cosmetic results of a simple method for repairing preputial skin defect in hypospadias

Hypospadias is a common birth defect of the penis. Besides the abnormal position of the urethral opening, there is usually a ventral preputial defect with preputial redundancy in dorsal shaft. There are many flap procedures for correcting this defect. Here, we present our experience of skin coverage procedure with better cosmetic results. It is a prospective study on patients with mid-shaft to glandular hypospadias operated from June 2008 to December 2012. The operations were performed by one surgeon in two hospitals and the cosmetic results were evaluated by the surgeon, parents, and another pediatric surgeon by a satisfaction questionnaire. In this procedure, inner prepuce was incised curvilinearly, remaining 5 mm in medial and 8 mm in lateral aspects of the inner prepuce. For skin repair, dorsal flaps were approximated in midline along median raphe. Sixty-three patients with mean age of 25.75 +/- 8.46 [7-93] months were followed up for 7.06 +/- 3.34 [2-15] months. There were 4 complications. The overall satisfaction with penile skin coverage was 93.7% for parents and 98.4% for surgeons. Patients' age and primary site of meatus had a significant correlation with cosmetic results [P<0.05], while urethroplasty techniques and post-operative complications were not significant. Reapproximation of dorsal flaps in midline is a simple method and can be used in most cases of uncomplicated primary hypospadias. By this technique a more normal appearance can be achieved

Toilet training in Iranian children: a cross-sectional study

There is still controversy about the methods and the age of toilet training that are varied in different cultures. This is a survey of Iranian parents' views about the appropriate age, the true age, the methods used for toilet training, and the association with voiding problems. Questionnaires were filled-out containing items on demographic data, the parents' view, the method applied, and the age at which toilet training was accomplished in children aged 2 months to 5 years. In addition, pediatric lower urinary tract scoring system questionnaires were distributed among 217 children aged 5-15 years with lower urinary tract symptoms between 2008 and 2010 in outpatient clinics. P<0.05 was considered significant. 566 children [335 girls and 231 boys] were assigned to the study. In asymptomatic group, the majority of parents believed that the appropriate age to start toilet training was 1-2 years. The method used by the parents was intensive in 52% and child-oriented in 44%. There was strong reverse correlation between the level of education of father with applying punishment for training and direct correlation between toilet refusal and the later age of completing toilet training [LR: 6.3, P<0.05]. The mean age of completing toilet training was about 23 months in asymptomatic and 23.7 months in symptomatic children [P>0.05]. There was no correlation between wetting episodes at day or night and the age of toilet training. Intensive approach was more popular and the age of toilet training had no influence on the lower urinary tract symptoms

Bladder Volume Wall Index in Children with Urinary Tract Infections

Few studies have focused on the correlation between bladder ultrasound and urinary tract infection. The aim of this study was to evaluate the bladder volume wall index in children with single or recurrent urinary tract infection. This case-control study was conducted between March 2008 and December 2009. The study was performed on one hundred children [8 boys, 92 girls] aged 4-15 years with a history of urinary tract infection and thirty-nine [20 males, 19 females] age- matched healthy children who had negative urine culture one month before investigation. The kidneys, ureters, and bladder sonography were performed in all children. Bladder volume wall index was calculated for each child and the result of 70-130 was presumed normal. Student T-test, chi-square, likelihood ratio, and risk ratio were used. P-value <0.05 was considered significant. The mean bladder volume was 262.5 [ +/- 82] in recurrent urinary tract infection, 235 [ +/- 54] in single urinary tract infection, and 278 [ +/- 80] in controls [P<0.05]. The bladder was thick [<70] in 37 [28 cases, 9 controls] and thin [>130] in 38 children [28 cases, 10 controls] [P>0.05]. The median residual volume was not different between the two groups. The abnormal BVWI in children with vesicoureteral [VU] reflux was 75% as compared to 51% in those without VU reflux [P>0.05]. There was no correlation between BVWI and age, gender, groups, vesicoureteral reflux status, or residual volume [P>0.05]. According to our findings, the bladder volume wall index is not sensitive enough to discriminate children who are prone to urinary tract infection

Helicobacter pylori infection in pediatric candidates for kidney transplantation

Chronic kidney failure was suggested to have a protective effect against Helicobacter pylori infection in adults. However, data about this effect in children is lacking. This study was designed to ascertain the prevalence, endoscopic findings, and histopathological features accompanying the Helicobacter pylori infection in children with end-stage renal disease. Data were collected from 117 children with end-stage renal disease aged 5 to 18 years that underwent routine upper gastrointestinal endoscopy before kidney transplantation between 1998 and 2009. The specimens that were taken from the antrum were stained with hematoxylin-eosin and Giemsa to detect Helicobacter pylori. Gastrointestinal symptoms were reported in 12% of the patients. Helicobacter pylori was detected in 24% of the children. The prevalence of Helicobacter pylori infection was high in children with abnormal endoscopic findings [P = .02]. There was no correlation between Helicobacter pylori infection and gender, dialysis status, duration of dialysis, underlying diseases, and gastrointestinal symptoms. Helicobacter pylori infection had a significant correlation with histopathological features [P = .005], age older than 10 years [P = .003], and upper gastrointestinal endoscopic findings [P = .001]. In this study, Helicobacter pylori infection had a high prevalence in children with end-stage renal disease, especially in older ones. The majority of children with Helicobacter pylori infection were asymptomatic, while they had abnormal findings on upper gastrointestinal endoscopy and chronic active gastritis features in histopathological assessment

Single dose of rasburicase for treatment of hyperuricemia in acute kidney injury: a report of 3 cases

Severe hyperuricemia accompanied by the other comorbidities such as anuria, fluid overload, calcium-phosphate imbalance, and/or tumor lysis syndrome is one of the indications for dialysis in the setting of acute kidney injury. Rasburicase is used in different clinical conditions such as tumor lysis syndrome and uric acid nephropathy. Among referred patients to our center from 2008 to 2010, there were 3 patients who had an indication for dialysis because of hyperuricemia. Contributing factors to the acute kidney injury were multi-organ dysfunction, rapidly progressive glomerulonephritis, and spontaneous tumor lysis syndrome. None of the patients showed any response to treatment with bicarbonate and hydration. After rasburicase administration, serum uric acid level declined, and urine output increased. Treatment with a single low dose of rasburicase would be effective to decrease the serum uric acid level and reverse kidney injury secondary to uric acid nephropathy

Role and structure of morning report in children's teaching hospitals in Iran

Morning report is an integral component of medical training programs. It is conducted as "evidence based" or "problem based". It takes an efficient time of all members of the medical team in teaching hospitals, it seems necessary to evaluate its role in the education. Because of the importance of morning report in education, we evaluated the current and ideal conditions of morning report according to the opinions of medical teams in teaching children's hospitals. A cross- sectional descriptive study conducted in three children's teaching hospitals in Tehran in 2005. The opinion and perception of 358 participants, including faculties, residents, fellows, interns, and medical students, were collected by a questionnaire regarding the importance and structure of morning report. The data were presented as frequency and percentage. 78% of respondents expected a high educational role for morning report. Although 317 [88.54%] had a regular attendance in morning report, only 34.1% were satisfied from current condition. The majority believed that faculty had better to lead the sessions, and voted for case presentation to be selected by senior resident on call, despite the prominent current leadership of the faculty. Most of the participants [88.6%] preferred complicated and unusual cases for presentation. Current morning reports predominantly based on the presentation of the interesting or complicated cases were admitted on the previous day. A few number of cases were reintroduced after achieving the final diagnosis. In addition out-patients and those under observation in emergency room were usually ignored in the meetings. Regarding the educational role of morning report, there is a far distance between the present and ideal condition. Unattractiveness of presentations and poor participation in discussion might have negative impact on achieving the goals

Correlation between Lower Urinary Tract Scoring System, Behavior Check List, and Bladder Sonography in Children with Lower Urinary Tract Symptoms

PURPOSE: The Pediatric Lower Urinary Tract Scoring System (PLUTSS) is a standardized questionnaire used for screening and evaluation of the response of children with lower urinary tract symptoms (LUTS) to therapy. We presumed that adding the Child Behavior Check List (CBCL) and bladder volume wall index (BVWI) to the PLUTSS would increase its validity in the detection of children with LUTS. MATERIALS AND METHODS: One hundred twenty-two children aged 5 to 15 years with LUTS were enrolled in the study. Seventy-two healthy, age-matched children without urinary complaints were considered as controls. The PLUTSS and CBCL were filled out for all children. Sonography was performed to measure BVWI. Chi-square test and likelihood ratio were used to compare frequencies, receiver operating curve (ROC) analysis was used to evaluate the correlation, and Cohen's kappa was used to measure the agreement between variables. p-values 0.05). ROC analysis showed that there was no correlation between PLUTSS, CBCL, and BVWI in either the LUTS subgroup or in the controls (p>0.05). The PLUTSS had the highest sensitivity and specificity, and adding the two other tests decreased its validity for the diagnosis of children with LUTS. CONCLUSIONS: The PLUTSS by itself was the best predictor of LUTS. The CBCL and BVWI were not helpful in making a diagnosis; however, the CBCL was useful in the detection of behavior problems in children with non-monosymptomatic enuresis.

value of serum uric acid as a mortality prediction in critically ill children

The role of initial serum uric acid on admission in critically ill patients is controversial; we presumed that uric acid level can predict the mortality of the admitted patients to intensive care unit as a simple test. Totally 220 consecutively admitted children [96 girls, 124 boys] with mean age 3.5 years, who were at least 24 hours in pediatric intensive care unit [PICU], were enrolled in a prospective cohort study during January 2006 to December 2007. The subsequent PICU admission in the same hospitalization, those who were discharged from the hospital and then re-admitted to the PICU during the observation period, and the patients with chronic renal failure were excluded. Serum uric acid level was measured during the first day of PICU admission. Death or transfer from PICU was considered as final outcome. The statistical analysis was done by suing linear regression analysis, ROC curve, student t-test, and Chi-square. P value less than 0.05 was considered significant. From 44 patients who had serum uric acid level more than 8 mg/dl, 17 cases died showing with a higher relative risk of 1.88, higher mortality [P<0.05]. The relative risk of death in patients who had serum uric acid > 8mg/dl and needed vasopressor was 1.04, and in those under mechanical ventilation 1.33. In patients who scored pediatric risk of mortality of > 38 it was 1.4, and in septic cases 4 [P<0.05]. Stepwise linear regression analysis showed that mainly the need for mechanical ventilation [P=0.001] and vasopressor had statistically significant correlation with the poor outcome [P=0.001]. Uric acid level during the first day of intensive critical care admission is not an independent risk of mortality in PICU. Need for mechanical ventilation or inotropic agents was associated with poor outcome and only higher uric acid level in sepsis played an additive risk factor role

Huge obstructive bladder diverticula and cystic dysplastic kidneys in a newborn: a challenging dilemma

This study investigated a 63-day boy with end stage renal disease and abdominal cysts. The antenatal sonography detected anhydraminos, posterior urethral valve, and cystic dysplastic kidneys. Voiding cystourethrogram revealed two obstructive giant diverticula which at first looked like enlarged renal pelvis. The patient had persistent urinary tract infection and perforation of diverticula. The dialysis was ineffective because of leakage, immeasurable inflow and dwell volume, peritonitis and tunnel infection. As a result, the availability of automated peritoneal dialysis for infants is recommended to reduce morbidity and increasing the survival rate. Nonetheless the giant bladder diverticules might be better managed by diverticulectomy procedure

Gastrointestinal manifestations of nephropathic cystinosis in children

Cystinosis is an autosomal recessive disorder which is characterized by both renal and extrarenal symptoms. Gastrointestinal dysfunction has been reported in adolescent with cystinosis, and it is rarely considered in the infants. The present case series reviewed gastrointestinal manifestations of these patients. Gastrointestinal signs and symptoms of 23 children aged 5.99 +/- 0.50 years [range, 1.0 to 12.5 years] on average with cystinosis, admitted to our department of nephrology between 1996 and 2005, were retrospectively reviewed. The inclusion criteria were the presence of the crystals of cystine in bone marrow aspiration and corneal deposition detected by slit lamp examination. Gastrointestinal signs and symptoms were as follows: vomiting in 16 patients [69.6%], hepatomegaly in 8 [34.8%], diarrhea in 6 [26.1%], splenomegaly in 5 [21.7%], constipation in 4 [17.4%], anorexia in 4 [17.4%], abdominal pain in 3 [13.0%], nausea in 2 [8.7%], and ascites in 2 [8.7%]. Height below the 3rd percentile in was seen in 16 patients [69.6%] and weight below the 3rd percentile, in 17 [73.9%]. Fifteen patients [65.2%] had both low weight and low height. Esophagogastroduodenoscopy had been performed in 6 cases and chronic inactive gastritis with H pylori infection was detected in 2 patients [8.7%]. Our study revealed a wide spectrum of gastrointestinal disturbances in young patients with cystinosis. Such findings should lead to greater awareness of the presence of gastrointestinal dysfunction in these children, encourage prompt gastrointestinal evaluation, and encourage treatment of more severely affected patients

Resistance pattern of breakthrough urinary tract infections in children on antibiotic prophylaxis

Prophylactic antibiotics are commonly used for prevention of urinary tract infections [UTIs] in children. It was postulated that the organisms and resistance patterns of breakthrough infections would differ with the choice of antimicrobial prophylaxis. This was a retrospective descriptive study of all breakthroughs UTI from 2000 to 2006 in children over 1 month of age discharged from a referral children's hospital in Tehran, Iran on continuous antibiotic prophylaxis for UTIs. Fifty-seven children discharged on prophylaxis had breakthrough UTIs of which 32 [56%] had a previously diagnosed urinary tract anomaly. Escherichia coli was responsible for the majority of infections irrespective of choice of prophylaxis. Thirty-three of 56 breakthrough UTIs [59%] were with organisms that were resistant to the prophylactic antibiotic. There was an increased incidence of resistance to prophylaxis in children on cefixime [16 of 22; 78%] when compared with children on cephalexin [7 of 19; 37%; p = 0.02] and a trend toward increased resistance when compared with children on trimethoprim-sulfamethoxasole [3 of 8; 37%] [p = 0.10]. In conclusion, the resistance pattern of organisms causing breakthrough UTIs varies with the choice of prophylaxis which should be taken into consideration in choosing empiric therapy for such infections

Urinary calcium excretion in healthy children living in Kashan/ Iran

Urinary calcium excretion is different in various geographical regions. Therefore, we decided to evaluate the urinary calcium excretion in pediatric inhabitants of residential districts in the Desert of Iran and to determine the frequency of hypercalciuria. This study was carried out from 2004 to 2005 on healthy children aged 7-12 years in Kashan [Central Desert of Iran]. By proportional cluster sampling 95 rural and 305 urban cases were selected. The second non fasting morning urine sample was collected for measuring sodium, creatinine and calcium. Children whose urine calcium to creatinine ratio was more than 0.2 and urine sodium more than 200 meq/l were considered as hypercalciuric and hypernatriuric. Water samples were collected by health worker from 9 regions of the city and 9 villages for chemical analysis. The differences between frequencies were assessed by chi square test. P values less than 0.05 were considered significant. A total of 362 [175 females, 187 males] with a mean age of 9.5 [ +/- 1.4] years were studied. Mean urinary calcium/creatinine concentration ratio was 0.2 [ +/- 0.17]. The 95th percentile value for urine calcium/creatinine concentration was 0.53 and prevalence of hypercalciuria was found as 37.8%. The contents of water were similar in Kashan city and the villages, only the mean of total water density was higher in water supply of the city [P<0.05]. By regression analysis we found only direct but weak correlation between urine calcium and urine sodium excretion [r=0.37, P=0.0001]. Urinary calcium excretion is high in desert of Kashan; thus it is important to conduct more studies to determine the risk factors and its untoward effect such as nephrolithiasis

Diuretic effect of powdered Cerasus avium [cherry] tails on healthy volunteers

In this study, the diuretic activity of powdered cherry stalk was evaluated in 13 healthy volunteers by means of their water balance. In addition to biochemical parameters, such as urinary electrolyte concentration, osmolality and any adverse reaction were determined. The capsules of cherry stalks were administered at an equivalent dose of 2.0 grams of the plant per person. Urinary biochemical determination was made of concentration of electrolytes [sodium, potassium, chloride and calcium], urinary volume and osmolality by standard laboratory procedures. Statistical evaluation was performed by Student's-t and Wilcoxon rank tests. After administration of cherry stalk, the mean of urine calcium, sodium, chloride, and urine volume increased, but the amount of urine potassium and urine osmolality did not change. No adverse reaction was observed. Powdered C. avium stalk increased mild urine volume confirming thus the claimed diuretic effect of the herb. Administration of cherry stalk caused urinary sodium and chloride rising less than loop diuretics but higher than the others. Because of rising calcium excretion, it should be used with cautious in those with urolithiasis

Fungal peritonitis in Iranian children on continuous ambulatory peritoneal dialysis

Fungal peritonitis [FP], causing catheter obstruction, dialysis failure, and peritoneal dysfunction, is a rare but serious complication of peritoneal dialysis. In this study, the frequency and risk factors of FP are evaluated in children who underwent peritoneal dialysis. A retrospective multicenter study was performed at the 5 pediatric peritoneal dialysis centers in Iran from 1971 to 2006, and FP episodes among 93 children were reviewed. Risk ratios were calculated for the clinical and demographic variables to determine the risk factors of FP. Ninety-three children aged 39 months on average were included in study. Sixteen out of 155 episodes of peritonitis were fungi infections, all by Candida albicans. The risk of FP was higher in those with relapsing bacterial peritonitis [P = .009]. Also, all of the patients had received antibiotics within the 1 month prior to the development of FP. Catheters were removed in all patients after 1 to 7 days of developing FP. Six out of 12 patients had catheter obstruction and peritoneal loss after the treatment and 5 died due to infection. Fungal peritonitis, accompanied by high morbidity and mortality in children should be reduced by prevention of bacterial peritonitis. Early removal of catheter after recognition of FP should be considered