Four-hour voiding observation with provocation test reveals significant abnormalities of bladder function in newborns with spinal dysraphism.

INTRODUCTION: Four-hour voiding observation with provocation test (VOP) using a scale, a damp detector and ultrasound for determination of residuals, is an easily performed non-invasive method for the evaluation of bladder function in newborns. Neonatal bladder function evaluated with VOP has been described for healthy newborns (HN) but not for children with spinal dysraphism (SD), for whom early bladder evaluation is essential for decisions regarding Clean Intermittent Catheterization and follow-up. The aim of the present study was to describe voiding observation with provocation test in newborns with spinal dysraphism and compare with corresponding data for healthy newborns. METHODS AND MATERIALS: At a tertiary hospital, a 4 h voiding observation with provocation (VOP) was performed in 50 neonates (22 girls, 28 boys) with spinal dysraphism (37 open SD, 13 closed SD) consecutively evaluated for possible neurogenic bladder-sphincter dysfunction (1998-2019). All newborns with open SD and 4/13 with closed SD had been through postnatal neurosurgery before the test. Mean age was 10 days. Voiding observation was performed during 4 h with visual observation the fourth hour recording behavior and urinary flow (e.g. stream, dribbling). Finally, bladder provocations (e.g. suprapubic compression) were performed, and any leakage was noted. Findings were compared to those of 50 healthy newborns (HN) earlier published (Gladh et al., 2002). There were no significant differences in background data such as gender, age or diuresis between newborns with SD and HN. RESULTS AND DISCUSSION: Voiding observation with provocation test of children with SD revealed significant differences compared to HN see summary table. Some children with SD had frequent small voids/leakages and low bladder volumes while three had no voiding and high volumes. Leakage during bladder provocation test and not voiding with a stream was not seen in HN but were common in newborns with SD (69% resp. 74%) (p < 0.01). A child with these findings should thus be investigated further. Identifying children needing Clean Intermittent Catheterization is important as well as being able to postpone or refrain from invasive urodynamic studies if not strongly indicated. VOP may give valuable information for these judgements. CONCLUSION: Newborns with spinal dysraphism differ from healthy newborns in many aspects of bladder function. Bladder function varies between newborns with closed and open spinal dysraphism. Many newborns with spinal dysraphism leak at bladder provocation and void without a stream but healthy newborns do not. Early determination of post-void residuals is mandatory in children with spinal dysraphism and non-invasive VOP gives this information in a standardized way, also adding information on frequency, voiding with a stream and leakage at provocation.

Children with myelomeningocele and independence in the toilet activity: a pilot study.

OBJECTIVE: Regarding adult life and independence the most common obstacles for young adults with myelomeningocele (MMC) are cognitive dysfunction and difficulties in performing toilet activities. A step-by-step method with goal setting for the training of self-care in toilet activities for children with MMC was evaluated. METHOD: Twenty-two children with MMC and bladder and bowel dysfunction (12 girls, 10 boys) aged 3-17.2 (m 9.1) were included. The toilet activities were observed at home jointly by an occupational therapist and urotherapist. Goal-setting procedures of self-training were promoted. Observation scores before and after intervention were compared, the goal setting being evaluated on a Goal Attainment Scale (GAS). RESULTS: Fifteen children who trained in self-catheterization had a median observation score of 22 before and 37 after the training period (p = 0.002). Another seven trained in trans-rectal irrigation with a median score of 30 before and 49 after (p = 0.02). As a result of GAS all children improved, of whom 17 reached the goal or even more so than expected. CONCLUSIONS: In this pilot study mutual goal setting in a step-by-step training programme based on professional observation of the toilet activity at home showed a better outcome than traditionally performed training in a hospital setting or with traditional habilitation support.

Renal preservation in children with neurogenic bladder-sphincter dysfunction followed in a national program.

PURPOSE: Neurogenic bladder-sphincter dysfunction (NBSD) constitutes the major reason for morbidity in children with spina bifida. The aim of this study was to identify risk factors for renal damage in children with NBSD followed according to the Swedish national guidelines. MATERIALS AND METHODS: Records and cystometries from 6 to 16 years (median 11) follow up of 41 consecutive children born 1993-2003 with NBSD were evaluated. The children were divided into a high pressure group (baseline pressure above 30 cmH(2)O at maximal clean intermittent catheterization volume in at least two cystometries) and a low pressure group. Most children (34/41) were followed from birth. RESULTS: Although renal scarring on DMSA-scintigraphy was found in 5/41 children, all but one had normal renal function. Two already had renal scars on entering the follow-up program at age 2.5 and 3 years. Renal scarring was more frequent in the high pressure group (P < 0.01). Most children with renal scars (4/5) had a combination of low compliant bladder and insufficient compliance with treatment and follow up. CONCLUSION: High baseline pressure is confirmed as a risk factor that, in combination with complex social issues, creates a demanding situation for families and professionals. A structured early follow up with treatment compliance effectively prevents renal damage.

Comparing ambient, air-convection, and fluid-convection heating techniques in treating hypothermic burn patients, a clinical RCT.

BACKGROUND: Hypothermia in burns is common and increases morbidity and mortality. Several methods are available to reach and maintain normal core body temperature, but have not yet been evaluated in critical care for burned patients. Our unit's ordinary technique for controlling body temperature (Bair Hugger®+ radiator ceiling + bed warmer + Hotline®) has many drawbacks e.g.; slow and the working environment is hampered.The aim of this study was to compare our ordinary heating technique with newly-developed methods: the Allon™2001 Thermowrap (a temperature regulating water-mattress), and Warmcloud (a temperature regulating air-mattress). METHODS: Ten consecutive burned patients (> 20% total burned surface area and a core temperature < 36.0°C) were included in this prospective, randomised, comparative study. Patients were randomly exposed to 3 heating methods. Each treatment/measuring-cycle lasted for 6 hours. Each heating method was assessed for 2 hours according to a randomised timetable. Core temperature was measured using an indwelling (bladder) thermistor. Paired t-tests were used to assess the significance of differences between the treatments within the patients. ANOVA was used to assess the differences in temperature from the first to the last measurement among all treatments. Three-way ANOVA with the Tukey HSD post hoc test and a repeated measures ANOVA was used in the same manner, but included information about patients and treatment/measuring-cycles to control for potential confounding. Data are presented as mean (SD) and (range). Probabilities of less than 0.05 were accepted as significant. RESULTS: The mean increase, 1.4 (SD 0.6°C; range 0.6-2.6°C) in core temperature/treatment/measuring-cycle highly significantly favoured the Allon™2001 Thermowrap in contrast to the conventional method 0.2 (0.6)°C (range -1.2 to 1.5°C) and the Warmcloud 0.3 (0.4)°C (range -0.4 to 0.9°C). The procedures for using the Allon™2001 Thermowrap were experienced to be more comfortable and straightforward than the conventional method or the Warmcloud. CONCLUSIONS: The Allon™2001 Thermowrap was more effective than the Warmcloud or the conventional method in controlling patients' temperatures.

Children and youth with myelomeningocele's independence in managing clean intermittent catheterization in familiar settings.

AIM: To examine the ability of children and youth with myelomeningocele to independently manage clean intermittent catheterization. METHODS: There were 50 participants with myelomeningocele (5-18 years); 13 of them had also participated in a previous hospital-based study. Their abilities and interest in completing the toilet activity were examined at home or in school using an interview and the Canadian Occupational Performance Measure (COPM). Actual performance was observed and rated. Background variables were collected from medical records and KatAD+E tests. RESULTS: In total, 48% were observed to perform the toilet activity independently, in comparison with 74% who self-reported independence. Univariate analyses found KatAD+E could predict who was independent. COPM failed to do so. Ability to remain focused and ambulation were predictors of independence, but age, sex and IQ were not. Multivariable analysis found time to completion to be the strongest predictor of independence. Four children were independent in their familiar environment, but not in the hospital setting, and six of 13 children maintained focus only in their familiar environment. CONCLUSIONS: Interviews were not sufficiently accurate to assess independence in the toilet activity. Instead, observations including time to completion are recommended. The execution of the toilet activity is influenced by the environmental context.

Voiding school for children with idiopathic urinary incontinence and/or bladder dysfunction.

OBJECTIVE: Individually applied urotherapy is first-line treatment in children with bladder dysfunction. A new concept of treatment for small groups of children was applied and evaluated. PATIENTS AND METHODS: Two hundred children, 116 of them girls, aged 3-14 years (median 7.2) with bladder dysfunction and incontinence received urotherapy in small groups (2-5), called voiding school (VS). Outcome was evaluated after 3 and 12 months by voiding/leakage diary and questionnaire, and at 3 months by uroflow and post-void residual urine as well. RESULTS: The outcome of VS was independent of age and gender. At follow up at 3 and 12 months, respectively, 35% and 40% of the children were cured and another 30% and 34% improved (P≤0.0001). Compared with the year before start of VS, urinary tract infections decreased from 34% to 6% (P<0.0001). Median residual urine decreased from 15 ml before VS to 6 ml after 3 months (P<0.001). CONCLUSION: The concept of VS is a good alternative to individual urotherapy, with the outcome of fewer urinary tract infections and improved continence. Urotherapy for groups of children compared to individual treatment is also expected to have financial benefits.