School children's perceptions about being offered the HPV vaccination - A focus group study.

AIM: There is limited knowledge about the perceptions of HPV vaccination in middle-school children. This qualitative study aimed to explore their views. METHODS: We conducted focus group interviews with children, 10-11 years of age, who had been offered HPV vaccination through the school health services in mid-north Sweden in spring of 2023. Data were analysed with qualitative content analysis. RESULTS: This study included six focus group interviews with 49 children (boys n = 29; girls n = 20), mean of 11 years of age. Participating children expressed the need to feel safe to be of utmost importance and the means to do so was to be prepared and informed by someone the child trusted. The school nurse was perceived as the expert, best suited to provide factual information, support and motivation, both to children and their parents. CONCLUSION: We confirm that healthcare providers' recommendations are crucial for HPV vaccine acceptance also from the child's perspective. Improved information about HPV vaccination to children is necessary. Children's right to participate on their own terms is not fulfilled today. Vaccine promotion, both to children and parents, should be actively managed by the school nurse.

Predictors of response and adherence to enuresis alarm therapy-a confirmatory study.

AIM: To look for predictors to response and adherence to the enuresis alarm while exploring the possibility of families managing therapy independently. METHODS: We used a body-worn alarm linked to a smartphone app. Subjects with enuresis were recruited both via paediatric nurses and independently as families bought the alarm and downloaded the app on their own. RESULTS: We recruited 385 nurse-supported and 1125 independent subjects. Many (79.9%) dropped out before 8 weeks, but among adherent subjects 48.2% had a full or partial response. Age was a predictor of non-response (p = 0.019). Daytime incontinence did not influence response. If enuresis frequency did not decrease during the first 4 weeks of therapy the chance of response was very small (p < 0.001). Adherence was higher among subjects supported by a nurse (p < 0.001), but for adherent subjects the outcome was similar regardless of nurse support (p = 0.554). CONCLUSIONS: Daytime incontinence is no contraindication to enuresis alarm therapy. Treatment can be managed independently by the families, but adherence is enhanced by nurse support. Alarm treatment should be reassessed after 4 weeks. Enuresis alarm treatment guidelines need to be updated.

Predictors of treatment response in therapy-resistant enuresis.

BACKGROUND: The voiding chart is part of the initial evaluation of enuresis, since the data gathered this way are assumed to carry predictive information. However, there is little evidence that the voiding chart actually does predict therapy response. Lundmark & Nevéus performed a pilot investigation in 2020 and found that anamnestic and voiding chart data did not predict response to second-line therapies. This study aims at evaluating whether these findings could be replicated. PATIENTS AND METHODS: This is an evaluation of clinical practice. All patients in a tertiary outpatient clinic with enuresis resistant to first-line therapy (i.e. the enuresis alarm and desmopressin medication) during the evaluation period were included in the study. Baseline anamnestic data focused on bladder and bowel habits, were gathered and the families were instructed to complete a voiding chart including measurements of nocturnal urine production. The children were then treated in accordance with international guidelines, which are anticholinergics and antidepressants as second- and third-line treatment, respectively. Desmopressin was added if needed. RESULTS: In total, 70 patients were included. At the end of the study 37 of these patients were dry, 11 patients were still wetting their beds and 22 patients were lost to follow-up. Of the dry patients 21 became dry on anticholinergics (and/or mirabegron, with or without desmopressin), five on tricyclic antidepressants (with or without desmopressin), seven after a new attempt with the alarm and five became dry spontaneously. The only statistically significant differences between responders and non-responders to the various treatments were that children responsive to anticholinergics had harder and more infrequent stools (p = 0.04 and p = 0.03, respectively). CONCLUSION: This study found that anamnestic and voiding chart data do not predict response to treatment in children with therapy-resistant enuresis. Because of this and the fact that we lose some children who need our help by demanding that they complete a voiding chart before initiating treatment, we question the use of this instrument in the evaluation of therapy-resistant enuresis.

Barriers in the School-Based Pan-Gender HPV Vaccination Program in Sweden: Healthcare Providers' Perspective.

BACKGROUND: Human papillomavirus (HPV) vaccines effectively prevent, and can even eliminate, HPV-related cancers. Currently, vaccination rates are suboptimal in the national Swedish school-based vaccination program. School nurses play a key role in all aspects of the vaccination process. Therefore, this study aims to explore school nurses' perceived HPV vaccination challenges. METHODS: Seven focus group interviews were conducted with school nurses (n = 35) working in nine socio-demographically diverse municipalities in mid-Sweden. Data were analyzed using qualitative content analysis. RESULTS: Participants described difficulties in encountering and handling the diversity of reasons for vaccine hesitancy. Parents known to be skeptical of vaccines in general were seen as most difficult to reach. Uncertainty was expressed concerning the extent of professional responsibility for vaccine promotion. The informants expressed a lack of guidelines for vaccine promotion and described challenges in supporting the child's own wishes. Creating a safe space for the individual child was seen as crucial. Other problems described were the challenges of overcoming children's fear of needles, supporting unvaccinated children, and being confronted with the remaining gender inequities of the pan-gender vaccination program. CONCLUSIONS: Our results suggest that school nurses, especially those new to their profession, may benefit from training and guidance22 material on how to address vaccine hesitancy.

Can enuresis alarm therapy be managed by the families without the support of a nurse? A prospective study of a real-world sample.

AIM: The alarm is the first-line treatment of nocturnal enuresis. However, the therapy is labour-intensive for both families and healthcare providers. Our aim was to see whether the treatment could be successfully used by the families, without support from healthcare providers. METHODS: An alarm linked to an application on a parent's smartphone was used. The app recorded enuretic events and gave instructions. Group A were children supported by a nurse. Group B were patients whose families had bought the alarm and downloaded the app independently. RESULTS: There were 196 children in group A and 202 in group B. The percentages of full responders, partial responders, non-responders and dropouts were 18.4%, 20.4%, 22.4% and 38.8% in group A and 13.4%, 11.4%, 14.9% and 60.4% in group B. The risk for dropping out of therapy was higher in group B (p < 0.001), whereas the chance for adherent children to become dry did not differ between the groups (p = 0.905). CONCLUSION: For families who are able to adhere to alarm therapy the chance of success is just as good when managed independently as when supported by a nurse. But the latter children will have a greater chance of adhering to the full treatment.

The value of case history and early treatment data as predictors of enuresis alarm therapy response.

BACKGROUND AND AIM: Two central problems with the enuresis alarm are the family workload and the lack of predictors of therapy response. We wanted to look at predictors of alarm response in a setting reflecting clinical reality. METHODS: An alarm linked to a smartphone app was provided to enuretic children managed at pediatric outpatient wards. Baseline data (sex, age, daytime incontinence, urgency, previous therapies, arousal thresholds and baseline enuresis frequency) were recorded. Further information, such as enuretic episodes and actual alarm use, was gathered via the app during therapy. Therapy was given for 8-12 weeks or until 14 consecutive dry nights had been achieved. RESULTS: For the 196 recruited children the outcome was as follows: full responders (FR) 18.4%, partial responders (PR) 20.4%, nonresponders (NR) 22.4% and dropouts 38.8%. We found no clear predictors of response or adherence among baseline data. But as treatment progressed responders reduced their enuresis frequency as compared to NR (week two P = 0.003, week three and onwards P < 0.001). This is further illustrated in the Figure below. Furthermore, the children unable to complete the full treatment had more non-registered nights already from the second week (week two P = 0.005, week three P = 0.002 and so on). DISCUSSION: Anamnestic data give little predictive information regarding enuresis alarm response or adherence. Contrary to common belief neither daytime incontinence nor previous alarm attempts influenced treatment success. But after 2-4 weeks of therapy the children with a good chance of treatment success could be discerned by decreasing enuresis frequency, and the families that would not be able to comply with the full treatment showed incomplete adherence already during the first weeks. CONCLUSIONS: Maybe the enuresis alarm strategy should be changed so that the treatment is reassessed after one month and only children with a high chance of success continue. This way, unnecessary frustration for the families of therapy-resistant children may be reduced.

Problems with enuresis management-A personal view.

Much has happened since the end of the era when enuresis was blamed on the parents or the children themselves. Still, there are large gaps in our knowledge and large parts of modern enuresis management guidelines are (still) not based on firm evidence. In this review I will question the following commonly made assumptions regarding enuresis evaluation and treatment: •It is important to subdivide enuresis according to the presence of daytime symptoms•Voiding charts are crucial in the primary evaluation of the enuretic child•All children with enuresis need to be screened for behavioral or psychiatric issues•Concomittant daytime incontinence needs to be successfully treated before addressing the enuresis•Concomittant constipation needs to be successfully treated before addressing the enuresis•Urotherapy is a first-line treatment against enuresis In this review I will argue that much of what we do with these children is based more on experience and well-meant but poorly supported assumptions than on evidence. Some advice and therapies are probably ineffective whereas for other treatments we lack reliable predictors of treatment response. More research is obviously needed, but awaiting new results enuresis management could be substantially simplified.

Fecal disimpaction in children with enuresis and constipation does not make them dry at night.

BACKGROUND: Constipation, daytime incontinence and nocturnal enuresis often overlap. Treatment of constipation has been shown to be an important aspect of therapy for children with daytime incontinence. However, the value of fecal disimpaction, as a part of constipation therapy, in children with enuresis has not been evaluated. AIM: Our aim was to evaluate the antienuretic effect of fecal disimpaction in children with enuresis and concomitant constipation. METHODS: The bladder and bowel function was assessed noninvasively in children aged six to ten years who sought help for enuresis for the first time. If they were constipated according to the Rome IV criteria or had a rectal diameter exceeding 30 mm, as assessed by ultrasound, they were given standard evacuation with mini-enemas and macrogol therapy for at least two weeks. Enuresis frequency was documented 14 nights preceding and following therapy. RESULTS: In total, 66 children (20 girls, 46 boys) were evaluated, 23 (35%) of whom were constipated. There were no differences in age, sex or baseline bladder function between the two groups. The enuresis frequency per two weeks was 9.8 ± 4.1 nights before and 9.3 ± 5.1 nights after constipation therapy (p = 0.43). DISCUSSION: This study found that fecal disimpaction in children with enuresis who are also constipated did not alleviate nocturnal enuresis. Bowel problems may still need to be addressed but the child should not be given the false hope that this approach alone will make them dry at night. It might be that evidenced based therapies, such as the enuresis alarm and desmopressin, could be less efficient in children with enuresis and constipation unless their bowel disturbance is first properly addressed. CONCLUSIONS: Fecal disimpaction in children with enuresis and concomitant constipation will, by itself, not make the children dry at night.

Daytime urotherapy in nocturnal enuresis: a randomised, controlled trial.

OBJECTIVE: According to international guidelines, children with enuresis are recommended urotherapy, or basic bladder advice, before treatment with evidence-based alternatives such as the enuresis alarm is given. The efficacy of this strategy has, however, not been supported by controlled studies. We wanted to test if basic bladder advice is useful in enuresis. DESIGN: Randomised, controlled trial. SETTING: Paediatric outpatient ward, regional hospital. PATIENTS: Treatment-naïve enuretic children aged ≥6 years, with no daytime incontinence. INTERVENTIONS: Three groups, each during 8 weeks: (A) basic bladder advice-that is, voiding and drinking according to a strict schedule and instructions regarding toilet posture, (B) enuresis alarm therapy and (C) no treatment (control group). MAIN OUTCOME MEASURES: Reduction in enuresis frequency during week 7-8 compared with baseline. RESULTS: The median number of wet nights out of 14 before and at the end of treatment were in group A (n=20) 12.5 and 11.5 (p=0.44), in group B (n=22) 11.0 and 3.5 (p<0.001) and in group C (n=18) 12.5 and 12.0 (p=0.55). The difference in reduction of enuresis frequency between the groups was highly significant (p=0.002), but no difference was found between basic bladder advice and controls. CONCLUSIONS: Urotherapy, or basic bladder advice, is ineffective as a first-line treatment of nocturnal enuresis. Enuretic children who are old enough to be bothered by their condition should be offered treatment with the alarm or desmopressin. TRIAL REGISTRATION NUMBER: NCT03812094.

Barriers towards HPV Vaccinations for Boys and Young Men: A Narrative Review.

BACKGROUND: HPV vaccination of both girls and boys can protect against infection and eliminate the risk for HPV-associated cancer. Due to a common misconception that the virus only poses risks to women, vaccine coverage is suboptimal among men in many countries. It is urgent to identify barriers to vaccination of boys and men. METHODS: We conducted a narrative review of publications examining attitudes and beliefs regarding HPV vaccination for boys and young men. The electronic databases searched were PubMed, PsychInfo and Scopus (December 2020; last update July 2021). A total of 103 original articles were included in the final analysis. RESULTS: The central barriers against vaccination of boys and men are: (1) lack of knowledge, (2) vaccine hesitancy in general, (3) lack of recommendation from and/or discussions with healthcare providers, (4) cost and logistics, and (5) the idea that HPV vaccination may promote promiscuity. Men who have sex with men and families belonging to ethnic minorities express a need for information tailored to their situation. CONCLUSIONS: Boys should be included in national immunization programs and men should also be offered catch-up vaccinations. Future studies should focus on addressing vaccine hesitancy and developing interventions to promote pan-gender HPV vaccination.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

Management and treatment of nocturnal enuresis-an updated standardization document from the International Children's Continence Society.

BACKGROUND: Enuresis is an extremely common condition, which, although somatically benign, poses long-term psychosocial risks if untreated. There are still many misconceptions regarding the proper management of these children. AIM: A cross-professional team of experts affiliated with the International Children's Continence Society (ICCS) undertook to update the previous guidelines for the evaluation and treatment of children with enuresis. METHODS: The document used the globally accepted ICCS terminology. Evidence-based literature served as the basis, but in areas lacking in primary evidence, expert consensus was used. Before submission, a full draft was made available to all ICCS members for additional comments. RESULTS: The enuretic child does, in the absence of certain warning signs (i.e., voiding difficulties, excessive thirst), not need blood tests, radiology or urodynamic assessment. Active therapy is recommended from the age of 6 years. The most important comorbid conditions to take into account are psychiatric disorders, constipation, urinary tract infections and snoring or sleep apneas. Constipation and daytime incontinence, if present, should be treated. In nonmonosymptomatic enuresis, it is recommended that basic advice regarding voiding and drinking habits be provided. In monosymptomatic enuresis, or if the above strategy did not make the child dry, the first-line treatment modalities are desmopressin or the enuresis alarm. If both these therapies fail alone or in combination, anticholinergic treatment is a possible next step. If the child is unresponsive to initial therapy, antidepressant treatment may be considered by the expert. Children with concomitant sleep disordered breathing may become dry if the airway obstruction is removed.

Rapid maxillary expansion in children with nocturnal enuresis: A randomized placebo-controlled trial.

OBJECTIVE: To investigate whether rapid maxillary expansion (RME) is a useful treatment method for nocturnal enuresis (NE) and whether the treatment effect is due to placebo. The study also aimed to identify prognostic variables in patients responding to treatment. MATERIALS AND METHODS: Thirty-eight children with therapy-resistant NE were recruited and randomized into two groups: the intervention group or placebo group. Both groups were treated with RME, but the placebo group received treatment with a sham appliance for 2 weeks before having the actual treatment. A medical history focused on micturition habits, previous treatment, heredity, and sleep disorders was taken. Daytime voided volumes and nocturnal urine production during wet nights were recorded before the intervention. RESULTS: Of the 38 patients recruited, two dropped out as one patient was unable to take dental impressions and one refused to have the appliance fitted. There was a statistically significant reduction of wet nights after the RME treatment (P < .001). No significant reduction was found after the placebo treatment (P < .40). Eleven patients (35%) had their enuresis frequency reduced by >50%. Large voiding volume and a wide maxilla at baseline had a strong association with positive treatment outcome. CONCLUSIONS: RME has a modest effect on children with therapy-resistant NE. The treatment outcome does not seem to be due to a placebo effect of the appliance. A wide maxillary width and large voiding volume at baseline seem to be positive predictors regarding response to treatment.

'I also want to be vaccinated!' - adolescent boys' awareness and thoughts, perceived benefits, information sources, and intention to be vaccinated against Human papillomavirus (HPV).

This study investigates boys' awareness and thoughts about human papillomavirus (HPV) and HPV vaccination, perceived benefits of vaccinating men, information sources and intention to be vaccinated against HPV. We used a qualitative approach and interviews were conducted with 31 upper secondary school male students. Two main themes 1) Promotion of equal health and 2) Increased knowledge facilitates the decision about HPV vaccination emerged from the analysis. The informants believed that it was important and fair to protect boys and girls equally against HPV. If HPV vaccination could prevent both girls and boys against an HPV-related disease, there was nothing to question or to discuss. It was not a matter of sex; it was a matter of equal rights. Moreover, an important reason for vaccinating boys was to prevent the transmission of the virus. However, the boys felt unsure and stated that they needed to know more. The school nurse and the school health were considered suitable both for distributing information and for providing the vaccinations. In conclusion, the participants were in favor of introducing HPV vaccination also for boys in the national vaccination program. Sex-neutral HPV vaccinations were viewed both as a way to stop the virus transmission and a means to promote equal health for the entire population.

Changes of arterial pressure following relief of obstruction in adults with hydronephrosis.

BACKGROUND: As much as 20% of all cases of hypertension are associated with kidney malfunctions. We have previously demonstrated in animals and in pediatric patients that hydronephrosis causes hypertension, which was attenuated by surgical relief of the ureteropelvic junction (UPJ) obstruction. This retrospective cohort study aimed to investigate: (1) the proposed link between hydronephrosis, due to UPJ obstruction, and elevated arterial pressure in adults; and (2) if elevated blood pressure in patients with hydronephrosis might be another indication for surgery. MATERIALS AND METHODS: Medical records of 212 patients undergoing surgical management of hydronephrosis, due to UPJ obstruction, between 2000 and 2016 were assessed. After excluding patients with confounding conditions and treatments, paired arterial pressures (i.e. before/after surgery) were compared in 49 patients (35 years old; 95% CI 29-39). Split renal function was evaluated by using mercaptoacetyltriglycine (MAG3) renography before surgical management of the hydronephrotic kidney. RESULTS: Systolic (-11 mmHg; 95% CI 6-15 mmHg), diastolic (-8 mmHg; 95% CI 4-11 mmHg), and mean arterial (-9 mmHg; 95% CI 6-12) pressures were significantly reduced after relief of the obstruction (p < 0.001). Split renal function of the hydronephrotic kidney was 39% (95% CI 37-41). No correlations were found between MAG3 and blood pressure level before surgery or between MAG3 and the reduction of blood pressure after surgical management of the UPJ obstruction. CONCLUSIONS: In adults with hydronephrosis, blood pressure was reduced following relief of the obstruction. Our findings suggest that elevated arterial pressure should be taken into account as an indication to surgically correct hydronephrosis.

Rapid Increase in Carriage Rates of Enterobacteriaceae Producing Extended-Spectrum ß-Lactamases in Healthy Preschool Children, Sweden.

By collecting and analyzing diapers, we identified a >6-fold increase in carriage of extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae for healthy preschool children in Sweden (p<0.0001). For 6 of the 50 participating preschools, the carriage rate was >40%. We analyzed samples from 334 children and found 56 containing >1 ESBL producer. The prevalence in the study population increased from 2.6% in 2010 to 16.8% in 2016 (p<0.0001), and for 6 of the 50 participating preschools, the carriage rate was >40%. Furthermore, 58% of the ESBL producers were multidrug resistant, and transmission of ESBL-producing and non-ESBL-producing strains was observed at several of the preschools. Toddlers appear to be major carriers of ESBL producers in Sweden.

Rectal diameter assessment in enuretic children-exploring the association between constipation and bladder function.

OBJECTIVES: Detrusor overactivity and constipation often co-exist in children with enuresis. Constipation is known to be linked to detrusor overactivity. The voiding chart is the best non-invasive way to investigate bladder function, whereas the ultrasonographical detection of rectal dilatation is the best way to objectify constipation. We wanted to investigate a possible relationship between the rectal diameter and voiding chart data in enuretic children. METHODS: Children with therapy-resistant enuresis were retrospectively evaluated. All had completed a voiding chart for at least 48 h. The rectal diameter was assessed ultrasonographically. The cutoff for rectal dilatation was set at 30 mm. RESULTS: We evaluated 74 patients (12 girls) aged 10.2 ± 2.8 years, 35 of whom had rectal dilatation. No significant differences in voiding chart parameters were found between children with normal versus dilated rectum. Neither did urgency or a history of daytime incontinence differ between the groups. Boys were more likely to have rectal dilatation than girls (p = 0.02). CONCLUSIONS: The absence of differences regarding voiding chart data may be explained as two mechanisms neutralizing each other: behavioral factors may make the constipated children void seldom and with large volumes, whereas detrusor overactivity caused by rectal compression of the bladder may have the opposite effect. Another option may be that the voiding chart is too blunt an instrument to detect detrusor overactivity. Constipation, and thus presumably bladder dysfunction, seems to be more important in enuretic boys than girls.

Changes in arterial pressure and markers of nitric oxide homeostasis and oxidative stress following surgical correction of hydronephrosis in children.

OBJECTIVE: Recent clinical studies have suggested an increased risk of elevated arterial pressure in patients with hydronephrosis. Animals with experimentally induced hydronephrosis develop hypertension, which is correlated to the degree of obstruction and increased oxidative stress. In this prospective study we investigated changes in arterial pressure, oxidative stress, and nitric oxide (NO) homeostasis following correction of hydronephrosis. METHODS: Ambulatory arterial pressure (24 h) was monitored in pediatric patients with hydronephrosis (n = 15) before and after surgical correction, and the measurements were compared with arterial pressure measurements in two control groups, i.e. healthy controls (n = 8) and operated controls (n = 8). Markers of oxidative stress and NO homeostasis were analyzed in matched urine and plasma samples. RESULTS: The preoperative mean arterial pressure was significantly higher in hydronephrotic patients [83 mmHg; 95% confidence interval (CI) 80-88 mmHg] than in healthy controls (74 mmHg; 95% CI 68-80 mmHg; p < 0.05), and surgical correction of ureteral obstruction reduced arterial pressure (76 mmHg; 95% CI 74-79 mmHg; p < 0.05). Markers of oxidative stress (i.e., 11-dehydroTXB2, PGF2α, 8-iso-PGF2α, 8,12-iso-iPF2α-VI) were significantly increased (p < 0.05) in patients with hydronephrosis compared with both control groups, and these were reduced following surgery (p < 0.05). Interestingly, there was a trend for increased NO synthase activity and signaling in hydronephrosis, which may indicate compensatory mechanism(s). CONCLUSION: This study demonstrates increased arterial pressure and oxidative stress in children with hydronephrosis compared with healthy controls, which can be restored to normal levels by surgical correction of the obstruction. Once reference data on ambulatory blood pressure in this young age group become available, we hope cut-off values can be defined for deciding whether or not to correct hydronephrosis surgically.

Standardization of pediatric uroradiological terms: a multidisciplinary European glossary.

To promote the standardization of nephro-uroradiological terms used in children, the European Society of Paediatric Radiology uroradiology taskforce wrote a detailed glossary. This work has been subsequently submitted to European experts in pediatric urology and nephrology for discussion and acceptance to improve the quality of radiological reports and communication between different clinicians involved in pediatric urology and nephrology.