical delivery and interpretation of ambulatory UDS in children.

Management of daytime urinary incontinence and lower urinary tract symptoms in children.

Lower urinary tract symptoms, particularly urgency, frequency and incontinence are common in school-aged children but are often overlooked. They may cause considerable physical, social and psychological difficulties to children and their families, and usually are manifestations of underlying non-neurogenic voiding disorders. The differential diagnoses include overactive bladder syndrome, dysfunctional voiding and vaginal reflux as well as less common conditions like giggle incontinence, voiding postponement, pollakiuria and diabetes insipidus. In this paper, we discuss an evidence-based approach to the management of conditions causing daytime urinary incontinence and lower urinary tract symptoms in children from a general paediatrician's perspective.

How Do We Know Co-Created Solutions Work Effectively within the Real World of People Living with Dementia? Learning Methodological Lessons from a Co-Creation-to-Evaluation Case Study.

Living Labs (LL) are a novel and potentially robust way of addressing real-life health challenges, especially within the dementia field. Generally, LLs focus on co-creating through implementing the quadruple helix partnership as a user-centric approach to co-creating. In the context of this paper, the users were people with dementia and their informal carers. LL are not necessarily environments that evaluate these co-created innovations within the real world. Considering this disconnect between co-creation and real-world evaluation, this paper, as a critical commentary, will reflect on the methodological lessons learnt during the development of an LL model aimed at addressing this discrepancy. The LL at Liverpool John Moores University (LJMU) was commissioned to co-create and then evaluate a new Dementia Reablement Service. The case study findings revealed that the Dementia Reablement Service had a positive impact on the quality of life of people with dementia, suggesting that the service is a catalyst for positive change. In addition, the critical learning from this case study highlights the potential role of LLs in seamlessly co-creating and then evaluating the co-created solution within the real world. A benefit of this way of working is that it provides opportunities for LLs to secure access to traditional research funding.

Parental decision regret among Australian parents after consenting to or refusing hypospadias repair for their son: Results of a survey with controls.

INTRODUCTION: Parental decision regret in hypospadias surgery is a recognised source of long-lasting psycho-social morbidity. High parental decision regret after their child's hypospadias repair is reported. The aim of this study is to report on decision regret in Australian parents, who accepted and declined surgery for their son and explore underlying factors for decision-making, satisfaction, and regret. MATERIALS AND METHODS: An online anonymous survey was administered to three groups of parents: 1) parents who consented for hypospadias repair, 2) parents who declined repair and 3) a control group who requested circumcision for their child. Operations occurred between 2010 and 2020 in two paediatric hospitals in New South Wales, Australia. The survey included a validated decision regret assessment tool and additional questions to explore the possible basis of the opinions. RESULTS: One hundred and eighteen parents (invited - 381, completed - 116, response rate - 31%) participated in the survey. Decision regret was present in group 1 (n = 89) - 55% (moderate-to-severe 15%), in group 2 (n = 14) - 71% (moderate-to-severe 57%), and in the control group (n = 15) - 15% (moderate-to-severe 8%) of parents. There was a significant difference in the median decision regret score between all three groups. Parents who chose hypospadias repair were mostly concerned about function. CONCLUSIONS: The prevalence of decision regret among Australian parents who consented for their son's hypospadias repair was lower compared with the mean decision regret reported in the literature to date (55% vs 65%). Decision regret and its severity were highest among parents who declined hypospadias repair. New strategies are needed to reduce decision regret in parents whether they elect for surgery or not.

GroundsWell: Community-engaged and data-informed systems transformation of Urban Green and Blue Space for population health - a new initiative.

Natural environments, such as parks, woodlands and lakes, have positive impacts on health and wellbeing. Urban Green and Blue Spaces (UGBS), and the activities that take place in them, can significantly influence the health outcomes of all communities, and reduce health inequalities. Improving access and quality of UGBS needs understanding of the range of systems (e.g. planning, transport, environment, community) in which UGBS are located. UGBS offers an ideal exemplar for testing systems innovations as it reflects place-based and whole society processes , with potential to reduce non-communicable disease (NCD) risk and associated social inequalities in health. UGBS can impact multiple behavioural and environmental aetiological pathways. However, the systems which desire, design, develop, and deliver UGBS are fragmented and siloed, with ineffective mechanisms for data generation, knowledge exchange and mobilisation. Further, UGBS need to be co-designed with and by those whose health could benefit most from them, so they are appropriate, accessible, valued and used well. This paper describes a major new prevention research programme and partnership, GroundsWell, which aims to transform UGBS-related systems by improving how we plan, design, evaluate and manage UGBS so that it benefits all communities, especially those who are in poorest health. We use a broad definition of health to include physical, mental, social wellbeing and quality of life. Our objectives are to transform systems so that UGBS are planned, developed, implemented, maintained and evaluated with our communities and data systems to enhance health and reduce inequalities. GroundsWell will use interdisciplinary, problem-solving approaches to accelerate and optimise community collaborations among citizens, users, implementers, policymakers and researchers to impact research, policy, practice and active citizenship. GroundsWell will be shaped and developed in three pioneer cities (Belfast, Edinburgh, Liverpool) and their regional contexts, with embedded translational mechanisms to ensure that outputs and impact have UK-wide and international application.

Factors influencing quality of life in children with urinary incontinence.

PURPOSE: We evaluated quality of life in children with urinary incontinence using a disease specific tool (Pediatric Incontinence Questionnaire) and determined factors that decrease quality of life in affected children. MATERIALS AND METHODS: The Pediatric Incontinence Questionnaire was self-administered by children 6 to16 years old with urinary incontinence while attending outpatient clinics at a tertiary pediatric hospital in Australia between October 2009 and May 2010. A weighted summative quality of life score with a range of 1.75 to 7 (7 being lowest quality of life) was generated, and patient characteristics (age, gender, ethnicity, symptom severity) were evaluated as potential predictors. RESULTS: Of 146 children invited to participate 138 consented (response rate 95%). About half of the participants (77) were boys, and mean patient age was 10 years. Girls had a lower quality of life than boys (mean score 3.60 vs 3.31, 95% CI 0.10-0.57, p=0.04), and nonwhite children had a lower quality of life than white children (3.97 vs 3.35, 95% CI 0.23-0.99, p<0.01). Older age (r=0.21, p=0.01) but not increasing symptom severity (r=0.15, p=0.09) or underlying chronic disease (difference 0.12, p=0.91) was correlated to decreased quality of life. Multivariate regression analysis demonstrated that older age, nonwhite ethnicity and female gender were independent predictors of decreased quality of life. CONCLUSIONS: Older age, female gender and nonwhite ethnicity are associated with a lower disease specific quality of life in children with urinary incontinence. Clinicians need to be aware of the differential effect of urinary incontinence in children of different ages and ethnic backgrounds.

High grade primary vesicoureteral reflux in boys: long-term results of a prospective cohort study.

PURPOSE: We evaluated the incidence of new permanent defects in boys with grade 4 or 5 vesicoureteral reflux, identified the risk factors for new permanent defects and reviewed the outcome of different management approaches by assessing the rates of urinary tract infection and new permanent defects. MATERIALS AND METHODS: This prospective cohort study recruited patients from July 1995 to December 2006. Study inclusion criteria were male gender and grade 4 or 5 primary vesicoureteral reflux. Patients were divided into 2 groups by presentation mode, including group 1-prenatal reflux diagnosis and group 2-reflux diagnosed after investigation for urinary tract infection. All patients underwent initial renal (99m)Tc-dimercapto-succinic acid scan evaluation. Continuous antibiotic prophylaxis was given in all patients until at least age 2 years. Surgical correction for reflux was done in 28 patients and 76 were circumcised. Followup included renal (99m)Tc-dimercapto-succinic acid scan with renal ultrasound at age 12 months with repeat (99m)Tc-dimercapto-succinic acid scan at ages 2 and 4 years. RESULTS: Included in our study were 151 patients (206 high grade refluxing renal units) with a median age at diagnosis of 1.9 months (range 1 day to 8.8 years). Median age at first followup was 14 months (range 3 months to 3 years) and at next followup it was 39 months (range 10 months to 11.3 years). There were 52 boys (34%) in group 1 and 99 (66%) in group 2. Baseline perfusion defects on initial renal (99m)Tc-dimercapto-succinic acid scan were identified in 41 of 52 boys (78.8%) in group 1 and in 74 of 99 (74.7%) in group 2. During followup new permanent defects developed in 8 of 52 boys (15%) in group 1 and in 10 of 99 (10%) in group 2. In 18 patients a total of 20 renal units showed new permanent defects, including 13 in kidneys with baseline perfusion defects and 7 in previously normal kidneys (p >0.9). In groups 1 and 2 combined infection developed before and after circumcision in 62 of 137 (45.2%) and 5 of 74 cases (6.7%), respectively (p <0.001). New permanent defects were seen in 4 of 76 circumcised (5.2%) and in 14 of 137 uncircumcised boys (10.2%) (p >0.3). CONCLUSIONS: Baseline perfusion defects were seen on (99m)Tc-dimercapto-succinic acid scan at presentation in 115 of our 151 patients (76%) independent of presentation mode. New permanent defects developed in abnormal and previously normal kidneys, and were associated with urinary tract infection. Being circumcised was associated with fewer urinary tract infections and a lower incidence of observed new permanent defects (5.2% vs 10.2%).