Conflicting views of physicians and surgeons concerning pediatric urinary tract infection: a comparative review.

BACKGROUND: A first febrile urinary tract infection (UTI) is a common condition in children, and pathways of management have evolved over time. OBJECTIVE: To determine the extent to which pediatricians and surgeons differ in their investigation and management of a first febrile UTI, and to evaluate the justifications for any divergence of approach. MATERIALS AND METHODS: A literature search was conducted for papers addressing investigation and/or management following a first febrile UTI in children published between 2011 and 2021. Searches were conducted on Medline, Embase, and the Cochrane Controlled Trials Register. To be eligible for inclusion, a paper was required to provide recommendations on one or more of the following: ultrasound (US) and voiding cystourethrogram (VCUG), the need for continuous antibiotic prophylaxis and surgery when vesicoureteral reflux (VUR) was detected. The authorship required at least one pediatrician or surgeon. Authorship was categorized as medical, surgical, or combined. RESULTS: Pediatricians advocated less imaging and intervention and were more inclined to adopt a "watchful-waiting" approach, confident that any significant abnormality, grades IV-V VUR in particular, should be detected following a second febrile UTI. In contrast, surgeons were more likely to recommend imaging to detect VUR (p<0.00001), and antibiotic prophylaxis (p<0.001) and/or surgical correction (p=0.004) if it was detected, concerned that any delay in diagnosis and treatment could place the child at risk of kidney damage. Papers with combined authorship displayed intermediate results. CONCLUSION: There are two distinct directions in the literature regarding the investigation of an uncomplicated first febrile UTI in a child. In general, when presented with a first febrile UTI in a child, physicians recommend fewer investigations and less treatment, in contrast to surgeons who advocate extensive investigation and aggressive intervention in the event that imaging detects an abnormality. This has the potential to confuse the carers of affected children.

Vesico-ureteric reflux in children and young people undergoing kidney transplantation.

Vesico-ureteric reflux (VUR) into transplanted kidneys in children and young people is a common occurrence, found in 19 to 60% of those who had an anti-reflux procedure and up to 79% in the absence of such a procedure. While VUR is unlikely to be of concern without evidence of symptomatic urinary tract infections, less certainty exists regarding outcomes when the VUR is associated with urinary tract infection (UTI) and transplant pyelonephritis. Issues explored will include additional risk factors that might predispose to UTI, any effect of pyelonephritis on acute and long-term kidney allograft function and practical strategies that may reduce the prevalence of infection.

Tidewater-glacier response to supraglacial lake drainage.

The flow speed of the Greenland Ice Sheet changes dramatically in inland regions when surface meltwater drains to the bed. But ice-sheet discharge to the ocean is dominated by fast-flowing outlet glaciers, where the effect of increasing surface melt on annual discharge is unknown. Observations of a supraglacial lake drainage at Helheim Glacier, and a consequent velocity pulse propagating down-glacier, provide a natural experiment for assessing the impact of changes in injected meltwater, and allow us to interrogate the subglacial hydrological system. We find a highly efficient subglacial drainage system, such that summertime lake drainage has little net effect on ice discharge. Our results question the validity of common remote-sensing approaches for inferring subglacial conditions, knowledge of which is needed for improved projections of sea-level rise.

A first constraint on basal melt-water production of the Greenland ice sheet.

The Greenland ice sheet has been one of the largest sources of sea-level rise since the early 2000s. However, basal melt has not been included explicitly in assessments of ice-sheet mass loss so far. Here, we present the first estimate of the total and regional basal melt produced by the ice sheet and the recent change in basal melt through time. We find that the ice sheet's present basal melt production is 21.4 +4.4/-4.0 Gt per year, and that melt generated by basal friction is responsible for about half of this volume. We estimate that basal melting has increased by 2.9 ± 5.2 Gt during the first decade of the 2000s. As the Arctic warms, we anticipate that basal melt will continue to increase due to faster ice flow and more surface melting thus compounding current mass loss trends, enhancing solid ice discharge, and modifying fjord circulation.

Kidney damage associated with vesico ureteric reflux.

PURPOSE OF REVIEW: The aim of this review is to highlight the most recent developments in the understanding of kidney damage associated with vesico ureteral reflux. The severe damage, with major adverse long-term sequelae, was thought to be, for the most part, the result of pyelonephritis, predisposed to by vesico ureteral reflux. RECENT FINDINGS: It is now recognized that there are two distinct forms of kidney damage (congenital and acquired), in association with reflux. We examined the most recent research regarding these two conditions. SUMMARY: The most recent articles focus on an understanding and the possible interventions for the congenital and acquired abnormalities of the kidney, associated with reflux. Of particular interest in congenital disorders, is the importance of urothelium and gene mutations in normal and aberrant development of the urinary tract. As regards the predisposition to urinary tract infections and kidney scarring, the importance of uromodulin in the defence mechanism preventing infection, and the role of interventions aimed at reducing scarring, such as vitamin A and steroids during the acute phase of the infection, are discussed. A recent article of particular value demonstrated the absence of long-term adverse outcomes during pregnancy, in women investigated for urinary tract infections in childhood.

Vesicoureteral reflux is it important to find?

Vesico-ureteral reflux (VUR) has long been recognized as associated with urinary tract infections (UTIs), renal scarring, and chronic kidney disease (CKD). The concept of "reflux nephropathy" was born, whereby the VUR was considered the culprit, predisposing to recurrent UTIs and providing a conduit whereby the infection could ascend to the kidneys resulting in scarring and destruction. The more severe grades of reflux were thought to place the young child at particular risk of CKD. The question being asked in this pro/con debate is whether VUR is indeed the culprit responsible for a significant proportion of children with CKD, a number of whom progress to end-stage kidney failure (ESKF), and is thus important to find and treat, or is it an innocent bystander associated with CKD and ESKF but not the cause. We believe the latter and will present convincing evidence supported by large scale prospective randomized controlled trials that VUR is not the ogre it was thought to be and is not important to find following a UTI (with some exceptions).

Indentation into a plastic fluid layer.

We study the indentation of a rigid object into a layer of a cohesive or non-cohesive plastic material. Existing approaches to this problem using slip-line theory assume that the penetration depth is relatively small, employing perturbation theory about a flat surface. Here, we use two alternative approaches to account for large penetration depths, and for the consequent spreading and uplift of the surrounding material. For a viscoplastic fluid, which reduces to an ideal plastic under the limit of vanishing viscosity, we adopt a viscoplastic version of lubrication theory. For a Mohr-Coulomb material, we adopt an extension of slip-line theory between two parallel plates to account for arbitrary indenter shapes. We compare the theoretical predictions of penetration and spreading with experiments in which a flat plate, circular cylinder or sphere are indented into layers of Carbopol or glass spheres with successively higher loads. We find reasonable agreement between theory and experiment, though with some discrepancies that are discussed. There is a clear layer-depth dependence of the indentation and uplift for the viscoplastic material. For a cylinder indented into a Mohr-Coulomb material, there is a much weaker dependence on layer depth.

Wettability-Independent Droplet Transport by Bendotaxis.

We demonstrate "bendotaxis," a novel mechanism for droplet self-transport at small scales. A combination of bending and capillarity in a thin channel causes a pressure gradient that, in turn, results in the spontaneous movement of a liquid droplet. Surprisingly, the direction of this motion is always the same, regardless of the wettability of the channel. We use a combination of experiments at a macroscopic scale and a simple mathematical model to study this motion, focusing in particular on the timescale associated with the motion. We suggest that bendotaxis may be a useful means of transporting droplets in technological applications, e.g., in developing self-cleaning surfaces, and discuss the implications of our results for such applications.

Rolling resistance of shallow granular deformation.

Experiments are conducted to measure the resistance experienced by light cylinders rolling over flat beds of granular media. Sand and glass spheres are used for the beds. The trajectories of the rolling cylinders are determined through optical tracking, and velocity and acceleration data are inferred through fits to these trajectories. The rolling resistance is dominated by a velocity-independent component, but a velocity-dependent drag exceeding the expected strength of air drag is also observed. The results are compared to a theoretical model based on a cohesionless Mohr-Coulomb rheology for a granular medium in the presence of gravity. The model idealizes the flow pattern underneath the rolling cylinder as a plastically deforming zone in front of a rigidly rotating plug attached to the cylinder, as proposed previously for cylinders rolling on perfectly cohesive plastic media. The leading-order, rate-independent rolling resistance observed experimentally is well reproduced by the model predictions.

Antibiotic Prophylaxis for Urinary Tract Infection-Related Renal Scarring: A Systematic Review.

CONTEXT: Acute pyelonephritis may result in renal scarring. Recent prospective studies have shown a small benefit of antibiotic prophylaxis in preventing symptomatic and febrile urinary tract infections (UTIs), while being underpowered to detect any influence in prevention of renal damage. OBJECTIVES: Review of the literature and a meta-analysis to evaluate the effect of antibiotic prophylaxis on UTI-related renal scarring. DATA SOURCES: Medline, Embase, and Cochrane Controlled Trials Register electronic databases were searched for studies published in any language and bibliographies of identified prospective randomized controlled trials (RCTs) performed and published between 1946 and August 2016. STUDY SELECTION: Subjects 18 years of age or younger with symptomatic or febrile UTIs, enrolled in prospective RCTs of antibiotic prophylaxis where 99mTc dimercaptosuccinic acid scans were performed at entry into the study and at late follow-up to detect new scar formation. DATA EXTRACTION: The literature search, study characteristics, inclusion and exclusion criteria, and risk of bias assessment were independently evaluated by 2 authors. RESULTS: Seven RCTs (1427 subjects) were included in the meta-analysis. Our results show no influence of antibiotic prophylaxis in preventing renal scarring (pooled risk ratio, 0.83; 95% confidence interval, 0.55-1.26) as did a subanalysis restricted to those subjects with vesicoureteral reflux (pooled risk ratio, 0.79; 95% confidence interval, 0.51-1.24). LIMITATIONS: Limitations include the small number of studies, short duration of follow-up, and insufficient children with high-grade dilating reflux and/or renal dysplasia enrolled in the studies. CONCLUSIONS: Antibiotic prophylaxis is not indicated for the prevention of renal scarring after a first or second symptomatic or febrile UTI in otherwise healthy children.

Long-term remission with eculizumab in atypical haemolytic uraemic syndrome.

The understanding of the role of complement dysregulation in atypical haemolytic uraemic syndrome (aHUS) has led to major changes in therapeutic approaches and outcomes. Eculizumab is a humanized anti-C5 monoclonal antibody that inhibits the terminal complement pathway and has revolutionized the treatment and prognosis of aHUS. However, published reports to date have had relatively short-term follow-up. We report two paediatric cases of aHUS successfully treated with eculizumab longer than 6 years with no serious adverse events and preservation of renal function.

Capillary Imbibition into Converging Tubes: Beating Washburn's Law and the Optimal Imbibition of Liquids.

We consider the problem of capillary imbibition into an axisymmetric tube for which the tube radius decreases in the direction of increasing imbibition. For tubes with constant radius, imbibition is described by Washburn's law (referred to here as the BCLW law to recognize the contributions of Bell, Cameron, and Lucas that predate Washburn). We show that imbibition into tubes with a power-law relationship between the radius and axial position generally occurs more quickly than imbibition into a constant-radius tube. By a suitable choice of the shape exponent, it is possible to decrease the time taken for the liquid to imbibe from one position to another by a factor of 2 compared to the BCLW law. We then show that a further small decrease in the imbibition time may be obtained by using a tube consisting of a cylinder joined to a cone of 3 times the cylinder length. For a given inlet radius, this composite shape attains the minimum imbibition time possible. We confirm our theoretical results with experiments on the tips of micropipettes and discuss the possible significance of these results for the control of liquid motion in microfluidic devices.