Virus-related neurological lower urinary tract dysfunction: Lessons learned during 4-year follow-up of patients with Congenital Zika Syndrome.

INTRODUCTION: We have previously reported on neurogenic bladder dysfunction among Congenital Zika Vírus Syndrome (CZS) patients, but it is unknown how they will respond to treatment. OBJECTIVE: To assess whether children with neurological lower urinary tract dysfunction and CZS will respond to Standard therapies. METHODOLOGY: A prospective observational cohort study of children with CZS referred for urological assessment between 2016 and 2020 to our quaternary center in Brazil. Urological protocol included clinical history, urinalysis and culture, renal and bladder ultrasonography and urodynamic study. Patients were treated based on findings from the first evaluation, with oxybutynin chloride for overactive bladder and low bladder compliance, clean intermittent catheterization for ineffective bladder emptying, or dual therapy when both were observed. Urological outcomes were evaluated between the first and second visits considering patient's adherence. Outcomes measured included clinical, imaging, and urodynamic variables. Data was analyzed using the IBM SPSS 22 software. RESULTS: From the cohort of 90 patients, 56 completed the second urodynamic assessment and were included. One presented underactive bladder and 55 overactive bladder. Among these 55, 39 were adherent and 16 non-adherents to the prescribed treatment. Among the 39 adherents, 8 adhered regularly to oxybutynin and clean intermittent catheterization (CIC), 29 to oxybutynin alone, and two to catheterization alone. During follow-up, the number of patients with urinary tract infection and postvoid residual increased, but all other parameters had improved. Renal and bladder ultrasonography improved in 10, maximum bladder pressure decreased in 22 and maximum cystometric capacity and compliance increased in 14 patients. Sixteen patients did not adhere regularly to the prescribed treatment and although the number of patients with urinary tract infection reduced with antibiotic therapy, their bladder capacity and compliance did not improve during follow-up. DISCUSSION: Ultrasonographic and urodynamic improvements were observed after 10.8 ± 7.5 months of treatment, including one patient with ureterohydronephrosis that resolved. Adherence to CIC remains a challenge and reflected in the number of patients presenting urinary tract infection and postvoid residual. The immediate clinical relevance is the major study strength, given the previously uncharacterized therapy options for this patient population. The number of patients remains one of the study limitations, reducing our ability to perform more advanced statistical analyses. CONCLUSION: Patients with Zika-related neurological lower urinary tract dysfunction may benefit from conventional therapies. Results confirmed ultrasonographic and urodynamic improvements after treatment, although not statically significant. Adherence to treatment, specifically to CIC, remains a challenge.

Neurogenic bladder in the settings of congenital Zika syndrome: a confirmed and unknown condition for urologists.

INTRODUCTION: Congenital Zika syndrome (CZS) is a recently discovered condition that affects central nervous system structures that control the lower urinary tract. The first cases of neurogenic bladder (NB) were recently reported as a sequalae of CZS in neurologically impaired children. OBJECTIVE: Our goal is to further evaluate NB in the setting of CZS, identifying urological risk indicators in hopes that early diagnosis will mitigate the impact of the disease. STUDY DESIGN: Urological assessment was performed in all patients with CZS and neurological impairment who were referred to our urodynamic clinic between June 2016 and May 2018. Neurogenic bladder was confirmed by urodynamic evaluation, and urological risk was based on urodynamic results. RESULTS: Sixty-nine patients with CZS were tested. The majority (63 patients, 91.3%) presented with overactive bladder with increased pressures and reduced capacity for age (table 1). Different urodynamic patterns were observed, and the association of reduced bladder capacity for age, high bladder-filling pressure, and increased postvoid residual were frequently observed. DISCUSSION: NB continues to be consistently diagnosed in our cohort of CZS, mostly with high-risk indicators for renal impairment. When not intervened upon in a timely manner, NB can cause progressive damage to the urinary tract, but the lack of knowledge that CZS causes NB delays investigation and treatment. Parents and health professionals will need to be sensitized to the risks that ZIKV can pose to the urinary tract so that appropriate therapies are initiated to prevent irreversible renal damage. CONCLUSION: NB is a common condition among our patients with CZS and microcephaly. This is a new cause of NB, unknown to urologists. While further investigation is necessary to understand long-term disease behavior and therapeutic response, increased knowledge among urologists may help to reduce morbidity related to untreated NB and to mitigate the disease burden for patients and families.

Foliar anatomy and microscopy of six Brazilian species of Baccharis (Asteraceae).

We report for the first time the presence of cluster crystals of calcium oxalate within the glandular trichomes and oil bodies in the mesophyll for Baccharis species. Moreover, the comparative leaf anatomy and micro-morphology of six species of Baccharis, namely B. illinita, B. microdonta, B. pauciflosculosa, B. punctulata, B. reticularioides, and B. sphenophylla is investigated by light and scanning electron microscopy. The studied species exhibited differences in their leaf anatomical features such as the morphology of the cuticle, type and occurrence of the stomata, presence or absence of glandular trichomes, shape of the flagelliform trichomes, and the arrangement of the mesophyll tissues. These differences can be helpful in the species identification and classification and could represent informative characters for the reconstruction of the evolution of the genus.

Outcome of invasive mechanical ventilation after pediatric allogeneic hematopoietic SCT: results from a prospective, multicenter registry.

Exact data on prognosis of children receiving invasive mechanical ventilation (IMV) after allogeneic hematopoietic SCT (HSCT) is lacking. We therefore started a prospective registry in four European university HSCT centers (Leiden, Paris, Prague and Utrecht) and their pediatric intensive care units (PICUs). The registry started in January 2009. In January 2013, the four centers together had treated a total of 83 admissions with IMV. The case fatality rate in these patients was 52%. Mortality 6 months after PICU discharge was 45%. There were significant differences between centers in the proportion of children who received IMV after HSCT (6-23%, P<0.01), in severity of disease on admission to PICU (predicted mortality 14-37%, P<0.01), in applying noninvasive ventilation before IMV (3-75% of admissions, P<0.01) and in the use of renal replacement therapy (RRT) (8-58% of admissions, P<0.01). Severe impairment in oxygenation, use of RRT and CMV viremia were independent predictors of mortality. Our study shows that mortality in children receiving IMV after HSCT remains high, but has clearly improved compared with older studies. Patient selection and treatment in PICU differed significantly between centers, which underscores the need to standardize and optimize the PICU admission criteria, ventilatory strategies and therapies applied in PICU.

Destruction of immunobiologicals and their disposal

The guidelines of the Brazilian National Health System (SUS) state that the municipal authorities are responsible for the vaccination of the population. The present study examined the types of immunobiologicals, amounts and reasons for their destruction and disposal by the Municipal Health Secretariat in the city of Bauru, São Paulo state, Brazil, between 2008 and 2009. This study comprises a descriptive, exploratory and retrospective work that employed search of bibliographic data, collection of secondary data from forms of immunobiologicals disposal and interview of the agent responsible for the disposal of these products in the municipality. It was observed that the total numbers of unused vaccines in 2008 and 2009 were similar (4523 and 4395, respectively), being the most discarded: the diphtheria, tetanus and pertussis (DTP) vaccine in 2008 and DTP, BCG and influenza in 2009. It was found that the amount of discarded vaccines could be reduced since the reasons for that were predictable. Moreover, the current study emphasized that although there is a municipal regulation for the disposal of immunobiologicals, the city still requires a better structure to handle such problem.

High-intensity, short-term biofeedback in children with Hinman's syndrome (non-neuropathic voiding dyssynergia).

OBJECTIVE: To evaluate the long-term response to high-intensity, short-term biofeedback in children with severe voiding dysfunction. PATIENTS AND METHODS: We retrospectively reviewed patients who underwent short-term, high-intensity biofeedback therapy from 1996 to 2004. Improvement was classified based on clinical and radiographic findings. Patients were categorized as having Hinman's syndrome when, in addition to urinary incontinence, at least four of the following categories were present: sphincter dyssynergia, bladder trabeculation, large post-void residual (PVR), hydronephrosis, vesicoureteral reflux (VUR) and urinary tract infections. There were 14 patients (eight males and six females), 13 of whom had Hinman's syndrome. Age when biofeedback was initiated varied from 5.6 to 12.9 years (mu=8.9+/-2.2). Before biofeedback, all had large PVRs, bladder trabeculation and sphincter dyssynergia. Nine had hydronephrosis and five had VUR. One patient had renal failure. RESULTS: Before biofeedback, the mean PVR was 109 ml (25-270 ml); after biofeedback, this decreased to 21 ml (0-150 ml), including two patients who eventually failed treatment. All 14 patients were able to relax their external sphincter and reduce the PVR during biofeedback and on short-term follow up. Long-term follow up (mu=59.4 months) in 12 patients established that seven had a durable response with remission of symptoms, reduced PVR and radiographic improvement. In three, symptoms partially recurred over time and two failed treatment completely. CONCLUSION: Short-term, high-intensity biofeedback achieves a durable response in the majority of children with Hinman's syndrome. Long-term follow up is needed to assure compliance.

Birth size, early childhood growth, and adolescent obesity in a Brazilian birth cohort.

DESIGN: Cross-sectional visit to a subsample of a population-based birth cohort. SAMPLE: A total of 1076 adolescents aged 14-16 y; 51% males. MEASUREMENTS: Weight, height, subscapular and triceps skinfolds were used for assessing overweight and obesity in adolescence, using WHO-recommended criteria. Anthropometric status in early life was measured through birthweight and through weight and length/height at average ages of 20 and 43 months. RESULTS: All analyses were adjusted for socioeconomic and maternal confounding factors. Birthweight and attained size (Z-scores of weight-for-age, height-for-age and weight-for-height) at 20 and 43 months were associated linearly and positively with overweight and obesity in adolescence. Four in each five obese adolescents were not overweight in childhood. Rapid weight gain, both between birth and 20 months, and between 20 and 43 months, was also associated with adolescent overweight and with obesity. Rapid height gain between 20 and 43 months was associated with overweight only. Most associations were stronger for boys. CONCLUSIONS: Birth size, attained size in childhood and particularly growth velocity in early life were associated with increased prevalence of obesity and overweight in Brazilian adolescents. On the other hand, the vast majority of overweight or obese adolescents were not overweight children. Early interventions are undoubtedly important, but population-based strategies aimed at improving diets and physical activity appear to have greater long-term potential than measures targeted at overweight children.

Serosubtypes and PorA types of Neisseria meningitidis serogroup B isolated in Brazil during 1997--1998: overview and implications for vaccine development.

Meningococcal disease caused by N. meningitidis serogroup B (MenB) has been endemic in Brazil since 1997. In this study, we determined the prevalence of serosubtypes of MenB isolated in 10 Brazilian states and the Federal District during 1997 and 1998 and investigated the extent of PorA VR sequence variation among the most prevalent serosubtypes to evaluate the possible use of an outer membrane vesicle (OMV)-, PorA-based vaccine to prevent meningococcal disease in Brazil. During this period, a total of 8,932 cases of meningococcal disease were reported. Only 42% (n = 3,751) of the reported cases were laboratory confirmed, and about 60% (n = 2,255) of those were identified as MenB. Among 1,297 MenB strains selected for this study, the most prevalent serosubtypes were P1.19,15 (66%), P1.7,1 (11%), and P1.7,16 (4%). PorA VR typing showed that 91% of the P1.19,15 strains analyzed had VR1 and VR2 sequences identical to those of the prototype strain. No sequence variation was detected among the 40 strains representing all isolated MenB P1.7,16 strains in the three southern states, where this serosubtype accounts for 75% of the serosubtypes identified. Similarly, all P1.7,1 strains were identified by PorA typing as P1.7-1,1. Although further improvements in the reporting of cases and collection of strains in Brazil are needed, our data suggest that a trivalent OMV-based vaccine prepared with PorA types P1.19,15, P1.7-1,1, and P1.7,16 may be appropriate to control serogroup B meningococcal disease in most of the Brazilian states.

Tardive dyskinesia controlled by anticholinergic agents.

Tardive dyskinesia appeared in a 17-year-old boy following withdrawal of pimozide (Orap) and thioridazine (Melleril). The choreodyskinetic movements, which were limited to the limbs and the trunk, cleared with anticholinergic drugs but were dramatically worsened by dopaminergic receptor blockers. Therefore, therapy with an initial high dose of benztropine mesylate (Cogentin) associated with bromazepam (Lexotan) was instituted and was well tolerated.