RESUMO
OBJECTIVE: To assess the quality of the evidence on which current recommendations for routine diagnostic imaging for childhood urinary tract infection are based. METHODS: A systematic overview of the literature using the MEDLINE database (1966 to October 1994), article bibliographies, and a manual search of current publications using Current Contents, was undertaken. Preset criteria were used to categorize study sample and design, and interrater reliability was assessed with a random sample. RESULTS: A total of 434 publications were evaluated, and 63 studies met the criteria for inclusion. There was 100% interrater agreement on inclusion eligibility and design classification. No controlled trials or analytic studies evaluating routine diagnostic imaging were found. All 63 studies were descriptive, and only 10 were prospective. None of the studies provided evidence of the impact of routine imaging on the development of renal scars and clinical outcomes in children with their first urinary tract infection. CONCLUSION: Methodologically sound, prospective studies are needed to assess whether children with their first urinary tract infection who have routine diagnostic imaging are better off than children who have imaging for specific indications. We conclude that the current recommendations are not based on firm evidence.
Assuntos
Infecções Urinárias/diagnóstico , Adolescente , Criança , Pré-Escolar , Humanos , Hipertensão Renovascular/etiologia , Hipertensão Renovascular/prevenção & controle , Lactente , Valor Preditivo dos Testes , Estudos Prospectivos , Insuficiência Renal/etiologia , Insuficiência Renal/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Infecções Urinárias/complicaçõesRESUMO
The objective of our prospective study was to compare the sensitivity and specificity of ultrasonography, intravenous pyelography, and dimercaptosuccinic acid scan in detecting scarred kidneys. Twenty-seven consecutive subjects with recurrent urinary tract infections, vesicoureteral reflux, scarred kidneys, or a combination of these problems had all three imaging procedures performed. With the total number of scars serving as the gold standard, the sensitivity (94%) and specificity (100%) in identifying renal scars in children were highest for the DMSA scan. Intraobserver (95%) and interobserver (90%) reliability were also high for the DMSA scan. However, the clinical interpretation of the increased sensitivity of the DMSA scan is unknown. Changes on the scan not identified by intravenous urography may not represent true scars. Research into the long-term significance of these scars is indicated.
Assuntos
Cicatriz/diagnóstico , Rim/patologia , Compostos de Organotecnécio , Succímero , Adolescente , Criança , Pré-Escolar , Cicatriz/diagnóstico por imagem , Feminino , Humanos , Rim/diagnóstico por imagem , Masculino , Variações Dependentes do Observador , Estudos Prospectivos , Cintilografia , Sensibilidade e Especificidade , Ácido Dimercaptossuccínico Tecnécio Tc 99m , Ultrassonografia , UrografiaRESUMO
A double-blind, randomized, crossover study assessed the effects of theophylline on behavior, mood, and efficiency of cognitive processing. Thirty-one children aged 8 to 12 years with moderate asthma were randomly assigned to 10-day theophylline followed by placebo or to placebo followed by theophylline experimental conditions separated by 2-day washout periods. Theophylline plasma concentrations and pulmonary function tests were performed throughout the study. Cognitive functioning tests and self-report measures were administered at baseline and after each medication phase. Behavior ratings were obtained from parents and teachers. Parents' and teachers' ratings did not reflect a theophylline effect on attention or activity level; children's self-reports showed no changes in mood, and no statistically significant differences were found on measures of cognitive processing. Large individual differences in sensitivity to theophylline effects were present. Although most of the children tolerated theophylline well, those already having attentional or achievement problems appeared vulnerable to adverse effects. Individual response differences should be a focus of future studies.
Assuntos
Afeto/efeitos dos fármacos , Asma/tratamento farmacológico , Comportamento Infantil/efeitos dos fármacos , Cognição/efeitos dos fármacos , Teofilina/uso terapêutico , Asma/psicologia , Atenção/efeitos dos fármacos , Criança , Método Duplo-Cego , Feminino , Fluxo Expiratório Forçado , Humanos , Inteligência/efeitos dos fármacos , Masculino , Cooperação do Paciente , Placebos , Classe Social , Teofilina/sangueRESUMO
We analyzed studies concerned with four important aspects of vesicoureteral reflux in infancy and childhood: the imaging procedures for the evaluation of vesicoureteral reflux, the treatment of reflux, and the correlation between reflux and later development of hypertension and end-stage kidney disease. The objectives of the study were to evaluate the validity and reliability of the current literature, to draw conclusions, and to recommend future studies for unresolved issues. We reached the following conclusions: (1) Retrograde cystography should be the gold standard for diagnosing vesicoureteral reflux. When ultrasonography and cystography are performed together, all clinically important abnormalities in the urinary system are detected. Intravenous pyelography is needed only when either or both of these studies are abnormal. (2) Other than abolishing reflux, surgery offers no short-term advantages (in terms of preventing breakthrough urinary tract infections, improving renal function, or preventing the development of new scars, hypertension, or end-stage kidney disease) over medical management. (3) The short periods of follow-up and methodologic flaws encountered in the reviewed studies make determination of the incidence of hypertension in children with vesicoureteral reflux impossible. (4) Although indications for an association between vesicoureteral reflux and end-stage kidney disease exist, the strength of this association has not been determined.
Assuntos
Refluxo Vesicoureteral , Criança , Diagnóstico por Imagem , Seguimentos , Humanos , Hipertensão Renal/prevenção & controle , Lactente , Falência Renal Crônica/prevenção & controle , Metanálise como Assunto , Projetos de Pesquisa , Refluxo Vesicoureteral/diagnóstico , Refluxo Vesicoureteral/epidemiologia , Refluxo Vesicoureteral/terapiaRESUMO
Forty-four patients with Haemophilus influenzae type b meningitis had follow-up evaluations approximately one year after hospital discharge. Patients with greater than or equal to 10(7) colony-forming units of H. influenzae type b per milliliters CSF had significantly greater frequencies of speech impairment (P less than 0.001), hearing loss (P = 0.04), and moderate or severe neurologic sequelae (P less than 0.01). Patients with greater than or equal to 1 microgram H. influenzae b antigen/ml CSF had a greater incidence of hearing loss (P = 0.03) but not of speech abnormalities (P = 0.06) or other neurologic sequelae (P = 0.64). Glucose concentrations less than 10 mg/dl correlated with the incidence of hearing loss (P = 0.02) and speech impairment (P = 0.02). "Partial" antibiotic therapy, CSF protein concentrations, and number of CSF polymorphonuclear leukocytes did not correlate well with sequelae. These data indicate that pretreatment concentrations of H. influenzae b and glucose concentrations in CSF were the best predictors of late sequelae of patients with H. influenzae b meningitis.
Assuntos
Infecções por Haemophilus/líquido cefalorraquidiano , Perda Auditiva Funcional/etiologia , Perda Auditiva/etiologia , Meningite por Haemophilus/líquido cefalorraquidiano , Distúrbios da Fala/etiologia , Adolescente , Adulto , Idoso , Antibacterianos/uso terapêutico , Proteínas do Líquido Cefalorraquidiano/análise , Criança , Pré-Escolar , Ensaio de Unidades Formadoras de Colônias , Glucose/líquido cefalorraquidiano , Infecções por Haemophilus/complicações , Infecções por Haemophilus/tratamento farmacológico , Humanos , Lactente , Leucócitos/análise , Masculino , Meningite por Haemophilus/complicações , Meningite por Haemophilus/tratamento farmacológico , Pessoa de Meia-Idade , Exame Neurológico , Estudos ProspectivosRESUMO
Nafcillin (150 mg/kg/day, divided every six hours) was administered intravenously to 46 patients ranging from 5 to 163 months of age with suspected or proved bacterial infections. Thirteen of 15 patients with bacteriologically proved infection responded to nafcillin. Two patients with cellulitis due to Escherichia coli or to Hemophilus influenzae type b did not improve with nafcillin therapy. A mean serum nafcillin concentration of 48 microgram/ml was observed 30 minutes after a dose of 37.5 mg/kg. The mean serum half-life was 0.76 hours. There was no significant relation between age and serum half-life, volume of distribution, or plasma clearance rate. Two patients developed neutropenia and six other patients developed an eosinophilia greater than 400/mm3 while receiving nafcillin. No significant toxic effect of nafcillin on liver or renal function was observed. One patient had phlebitis. There was a significant correlation between nfacillin concentrations and serum inhibitory and bactericidal titers (P less than 0.001). Results from this study indicate that nafcillin is a safe and effective antibiotic for the treatment of infections due to susceptible bacteria in the dosage tested.
Assuntos
Infecções Bacterianas/tratamento farmacológico , Nafcilina/uso terapêutico , Adolescente , Criança , Pré-Escolar , Avaliação de Medicamentos , Humanos , Lactente , Testes de Sensibilidade Microbiana , Nafcilina/metabolismo , Nafcilina/farmacologia , Infecções Estafilocócicas/tratamento farmacológico , Staphylococcus aureus , Infecções Estreptocócicas/tratamento farmacológicoRESUMO
The usual treatment for recurrent syndrome of inappropriate secretion of antidiuretic hormone has been fluid restriction. Recently White and Fetner described an adult with SIADH successfully managed with lithium carbonate. Described here is a child with recurrent SIADH who was diagnosed as having an acute hyponatremic episode and who then relapsed twice in a two-month period while chronic fluid restriction was attempted. He has now been maintained on 300 mg/day of lithium carbonate and is asymptomatic with normal serum sodium concentration and urine osmolalities. Lithium appears to be effective in the management of recurrent SIADH and may allow control in a patient who cannot comply with long-term fluid restriction.
Assuntos
Lítio/uso terapêutico , Vasopressinas/deficiência , Criança , Humanos , Masculino , Doenças da Hipófise/tratamento farmacológico , Neuro-Hipófise/metabolismo , Recidiva , Síndrome , Vasopressinas/metabolismoAssuntos
Doenças do Recém-Nascido/tratamento farmacológico , Infecções Estreptocócicas/tratamento farmacológico , Streptococcus agalactiae/efeitos dos fármacos , Ampicilina/uso terapêutico , Líquido Cefalorraquidiano/microbiologia , Relação Dose-Resposta a Droga , Quimioterapia Combinada , Gentamicinas/uso terapêutico , Humanos , Recém-Nascido , Testes de Sensibilidade Microbiana , Penicilina G/uso terapêuticoRESUMO
Concentrations of bacteria in cerebrospinal fluid ranged from 4.5 X 10(3) to 3 X 10(8) colony-forming units/ml in 27 patients with bacterial meningitis before antibiotic therapy and from 4 X 10(1) to 1.4 X 10(6) CFU/ml in four patients after one to two days of antibiotic therapy. All patients with persistent positive cultures had pretreatment concentrations of 10(7) CFU/ml or greater. A significant association was observed between cerebrospinal fluid lactic acid dehydrogenase activity and concentrations of bacteria (p less than 0.01). Large inocula of Hemophilus influenzae type b (10(7)) increased the minimal inhibitory concentration for penicillin and ampicillin but not for chloramphenicol. The minimal inhibitory concentration of each of the three antibiotics increased when group B streptococci were assayed. These data indicate that persistence of a positive culture may be related to large initial concentrations of bacteria. The relative "resistance" in vitro of large inocula possibly contributes to this persistence. These observations are also consistent with the hypothesis that lactic acid dehydrogenase activity in cerebrospinal fluid is derived from bacteria.