Long-term effects of fundoplication in children with chronic airway diseases.

BACKGROUND: Association between chronic airway diseases (CAD) and gastroesophageal reflux disease (GERD) is well described, but causality has not yet been conclusively established. This study evaluates the therapeutic significance of laparoscopic Thal fundoplication in children with CAD and diagnosed GERD. METHODS: We performed a retrospective analysis of 182 neurologically nonimpaired children, all with medically refractory CAD and GERD undergoing laparoscopic Thal fundoplication. The clinical response, ability to wean oral and inhaled medication and satisfaction with postoperative results were evaluated. RESULTS: Main symptoms disappeared completely in 68.7% of patients and were markedly improved in a further 22% of patients following surgery. Complete discontinuation of medication was achieved in 70.1-96.4% of cases and reduced in a further 1.8-23.5%. One intraoperative complication occurred (gastric perforation), however no conversion to laparotomy was necessary. Postoperative Dumping Syndrome occurred in 1% of cases and was managed dietetically. Prolonged postoperative dysphagia occurred in 4.3% of patients, but disappeared within 8 weeks in all but one case. CONCLUSIONS: Our study suggests that Thal fundoplication in neurologically nonimpaired children with CAD and documented GERD is effective and safe. Children unresponsive to preoperative medical management showed significant improvement in airway symptoms together with a marked reduction in the need for medication. We conclude that laparoscopic Thal fundoplication represents a significant treatment worthy of consideration in this group of patients.

Urge incontinence and voiding postponement in children: somatic and psychosocial factors.

AIM: To analyse the number of urinary tract infections, uroflowmetry, behavioural symptoms and intrafamilial interaction in two groups of daytime wetting children in a paediatric and a child psychiatric unit. METHODS: Ninety-four children with either voiding postponement (52) or urge incontinence (42) were examined prospectively for history of urinary tract infections (UTIs), uroflowmetry, the syndrome scales of the Child Behaviour Checklist (CBCL 4/18-Achenbach) and the Family Adaptability and Cohesion Evaluation Scales (FACES-III) (Olson) questionnaire. RESULTS: Children with urge incontinence had a significantly higher rate of previous urinary tract infections (50%) than children with voiding postponement (19.2%; p < 0.001), who showed a high rate of plateau (12.2%) and staccato (20.4%) curves and were characterized by a wide variety of behavioural symptoms, including withdrawn (11.6%), aggressive (11.8%), delinquent (19.6%) behaviour and attention problems (13.7%). Clinically relevant behavioural scores were 4-10 times higher for the voiding postponers, and 2-3 times higher for children with urge incontinence. Furthermore, families of voiding postponers had significantly fewer balanced types of intrafamilial function (FACES-III). Problematic "rigid/disengaged" and "rigid/separated" types predominated. CONCLUSION: Urge incontinence is characterized by a higher rate of UTIs, a lower urine volume in uroflowmetry, a lower rate of behavioural scores in the clinical range and well-functioning families. Voiding postponement children, on the other hand, have a higher, though not significant, rate of abnormal uroflow curves, a wide variety of clinically relevant behavioural symptoms, which were significantly higher for attention and delinquent problems. Conduct problems predominated; only 13.7% of the children had attention problems in the clinical range. The findings lend empirical support to the entity of voiding postponement as an acquired or behavioural syndrome characterized by wetting in association with a delay of micturition and other externalizing conduct problems.

[Prophylaxis of recurrent urinary tract infections in children. Results of an open, controlled and randomized study about the efficacy and tolerance of cefixime compared to nitrofurantoin]. / Reinfektionsprophylaxe rezidivierender Harnwegsinfektionen im Kindesalter - Ergebnisse einer offenen, kontrollierten und randomisierten Studie zur Wirksamkeit und Verträglichkeit von Cefixim im Vergleich zu Nitrofurantoin.

UNLABELLED: Urinary tract infections are quite frequent in children. Urinary tract obstruction combined with recurrent urinary tract infections increase the risk for renal impairment. Therefore prophylaxis of reinfection is an important nephroprotective procedure. The aim of this open, controlled, randomised pilot study was to compare the efficacy and tolerance of a low dose prophylaxis with Cefixime versus Nitrofurantoin. 60 girls aged 1 to 11 years with at least 2 urinary tract infections within the preceding year were included in the study. The minimum duration of therapy was 6 months and was extended to 12 months for most of the children. The number of recurrent infections was the main criteria for efficacy evaluation, whereas adverse events were analysed to evaluate tolerance. Statistical significant differences between the two treatment groups, regarding recurrence rates could not be demonstrated. Tolerance was comparable in both groups. The influence on gut flora of cefixime given as a low dose regimen over a long period of time corresponds with already published results and was not correlated with a higher number of gastrointestinal side effects. CONCLUSION: Low-dose Cefixime (2 mg/kg bodyweight) is effective and well tolerated in the prophylaxis of recurrent urinary tract infections. Efficacy and tolerance of cefixime were comparable to the results obtained with nitrofurantoin. Due to the small number of patients this study was only a pilot study. Low-dose cefixime, however, could become an alternative to standard regimens in the prophylaxis of recurrent urinary tract infections. This should be investigated in further studies.

Behavioural problems in children with urge incontinence and voiding postponement: a comparison of a paediatric and child psychiatric sample.

UNLABELLED: OBJECTIVE; To analyse prospectively the incidence of behavioural disorders and the subjective views of children with urge incontinence (defined by detrusor instability, sudden urge symptoms and frequent micturitions) and voiding postponement (characterized by delayed micturition in typical situations and a low voiding frequency) according to an identical protocol in a paediatric and a child psychiatric unit. PATIENTS AND METHOD: Ninety-four consecutive or randomly selected children aged 5.0-10.9 years with either voiding postponement (52) or urge incontinence (42) were examined prospectively using an intelligence test (CFT1 or CFT20), the Child Behaviour Checklist (CBCL 4/18), the ICD-10 child psychiatric diagnoses and a structured interview. RESULTS: In the groups from both centres combined, those postponing voiding had a significantly higher incidence of externalizing behavioural symptoms (31% vs. 8%; P < 0.01) and total problems (37% vs. 13%; P < 0.05) in the clinical range (CBCL), and a higher rate of at least one ICD-10 child psychiatric diagnosis (54% vs. 29% P < 0.05) and of expansive disorders (31% vs. 5%; P < 0.01). The incidence of children with behavioural symptoms was lower in the paediatric centre, being exceptionally low among urge incontinent children (only 6%, CBCL). In contrast, from the children's subjective appraisal, there were no significant differences in concepts, explanations and implications of wetting; 79% of urge incontinent children and 64% of those postponing voiding suffered emotionally from the adverse effects of wetting. Only a minority (3% vs. 6%) saw any advantages at all. CONCLUSION: Children with voiding postponement had a significantly higher incidence of behavioural problems, especially expansive/externalizing behaviour, 3-4 times higher than in the normal population. Children with urge incontinence had a significantly lower incidence of behavioural problems, mainly emotional/ internalizing behaviour, that was only slightly higher (1-2 times) than that in the normal population. Because of selection, similar trends but lower incidences were found in the paediatric setting, with very few problems among urge incontinent children. In contrast, the children's subjective views did not differ; disadvantages associated with emotional suffering were reported by all children.

Decreased trabecular bone mineral density in patients with phenylketonuria measured by peripheral quantitative computed tomography.

The bone mineral density (BMD) of 14 children, adolescents, and adults with phenylketonuria (PKU) on dietary treatment (age 5-28 y; 6F, 8M) was investigated using peripheral quantitative computed tomography (pQCT) of the distal radius. BMD of total (TBMD) and spongy bone (SBMD) were compared to those of healthy gender-, age-, weight- and height-matched controls. We found a significant decrease of SBMD in patients with PKU while TBMD was only slightly decreased, reaching no statistical significance. These results indicate minor changes of BMD in patients with PKU under treatment, which are more accentuated in the trabecular bone compartment. One additional patient who was untreated until the pQCT investigation at the age of 10 y also showed markedly decreased SBMD and TBMD.

[Differential enuresis nocturna diagnosis]. / Differentialdiagnose der Enuresis nocturna.

The symptom of enuresis can be a feature of many conditions, including renal, neurological and organic disease states. It is important to differentiate primary nocturnal enuresis from secondary enuresis and from daytime incontinence with a nocturnal component. It is recommended that the routine investigation of enuretic children should comprise four components: structured interview, physical examination, urine analysis and ultrasound investigation. Additional intensified diagnostic and invasive procedures should be reserved for patients with suspected neurological disorders or urological dysfunction.

Differential diagnoses for nocturnal enuresis.

The symptom of nocturnal enuresis can be a feature of many conditions, including renal, neurological and organic disease states. It is important to differentiate primary nocturnal enuresis from secondary enuresis and from daytime incontinence with a nocturnal component. It is recommended that the routine investigation of enuretic children should comprise four components: structured interview, physical examination, urinalysis and ultrasound investigation. Additional intensified diagnostic and invasive procedures should be reserved for patients with suspected neurological disorders or urological dysfunction.

Calcium acetate versus calcium carbonate as oral phosphate binder in pediatric and adolescent hemodialysis patients.

Calcium carbonate is widely used as an oral phosphorus binder to control hyperphosphatemia in children on maintenance hemodialysis. Intestinal calcium absorption may induce hypercalcemia, particularly if calcitriol is given simultaneously. In adults, calcium acetate binds phosphorus more effectively than calcium carbonate, while reducing the frequency of hypercalcemic events. We therefore compared calcium acetate with calcium carbonate in nine pediatric patients on long-term maintenance hemodialysis. Following a 1-week withdrawal of phosphorus binders, calcium carbonate was administered for 7 weeks; after a second withdrawal, calcium acetate was given for another 7 weeks. All patients received calcitriol regularly. Both agents lowered the serum phosphorus concentration significantly (calcium carbonate 5.7 +/- 1.4 vs. 7.7 +/- 2.1 mg/ dl, P < 0.005; calcium acetate 5.8 +/- 1.4 vs. 7.8 +/- 2.0 mg/dl, P < 0.005). Significantly less elementary calcium was ingested with calcium acetate than with calcium carbonate: 750 (375-1,500) vs. 1,200 (0-3,000) mg calcium/day, P < 0.0001. Wit calcium carbonate serum calcium increased significantly. The number of episodes of hyperphosphatemia or hypercalcemia did not differ between treatments. Intact plasma parathyroid hormone (PTH) decreased significantly with both phosphate binders, and serum 25-hydroxyvitamin D3 increased. There was a close relationship between serum phosphorus and PTH in prepubertal but not in pubertal patients. We conclude that hyperphosphatemia can be controlled effectively by both calcium acetate and calcium carbonate in pediatric hemodialysis patients. The oral load of elementary calcium is reduced significantly by binding phosphorus with calcium acetate instead of calcium carbonate; nevertheless, hypercalcemic episodes remain equally frequent with both phosphate binders.

24-hour blood pressure monitoring in children and adolescents after recovery from hemolytic uremic syndrome.

24-hour blood pressure monitoring is a valuable method for the diagnosis of arterial hypertension as well as for assessment of the diurnal rhythm of the arterial blood pressure (BP). The nocturnal decrease of blood pressure ("dipping") may be attenuated or abolished in children with advanced renal failure and glomerular diseases. Arterial hypertension is a longlasting problem in children who had recovered from hemolytic uremic syndrome (HUS). We therefore performed BP monitoring in 11 children and adolescents (age 1.3 to 18.8 years, 6 males, 5 females) after HUS using a portable oscillometric device (SpaceLabs 90207). Six of the subjects had a normal renal function (group A). The other 5 patients had impaired renal function with a glomerular filtration rate <60 ml/min/1.73 m2 (group B). Nocturnal dipping was calculated as nocturnal mean blood pressure minus diurnal mean blood pressure given in per cent of diurnal mean blood pressure. Two of the patients in group A had diurnal mean BP above the 95th percentile of the German collaboration study, but none of the group was hypertensive during the night, and nocturnal dipping was 13.6% (9.7-15.5%, median and range) for systolic BP and 23.7% (15.5-29.9%) for diastolic BP which is very similar to healthy children. All of the patients had a normal diurnal BP rhythm. From patients of group B, 4 had elevated diurnal mean BP and also 4 were hypertensive during the night. Nocturnal dipping was 1.4% (0.7-4.1%) for systolic and 6.8% (0-10.7%) for diastolic BP which is clearly attenuated compared to group A. We therefore conclude that arterial hypertension is more common in patients after HUS if they have impaired renal function, and diurnal rhythm of arterial blood pressure is attenuated in these patients. However, nocturnal dipping of blood pressure is not disturbed in children after HUS without renal insufficiency, even if they were hypertensive.

[Bone density in children and adolescents with rheumatic diseases. Preliminary results of selective measurement of trabecular and cortical bone using peripheral computerized tomography]. / Knochendichte bei Kindern und Jugendlichen mit rheumatischen Erkrankungen. Vorläufige Ergebnisse einer selektiven Messung von Spongiosa und Kortikalis mittels peripherer Computertomographie.

UNLABELLED: Selective measurements of bone mineral density (BMD) of trabecular and cortical bone at the ultradistal radius were made in 27 children with rheumatic diseases and in age- and sex-matched healthy controls using peripheral quantitative computed tomography (pQCT). RESULTS: Mineral density of trabecular bone (-34,5%) and total bone mineral density (-18,9%) differed significantly between patients and controls (p < 0.01). BMD of the cortical bone (-13,6%) did not differ significantly between the groups. There was no difference in BMD in patients with systemic or non-systemic diseases. BMD did not correlate with duration of disease or steroid medication. CONCLUSIONS: Total bone mineral density and trabecular bone density are decreased in children and adolescents with sytemic and non-systemic rheumatic diseases. Age of onset of disease and steroid medication did not correlate with bone mineral density. PQCT has the advantages of low local and no total body radiation, high sensitivity, high reproducibility and selective measurement of different bone compartements. Because selective measurement can be made in metabolically active trabecular bone changes of BMD can be detected at an early stage before the whole bone is affected. With this method therapy for chronic diseases affecting bone density can be initiated and the course of the disease can be followed.

[Pediatric ureteral ureteral outlet obstruction and obstructive megaureter: observation or operation?]. / Kindliche Ureterabgangsstenose und obstruktiver Megaureter: Observation oder Operation?

Stenosis of the ureteropelvic junction and obstructive megaureter are still a diagnostic and therapeutic problems. So far, there is no reliable prognostic factor to predict the outcome of a primary dilated upper urinary tract under the "wait and see" strategy and to decide which child must be operated upon and which should not. In practice, basic diagnostic evaluation with sonography, possibly i.v.-pyelography and voiding cystography is accompanied by quantifying isotope-based procedures such as DMSA-uptake or diuretic renography. The Whitaker test has become less important. Based on the investigation by Koff et al., it seems to be possible to follow the "wait and see" procedure in more than 85% of the children without any loss of renal function of the dilated kidney.

Validity of G1-cells in the differentiation between glomerular and non-glomerular haematuria in children.

Urine samples from 100 children and adolescents with micro- or macrohaematuria were investigated using phase contrast microscopy to establish the percentage of G1-cells that could differentiate glomerular from non-glomerular haematuria. The G1-cell is a special form of dysmorphic erythrocyte which seems to be specific for glomerular haematuria. Glomerular haematuria, defined by clinical criteria from biopsy, physical examination, standard laboratory evaluation and family history, was observed in 51 patients (group 1). Non-glomerular haematuria was found in 49 patients (group 2). The latter group had urinary tract infections, urolithiasis, hypercalciuria or haematuria caused by urological operation or diagnostic procedure. The percentage of dysmorphic erythrocytes differed significantly between the two groups studied (42 +/- 3% in group 1 vs. 6 +/- 1% in group 2, mean +/- SEM, P < 0.01); there was also a significant difference in G1-cells (19.4 +/- 1.7% in group 1 vs. 0.6 +/- 0.2% in group 2, mean +/- SEM, P < 0.01). When glomerular haematuria was defined on the basis of > or = 30% dysmorphic erythrocytes by phase contrast microscopy, sensitivity, specificity and efficiency were 71%, 100% and 85%, respectively. When glomerular haematuria was defined on the basis of > or = 5% G1-cells, sensitivity, specificity and efficiency were 100%, 100% and 100%, respectively. The differentiation of glomerular and non-glomerular haematuria in children by determination of G1-cells appears to be more sensitive and efficient than the determination of the percentage of dysmorphic erythrocytes by phase contrast microscopy.

Bone mineral density in children and adolescents with juvenile diabetes: selective measurement of bone mineral density of trabecular and cortical bone using peripheral quantitative computed tomography.

Bone mineral density (BMD) was studied in 21 children and adolescents with type I diabetes and in age- and sex-matched healthy controls. BMD was selectively measured in trabecular and total bone using peripheral quantitative computed tomography (pQCT). Cortical bone density was calculated. There was a decrease of trabecular bone density (-18.9%, p < 0.01), total bone density (-9.0%, NS) and cortical bone density (-5.1%, NS) in diabetes. Trabecular bone density was inversely correlated with the duration of diabetes and the concentration of glycosylated hemoglobin (HbA1) (r = -0.48, p = 0.027 and r = -0.63, p = 0.002, respectively). Total BMD correlated inversely with HbA1 (r = -0.52, p = 0.017). pQCT allows the selective measurement of metabolically active trabecular bone where changes of mineralization first occur. We conclude that pQCT is a useful method for investigating BMD in diabetes.

Influence of steroid medication on bone mineral density in children with nephrotic syndrome.

Bone mineral density (BMD) was studied in 26 children with idiopathic nephrotic syndrome and in age- and sex-matched healthy controls. BMD was selectively measured in trabecular (TBD), cortical (CBD) and total bone (BD) using peripheral quantitative computed tomography. Patients showed a decrease in BD, CBD and TBD. BD and CBD were inversely correlated with the cumulative dose of steroid treatment. Of the 26 patients with high cumulative doses of steroid, 16 were also treated with cyclophosphamide. In this group BD and CBD were decreased significantly compared with the children with a low cumulative steroid dose only. Compared with controls for each subgroup, significant decreases in BD, CBD and TBD were found in the group with high cumulative doses of steroids only. The higher cumulative steroid dose and the initial steroid toxicity which made cytotoxic therapy necessary, rather than cyclophosphamide itself, may be responsible for these findings.

Differentiation of glomerular and non-glomerular hematuria in children by measurement of mean corpuscular volume of urinary red cells using a semi-automated cell counter.

Urine samples from 110 children and adolescents with micro- or macrohematuria were compared using phase-contrast microscopy and a semi-automated cell counter to differentiate glomerular from non-glomerular hematuria. Glomerular hematuria, defined by clinical criteria from biopsy and standard chemical evaluation, was observed in 73 patients (group 1): non-glomerular hematuria was found in 37 patients (group 2). The latter group underwent urological operation and had normal urine before operation. Mean corpuscular erythrocyte volume (MCVU) and percent of dysmorphic erythrocytes were determinated. To exclude the influence of mean erythrocyte volume of blood erythrocytes (MCVB), MCVB was determined and additionally the quotient of MCVU/MCVB was calculated (MCVUB). The percentage of dysmorphic erythrocytes differed significantly between the two groups ((75 +/- 13% in group 1 versus 38 +/- 27% in group 2 (mean +/- SD); p < 0.01), MCVU (34.0 +/- 11.1 fl in group 1 versus 55.5 +/- 16.3 fl in group 2; p < 0.01) and MCVUB (0.41 +/- 0.14 in group 1 versus 0.67 +/- 0.20 in group 2; p < 0.01). When glomerular hematuria was defined on the basis of more than 80% dysmorphic erythrocytes, the sensitivity of phase-contrast microscopy was 0.52, specificity versus 0.96 and efficiency 0.64. When glomerular hematuria was defined as < 50 fl MCVU, sensitivity was 0.92, specificity 0.57 and efficiency 0.80 and as < 0.06 MCVUB, sensitivity was 0.89, specificity 0.62 and efficiency 0.80. The correlation coefficient between MCVU and dysmorphic erythrocytes was -0.71 (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Elevated plasma concentration of neuropeptide Y in adolescents with primary hypertension.

Neuropeptide Y (NPY) has been recently characterised as a circulating vasoconstrictor peptide which is co-stored with noradrenaline (NA) in sympathetic neurons. We measured NPY by radioimmunoassay and NA by HPLC in plasma of ten healthy volunteers (23-27 years of age) during bicycle ergometry and found a rapid increase of both NPY and NA during exercise. NPY rose from 1.3 +/- 0.5 to 9.6 +/- 7.8 pmol/l and NA from 1.3 +/- 0.3 to 10.8 +/- 5.6 mnol/l (mean +/- SD). Following maximal exercise NA disappeared more rapidly from plasma than NPY. Compared with these healthy volunteers, plasma NPY was found to be elevated in 23 children and adolescents aged 9-18 years with borderline primary hypertension (NPY 3.1 +/- 1.7 pmol/l, P < 0.01). Basal NPY was also elevated when compared with 21 age-matched pediatric controls (P < 0.05). The bicycle ergometry protocol performed in 23 patients separated ten adolescents with normal basal and exercise blood pressure from 13 with high BP also during ergometry. In the latter group, NPY rose to 11.9 +/- 7.3 pmol/l and NA to 12.3 +/- 8.6 nmol/l during exercise. Treatment of the hypertensive patients with the beta-adrenergic blocker atenolol (50 mg per day) lowered basal and exercise BP. Heart rate fell during atenolol treatment from 92 +/- 19 to 72 +/- 15 beats/min. Treatment did not alter plasma concentrations under basal conditions and during exercise (NPY from 2.8 +/- 2.1 to 11.7 +/- 5.3 pmol/l and NA from 2.0 +/- 0.8 to 15.6 +/- 14.1 nmol/l).(ABSTRACT TRUNCATED AT 250 WORDS)

[Prenatal ultrasound diagnosis in congenital abnormalities of the kidneys and efferent urinary tract from the pediatric nephrology viewpoint]. / Antenatale Ultraschalldiagnostik bei angeborenen Fehlbildungen der Nieren und des ableitenden Harntraktes aus pädiatrisch-nephrologischer Sicht.

Antenatal foetal abnormalities are found in 0.5% of all pregnancies. 30-50% of these abnormalities are related to the urinary tract. Although congenital abnormalities of the urinary tract can be detected as early as in the 15th-18th weeks of gestation, most abnormalities are detected between the 28th-30th weeks of gestation. At this time irreversible damage of the kidneys has taken place and the foetus will not benefit from antenatal therapy. On the other hand, a foetus with late onset of obstruction will benefit from antenatal intervention. Repeated ultrasonography is crucial for initiating further invasive diagnostic procedures, antenatal therapy and for planning the time of labour. There is a great risk of overdiagnosis and inadequate therapy because 25% of all antenatally diagnosed dilatations of the urinary tract could not be confirmed postnatally.