Occurrence of vesicoureteral reflux in children.

AIM: The reported low occurrence of vesicoureteral reflux in the general population seems implausible. We wanted to test the hypothesis that reflux is more common and more independent of urinary-tract infection than has previously been thought. METHODS: We tested our hypothesis by analysing the characteristics of 406 consecutive children aged <5years who had been referred for consultation because of urinary-tract infection. Using data on their urine samples, we evaluated the reliability of the urinary-tract infection diagnosis and analysed the frequencies of vesicoureteral reflux and abnormal ultrasound findings in three reliability groups (A: certain urinary-tract infection, B: possible and C: improbable). RESULTS: The occurrence of reflux was the same irrespective of the diagnostic reliability of urinary-tract infection (A: 98/276 [36%] versus B: 13/46 [28%] versus C: 9/25 [36%]). Most of the abnormal ultrasound findings (58/71, 80%) were found among patients with a certain diagnosis (Group A). CONCLUSION: We suggest that vesicoureteral reflux is more common in children even without urinary-tract infection than has been thought previously. The guidelines recommending a search for reflux by means of voiding cystourethrography should be reconsidered.

Outcome of Henoch-Schoenlein nephritis with nephrotic-range proteinuria.

PATIENTS AND METHODS: All children with Henoch-Schoenlein glomerulonephritis (HSP-GN) and nephrotic-range proteinuria (> 40 mg/h/m2), treated at 5 university hospitals and in 1 central hospital in Finland during in 1990-1997, were analyzed retrospectively. The mean age of these 19 patients (8 girls, 11 boys) at the time of diagnosis was 9.9 years (range 4.6-15.1 years). A renal biopsy had been performed in all cases, giving findings according to the classification used in the International Study of Kidney Diseases in Children (ISKDC) of grade II (4 patients), grade III (10), grade IV (4) and grade V (1). Six patients underwent a second biopsy. RESULTS: The yearly incidence of nephrotic-range HSP-GN in Finland was 2 per 1 million children under 15 years of age. After a mean follow-up of 4.6 years (range 9 months-9.1 years), 3 patients (15.7%) had no signs of nephritis, 11 (57.9%) had proteinuria < 1 g/day or microscopic hematuria, 2 (10.5%) had proteinuria > 1 g/day, and 3 (15.7%) had developed ESRD or uremia. 47% of the patients needed medication for proteinuria at the time of the latest follow-up. The first kidney biopsy did not predict the outcome of HSP-GN, since all the patients with the poorest outcome had only ISKDC II-III findings in their first biopsy. CONCLUSION: According to our series, the morbidity in cases of HSP-GN with nephrotic-range proteinuria is high and a close clinical follow-up is needed. The treatment of HSP-GN patients should be based on the clinical presentation rather than on the biopsy findings.

[Diabetic nephropathy--screening, follow-up and treatment. Nephropathy Study Groups of The Finnish Diabetes Organization]. / Diabetesnefropati--screening, uppföljning och behandling. Nefropatiarbetsgruppen vid Finlands Diabetesförbund]

Owing to advances in the diagnosis and treatment of diabetic nephropathy, its management has become more active and is now initiated earlier after the presence of microalbuminuria has been established. In 1996 the Finnish Diabetic Association's nephropathy group issued recommendations concerning screening for diabetic nephropathy, and treatment and follow-up of patients with the disease.

Pulmonary adiaspiromycosis in a two year old girl.

A case of disseminated bilateral pulmonary adiaspiromycosis is reported in a two year old Finnish girl. She recovered from this rare infection after treatment with amphotericin B. She is the first human case of adiaspiromycosis in Scandinavia and she is the youngest child with this disease reported so far. Electron microscopy showed that the three layers of the spore wall were not typical; rather, there seemed to be a gradual transition between the main wall zones, which may be split into an indefinite number of thin layers. Varying numbers and thicknesses were seen with different staining methods, and in different spores. Diagnosis relies on recognition of the fungus in a pulmonary biopsy specimen, because there are no reliable serological tests and culture of the fungus is time consuming and not always successful. It was thought that this patient had become infected as a result of contact with soil dust containing the spores in the yard surrounding her home, and as a result of her mother's work in a large garden shop.

Type of nappy and nursing habits in acquiring acute urinary tract infection.

The role of the nappy and nursing habits as possible risk factors of urinary tract infection (UTI) were analysed in a prospective case-control study. Cases entered hospital due to their first UTI attack. Children hospitalized for some other reason, mainly upper respiratory infections or elective surgery, served as controls matched for age and sex. Cases and their controls (208 girls and 184 boys) used nappies day and night. The odds ratios for risk of contracting UTI according to different nappy types used prior to the first UTI diagnosis were 0.95 for all-in-one (superabsorbent) nappies (95% CI 0.62-1.46), 1.04 (0.69-1.57) for standard disposable nappies and 1.00 (0.46-2.16) for washable cotton nappies. The type and number of nappies used daily as well as the number of defecations per day were similar in UTI patients and the controls. There were no significant differences in the frequency of buttock washes nor in the daily time spent without nappy. The use of cotton nappies practically finished during the study. The type of nappy used or other nursing habits with the baby appeared to be insignificant risk factors for UTI during nappy age. The use of modern nappies has become so thoroughly commonplace that the true impact of nappy type on any condition during infancy is difficult or even impossible to evaluate in a case-control setting.

A review and meta-analysis of hormonal treatment of cryptorchidism.

To assess the effect of LH-releasing hormone (LHRH) and hCG in the treatment of cryptorchidism, 33 articles published in English between 1958-1990 were analyzed. Altogether, 3282 boys with 4524 undescended testes were included in the analysis; 872 boys with 1174 undescended testes were treated in randomized trials. The meta-analysis showed LHRH to be more effective than placebo; the risk ratio was 3.21 [95% confidence interval (CI) of 1.83-5.64] and 2.57 (95% CI, 1.39-4.74) in trials excluding retractile testes, respectively. In the combined randomized trials, the success rate with LHRH was 21% (95% CI, 18-24%), that with hCG was 19% (95% CI, 13-25%), and that with placebo was 4% (95% CI, 2-6%). The effect of the hormonal treatment was overestimated in nonrandomized trials. In conclusion, LHRH is effective in the treatment of cryptorchidism, and hCG is more effective than placebo, but data about the effect are scanty.

Normal stimulated growth hormone secretion but low peripheral levels of insulin-like growth factor I in prepubertal children with insulin-dependent diabetes mellitus.

The hypothalamo-pituitary-insulin-like growth factor I (IGF-I) axis was studied in 24 prepubertal children with insulin-dependent diabetes mellitus (IDDM) and 12 non-diabetic children. There were no significant differences between the diabetic and control subjects in basal concentrations of immunoreactive growth hormone releasing hormone (ir-GHRH), growth hormone (GH) or stimulated GH levels, but after exercise ir-GHRH concentrations were higher in the diabetic children. Peripheral IGF-I levels were significantly lower in the diabetic children, and even lower in those with poor metabolic control. A positive correlation was found between IGF-I levels and circulating free insulin concentrations in the diabetic subjects (r = 0.49, p < 0.05). These observations suggest that the GH response to physiological stimulation is normal in prepubertal diabetic children. Exercise-induced GH response may not be mediated by GHRH. IGF-I levels were reduced in prepubertal children with IDDM and even more so in subjects with poor metabolic control. This may be a consequence of transitory hypoinsulineamia, emphasizing the importance of adequate insulinization to facilitate optimal growth in children and adolescents with IDDM.

Clinical picture of nephropathia epidemica in children.

The clinical picture of nephropathia epidemica (NE) among children is poorly understood. We made a retrospective analysis of 32 patients aged 4-15 years treated in hospital for serologically verified recent NE. The most common clinical findings were high fever (100%), nausea (81%), vomiting (72%), tenderness in the kidney area (63%), abdominal pains (59%) and headache (59%). A peculiar symptom of NE, transient visual abnormalities, was found in 25% of patients. Four children had clinical bleeding and 1 had encephalitis. 44% were transiently hypertensive. Renal function was impaired in 84%, proteinuria was present in 97%, hematuria in 73% and leukocyturia in 44%. Other common laboratory findings were thrombocytopenia (87%), leukocytosis (41%), elevated ERS (74%, up to 76 mm/h) and CRP level (89%, up to 97 mg/l), elevated liver enzymes (53%) and hypoalbuminemia (50%). No child needed dialysis therapy and all recovered. NE seems to be less severe in children than in adults.

Aetiological and precipitating factors for childhood enuresis.

Aetiological factors for enuresis in 68 nightwetting (NW) and 73 day and mixed day and nightwetting (DW/MW) children were examined against a random sample of 142 control children drawn from a population of 3,375 seven-year-old children. Twenty-six variables concerning age, sex, social background, life changes, familial and perinatal history, development, growth, neurological damage, psychic structure and urinary tract disorders were included in the logistic regression analysis. The familial influence on enuresis was clearly seen in both nightwetters and daywetters. The NW children were further discriminated from the controls by items connected with delayed development, such as slower growth and poorer visuomotor and spatial perception. Marital separation or birth of a sibling were also found to be precipitating factors especially for nightwetters. The DW/MW children were discriminated from the controls by perinatal risk factors, signs of neurological dysfunction and smaller voided volume, and especially secondary daywetters by urinary tract infections. These models showed that there are similarities between nocturnal and diurnal enuresis, although there are still many differences and every individual case requires consideration of all these disposing factors.

Bladder function in the mentally retarded.

A group of 21 mentally retarded patients with severe, long-standing urinary symptoms underwent urodynamical investigation. The most common abnormalities were detrusor areflexia and detrusor hyper-reflexia. Of 11 patients treated surgically, 10 derived marked benefit. Drugs were successful in reducing micturition problems in 3/6 patients. Severely retarded patients with spastic quadriplegia are difficult to investigate and if this is associated with detrusor hyper-reflexia it is impossible to treat them in any way. Severely retarded patients with detrusor areflexia and infrequent voiding can benefit from bladder outlet surgery. Patients with moderate (especially mild) retardation can be investigated and treated in the same way as non-retarded people.

Life changes and protective capacities in enuretic and non-enuretic children.

Life changes and protective factors of 156 enuretic and 170 non-enuretic 7-yr-old children were analysed using the multi-item Life Change Unit method and psychological examination. Of the single life events, divorce or separation were seen to increase the risk of enuresis. The weighted life change scores were significantly higher for the enuretics than for the controls at age levels of 3, 5 and 6 yrs. Secondary night-wetting was precipitated by increased life stress, but this was not the case with secondary day-wetting. Repression showed a predominance in enuretics. A strong ego was found to serve as a protective factor against enuresis under changing life conditions.

Screening of urinary tract abnormalities among day and nightwetting children.

In order to detect possible urinary tract abnormalities among wetters, assessments of previous history completed by ultrasonography of the urinary tract and uroflowmetry were obtained for 145 wetting children and a random sample of 156 sex-matched non-wetting children drawn from a population of 3,375 seven-year-olds. Ultrasonography revealed abnormalities, including both morphological ones and cases with incomplete bladder emptying, in 5 out of 73 nightwetters (6.8%, 95% confidence limit, CL, 1.1-12.6), 10 out of 72 day and day and nightwetters (hereafter daywetters) (13.9%, CL 5.9-21.9) and 4 controls (2.6%, CL 0.1-5.0), the figure for the daywetters differing significantly from that for the controls (p less than 0.01). A fractioned voiding curve was recognized in 1 nightwetter (1.4%, CL -1.3-4.0), 7 daywetters (9.7%, CL 2.9-16.6) and 7 controls (4.5%, CL 1.2-7.7) the difference between the nightwetters and daywetters being significant (p less than 0.05). Depending on the previous history and abnormal findings in ultrasonography or uroflowmetry, examinations were continued with intravenous pyelography, voiding cystography, cystoscopy and/or by cystometry. Finally, marked structural or functional disorders of the urinary tract were detected in 11 out of 72 daywetters (15.3%, CL 7.0-23.6), 1 out of 73 pure nightwetters and 1 out of 156 control children. It is concluded that imaging of the urinary tract is not necessary for pure nightwetters, while ultrasonography or uroflowmetry and more sophisticated radiological or urological methods should be focused on those children with daytime wetting and clinical symptoms of voiding disturbances.

Effect of once-a-week training program on physical fitness and metabolic control in children with IDDM.

To examine whether a physical activity program could improve physical fitness and glycemic control, 32 children and adolescents with insulin-dependent diabetes mellitus (IDDM) were examined before the program and 3 mo later. Fifty percent of the subjects (n = 16) participated in the training for 1 h/wk (exercise group), whereas the remaining subjects were engaged in nonphysical activities for an equal amount of time (nonexercise group). Age of the subjects ranged from 8.2 to 16.9 yr, (mean 11.9 yr), with mean duration of diabetes 0.6-13.1 yr (5.2 yr). During the 3-mo program peak oxygen consumption (VO2) rose from 40.0 to 43.8 ml.min-1.m-2 (P less than .01) in the exercise group but only by 1.3 ml.min-1.m-2 in the nonexercise group (NS). Metabolic control did not improve in either group, with glycosylated hemoglobin level rising from 9.8 to 10.5% (P less than .01) in the exercise group and from 9.4 to 9.7% (NS) in the control group. When subjects were stratified according to their participation, metabolic control was significantly better among diabetic subjects participating frequently (greater than or equal to 11 of 13 sessions) than among those participating infrequently (less than 11 of 13 sessions), regardless of the type of activity. It was concluded that a training program of 1 h/wk for 3 mo does improve physical fitness but not the metabolic control of diabetes. On the other hand, glycemic control appears to be best among diabetic subjects who are motivated to participate in any kind of program related to the treatment of their disease.

Clinical significance of urinary C-peptide excretion in children with insulin-dependent diabetes mellitus.

In order to evaluate the accuracy of urinary C-peptide determination and the clinical significance of C-peptiduria for the early course of insulin-dependent diabetes (IDDM), the rate of urinary excretion of C-peptide was determined in 32 children and adolescents with IDDM and correlated with serum C-peptide concentration, urinary excretion of albumin and beta 2-microgloublin and with the glomerular filtration rate (GFR) measured in terms of the clearance of 99mTc-DTPA. The age of the subjects ranged from 9.1 to 17.1 years (mean 13.1) and the duration of diabetes from 0.3 to 11.9 years (mean 4.6). There was a good correlation between postprandial serum C-peptide concentration and the 24-hour urinary C-peptide excretion rate (r = 0.81; p less than 0.001). GFR and urinary albumin excretion were slightly elevated in the diabetic patients as compared with non-diabetic subjects (p less than 0.05 and p less than 0.001, respectively), but C-peptide excretion was unrelated to the degree of hyperfiltration or albuminuria, neither was there any correlation between the excretion rate of beta 2-microglobulin and C-peptide. Glycaemic control was poorer in the diabetic children who had only trace amounts of C-peptide in their urine (less than 0.05 nmol/m2/24 h) than in those with minimal (0.05-1.0 nmol/m2) or moderate 24-hour urinary C-peptide excretion (greater than 1.0 nmol/m2). It is concluded that urinary C-peptide excretion serves very well to reflect residual beta-cell function and is unrelated to the slight renal hyperfunction and albuminuria often seen in diabetic subjects.(ABSTRACT TRUNCATED AT 250 WORDS)