[Encopresis in children, the view of child psychiatry]. / Comment j'explore... L'encoprésie chez l'enfant, le point de vue pédopsychiatrique.

The article aims to provide a state of knowledge in the literature on encopresis in the child psychiatric population. The general definition of the symptom and its analysis are presented according to different approaches. Then, the clinic of encopresis is described according to its specificities. The main associated disorders and psychiatric/psychosocial risk factors are discussed in detail. Regarding patient care, the multidisciplinary approach, including the complementarity with the paediatrician, is essential in a number of cases. Finally, family approach and the impact of trauma would be interesting research perspectives.

L'article a pour objectif de proposer un état des connaissances dans la littérature au sujet de l'encoprésie parmi la population pédopsychiatrique. La définition générale du symptôme et son analyse sont exposées selon différentes approches. Ensuite, la clinique de l'encoprésie est abordée selon ses spécificités. Les principaux troubles associés et les facteurs de risques psychiatriques/psychosociaux sont alors abordés dans le détail. Au niveau de la prise en charge du patient, l'approche multidisciplinaire, dont la complémentarité avec le pédiatre, est primordiale dans un certain nombre de cas. Enfin, l'approche familiale et l'impact des traumatismes constitueraient des perspectives de recherche intéressantes.

Functional urination or defecation disorders may be warning signs of attention-deficit/hyperactivity disorder among children in rural China.

BACKGROUND: This study was designed to investigate the prevalence of attention-deficit/hyperactivity disorder (ADHD) and its association with functional urination and defecation disorders among children in rural China. METHODS: A cross-sectional study was conducted with children aged 6-18 in rural schools in southwest China using a survey questionnaire. The Swanson, Nolan, and Pelham Questionnaire-IV (SNAP-IV) was used to measure ADHD symptoms, and standardized questions about urination and defecation were used to measure lower urinary tract symptoms (LUTS) and functional defecation disorders (FDDs). The association of ADHD with LUTS and FDDs was analyzed by matched logistic regression after propensity score matching was performed to minimize the influence of potential confounders, including demographic characteristics. RESULTS: A total of 17,279 participants were included in the analyses. The prevalence of ADHD was 2 % mainly among boys before age 12, after which it showed a decreasing trend with age, resulting in a concomitant reduction in gender differences. The risk of ADHD was positively associated with the presence of enuresis, holding maneuvers, intermittency, and encopresis, with encopresis having the strongest association (P = 0.001). The presence of holding maneuvers, intermittency, excessive volitional stool retention, and encopresis were associated with a higher risk of ADHD at 6-15 years-old, with intermittency exhibiting an increasingly positive association with ADHD risk across ages 6-15. CONCLUSIONS: ADHD was associated with LUTS and FDDs, which highlights that functional urination and/or defecation disorders could serve as warning signs for ADHD that should trigger screening, especially in relatively backward regions with little ADHD awareness.

Prevalence and sequelae of self-reported and other-reported sexual abuse in adults with intellectual disability.

BACKGROUND: Sexual victimisation is an important problem that affects millions of people around the world, especially those with some kind of disability. The aim of this study was to determine the prevalence of self-reported and documented sexual abuse in people with mild or moderate intellectual disability and to analyse the sequelae that such experiences can have on their psychosocial health. METHODS: The sample consisted of 360 adults (50% men and 50% women) between 18 and 55 years of age (M = 39.87; standard deviation = 10.55). RESULTS: The prevalence of sexual abuse is 6.10% when it is self-reported (9.4% in women and 2.8% in men) and 28.6% when it is reported by professionals (27.8% in women and 29.4% in men). People who self-report cases of abuse present poorer quality of life, more negative attitudes towards sex and a lower capacity to identify situations that entail a risk of sexual abuse. Individuals who have suffered documented cases of abuse are more likely to present encopresis, social isolation, self-harm and a higher number of suicide attempts. CONCLUSIONS: Our results evidence the need to have access to all sources of information so as to be able to obtain prevalence figures that match the real situation and to perform a proper analysis of the sequelae.

The prevalence of abnormal genital findings, vulvovaginitis, enuresis and encopresis in children who present with allegations of sexual abuse.

OBJECTIVE: To assess the prevalence of vulvovaginitis, enuresis and encopresis in children who were referred for allegations of sexual abuse. SUBJECTS: A retrospective chart review of 1280 children presenting for non-acute examination after allegations of sexual abuse during a 15-year time span. Interview documentation, physical examination documentation, urinalysis, urine and vaginal cultures were reviewed. RESULTS: Of the 1280 children, 73.3% were female and 26.7% male. The ages of the children ranged from 6 months to 18 years (median age was 6 years). Interviews revealed that fondling contact was the most common allegation, followed by oral, vaginal, and anal penetration. Interviews also disclosed lower urinary tract symptoms, UTI, constipation, encopresis and enuresis. Physical examination revealed no abnormal genital findings in 44.7% of cases. Examinations of the vagina noted: erythema (18.1%); hymenal notching (posterior 16.8%, anterior 4.4%); vuvlovaginitis (14.0%); laceration or transection (0.6%); and bruising (0.4%). Examination of the anus noted: anal fissure/tear (14.9%); loss of anal tone (10.6%); reflex anal dilatation (9.2%); venous congestion (3.8%); and proctitis (0.9%). Vulvovaginitis was noted in 14% (131/936) and encopresis in 2.3% (21/936). Enuresis according to age was reported in 13% of 5-9 year olds, 14.7% of 10-16 year olds and 18.2% of 17-18 year olds suspected of being abused. CONCLUSION: Prevalence of vulvovaginitis and enuresis were increased, and encopresis was decreased in children with allegations of sexual abuse when compared to the general pediatric population. Physicians should continue to be aware of the possibility of the presence of these conditions in children who have been sexually abused, and offer appropriate treatment.

Fecal overflow often affects children with chronic constipation that appears after the age of 2 years.

Chronic functional constipation with or without encopresis is a common problem in the pediatric population, and the prevalence of encopresis may be underestimated. The aim of this study was to assess the prevalence and risk factors for overflow incontinence in patients with chronic constipation seen at a pediatric gastroenterology consultation. A retrospective study of 270 files of patients seen between 1997 and 2012 was conducted, and a classification according to Rome III criteria was done. Among 145 (53.7%) boys and 125 (46.2%) girls, 117 had overflow incontinence (43.3%) - 41 (35%) girls and 76 (65%) boys. The first symptoms of chronic constipation appeared at a median age of 30 and 33 months in encopretic and 16 and 12 months in nonencopretic girls and boys, respectively. The first specialized consultation took place after a median disease duration of 26.5 and 24 months in encopretic and 16 and 9 months in nonencopretic girls and boys, respectively. A history of stool retention and the presence of scybala at examination, but not of pain at defecation or anal fissure, were associated with encopresis. The onset of chronic constipation after the age of 2 years, a longer disease duration, male gender, and a history of stool retention were seen as risk factors for the development of encopresis in patients with chronic functional constipation.

Resultados funcionales en pacientes con enfermedad de Hirschsprung intervenidos mediante las técnicas de Duhamel y De la Torre / Functional results of Hirschsprung’s disease patients after Duhamel and De la Torre procedures

Introducción. Los resultados funcionales a largo plazo de las distintas técnicas quirúrgicas en la Enfermedad de Hirschsprung (EH) son variables según las series. Analizamos los resultados funcionales a medio plazo en pacientes con EH intervenidos mediante las técnicas de Duhamel (D) y De la Torre (dlT).Material y métodos. Revisión de historias clínicas y encuestas telefónicas a pacientes con EH intervenidos en los últimos 16 años. Resultados. Se encontraron 38 pacientes, edad media 7,7; rango 1,5-21 años. La media de seguimiento fue de 5,9 años (mediana 5,5; rango 1-16 años). 13,2% presentaron afectación del segmento largo. Se realizaron 17 (44,7%) intervenciones de D, 16 (42,1%) de dLT, 4 (10,5%) intervenciones de Duhamel-Lester-Martin y 1 (2,6%) intervención de Soave. En la última visita o contacto telefónico, 12 (31,6%) presentaban estreñimiento y entre los pacientes ≥4 años (n=33), 11 (33,3%) referían fugas. Diez pacientes (29,4%) presentaron encopresis a lo largo del seguimiento. Los pacientes D presentaron mayores tasas de estreñimiento a los dlT (53,3% vs 20%, p=0,048). Los pacientes intervenidos mediante Duhamel presentaron menos fugas que los de de La Torre, (13,3% vs 46,1% p=0,05). Los pacientes con resecciones muy pequeñas (<10 cm) presentaron más estreñimiento (66,6% vs 17,4%, p=0,007), y menos fugas (12,5% vs 47,3% p=0,08). Todos los grupos presentaron tasas de encopresis similares. Discusión. Ambas técnicas tienen unos resultados a medio plazo similares, si bien en la técnica de Duhamel existe más tendencia al estreñimiento y en la de De la Torre existe más proporción de niños con fugas. Creemos necesario un seguimiento a largo plazo de todos los pacientes con EH (AU)

Introduction. Long term results of different surgical techniques in Hirschsprung´s Disease (HD) are contradictory. There are still no long term large or multicentric reports about functional results of De la Torre technique. We have studied the mid term functional results of the patients operated on Duhamel (D) and De la Torre (dlT) pull-through procedures. Patients and methods. We collected data from medical records and telephone interviews of the HD patients operated in our unit in the last 16 years. Results. 38 patients were found. Ages ranged from 1.5 to 21 years. Mean age was 7.7 years. Median follow up was 5.9 years. 33 (86.8%) had rectosigmoid disease and 5 (13.2%) had long segment disease. D procedure was performed in 17 (44.7%) , Soave in 1 (2.6%) , Duhamel-Lester-Martin in 4 (10.5%) and dlT pull-through in 16 (42%). In the last visit record, 12 (31.6%), had constipation, and fecal leaks were noted in 11 (33.3%) of the 33 patients ≥4 years old.. 10 patients (29.4% of the ≥4 years old group) referred encopresis along the follow-up. Patients from the D group referred higher rates of constipation than those in the dlT group (53.3% vs 20% p=0.048). dlT patients referred more frequency of leaks (46,1% vs 13,3%, p=0,05) Children with very short resections (≤10 cm) were more prone to constipation than children with longer resections (66,6% vs 17.4% p=0.007), and less prone to present leaks (12.5% vs 47.3% p=0.08). Encopresis was similar in all groups. Discussion. Both techniques show similar functional results in the mid term, although children in the D group were more prone to constipation and those in the dlT group presented more fecal leaks. All patients with EH need long follow-ups (AU)

Incidence of enuresis and encopresis among children with attention-deficit/hyperactivity disorder in a population-based birth cohort.

OBJECTIVE: This study reports the incidence of enuresis and encopresis among children with attention-deficit/hyperactivity disorder (ADHD) versus those without ADHD. METHODS: Subjects included 358 children (74.5% boys) with research-identified ADHD from a 1976 to 1982 population-based birth cohort (n = 5718) and 729 (75.2% boys) non-ADHD control subjects from the same birth cohort, matched by gender and age. All subjects were retrospectively followed from birth until a diagnosis of enuresis or encopresis was made or last follow-up before 18 years of age. The complete medical record for each subject was reviewed to obtain information on age of initial diagnosis of an elimination disorder, frequency and duration of symptoms, and identification of exclusionary criteria specified by DSM-IV, with confirmation of the diagnosis by expert consensus. RESULTS: Children with ADHD were 2.1 (95% confidence interval [CI], 1.3-3.4; P = .002) times more likely to meet DSM-IV criteria for enuresis than non-ADHD controls; they were 1.8 (95% CI, 1.2-2.7; P = .006) times more likely to do so than non-ADHD controls when less stringent criteria for a diagnosis of enuresis were employed. Though not significant, children with ADHD were 1.8 (95% CI, 0.7-4.6; P = .23) times more likely to meet criteria for encopresis than non-ADHD controls. The relative risk was 2.0 (95% CI, 1.0-4.1; P = .05) when a less stringent definition for encopresis was utilized. CONCLUSIONS: Children with ADHD are more likely than their peers without ADHD to develop enuresis with a similar trend for encopresis.

Dysfunctional elimination syndromes--how closely linked are constipation and encopresis with specific lower urinary tract conditions?

PURPOSE: It is recognized that there is a strong association between bladder and bowel dysfunction. We determined the association of constipation and/or encopresis with specific lower urinary tract conditions. MATERIALS AND METHODS: We reviewed our database of children with lower urinary tract dysfunction and divided cases into 3 categories of bowel dysfunction (constipation, encopresis and constipation plus encopresis) and 4 lower urinary tract conditions (dysfunctional voiding, idiopathic detrusor overactivity disorder, detrusor underutilization disorder and primary bladder neck dysfunction). Associations between bowel dysfunction types and each lower urinary tract condition were determined. RESULTS: Of 163 males and 205 females with a mean age of 8.5 years constipation was the most common bowel dysfunction (27%). Although encopresis is generally thought to reflect underlying constipation, only half of children with encopresis in this series had constipation. Dysfunctional voiding was associated with the highest incidence of bowel dysfunction. All but 1 patient with encopresis had associated urgency and detrusor overactivity, and the encopresis resolved in 75% of patients after initiation of anticholinergic therapy. Constipation was significantly more common in girls (27%) than in boys (11%, p <0.01), while encopresis was more common in boys (9%) than in girls (3%, p = 0.02), likely reflecting the higher incidence of dysfunctional voiding in girls and idiopathic detrusor overactivity disorder in boys. CONCLUSIONS: Active bowel dysfunction was seen in half of the children with a lower urinary tract condition. Constipation was more common in patients with dysfunctional voiding, while encopresis was significantly increased in those with idiopathic detrusor overactivity disorder and in those with dysfunctional voiding, severe urgency and detrusor overactivity. Anticholinergics, despite their constipating effect, given for treatment of detrusor overactivity resolved encopresis in most children with this bowel dysfunction.

[Functional results of Hirschsprung's disease patients after Duhamel and De la Torre procedures]. / Resultados funcionales en pacientes con enfermedad de Hirschsprung intervenidos mediante las técnicas de Duhamel y De la Torre.

INTRODUCTION: Long term results of different surgical techniques in Hirschsprung's Disease (HD) are contradictory. There are still no long term large or multicentric reports about functional results of De la Torre technique. We have studied the mid term functional results of the patients operated on Duhamel (D) and De la Torre (dlT) pull-through procedures. PATIENTS AND METHODS: We collected data from medical records and telephone interviews of the HD patients operated in our unit in the last 16 years. RESULTS: 38 patients were found. Ages ranged from 1.5 to 21 years. Mean age was 7.7 years. Median follow up was 5.9 years. 33 (86.8%) had rectosigmoid disease and 5 (13.2%) had long segment disease. D procedure was performed in 17 (44.7%), Soave in 1 (2.6%), Duhamel-Lester-Martin in 4 (10.5%) and dlT pull-through in 16(42%). In the last visit record, 12 (31.6%), had constipation, and fecal leaks were noted in 11 (33.3%) of the 33 patients > or = 4 years old.. 10 patients (29.4% of the > or = 4 years old group) referred encopresis along the follow-up. Patients from the D group referred higher rates of constipation than those in the dlT group (53.3% vs 20% p=0.048). dlT patients referred more frequency of leaks (46,1% vs 13,3%, p=0,05) Children with very short resections (< or = 10 cm) were more prone to constipation than children with longer resections (66,6% vs 17.4% p=0.007), and less prone to present leaks (12.5% vs 47.3% p=0.08). Encopresis was similar in all groups. DISCUSSION: Both techniques show similar functional results in the mid term, although children in the D group were more prone to constipation and those in the dlT group presented more fecal leaks. All patients with EH need long follow-ups.

Encopresis in children. Outcome and predictive factors of successful management.

OBJECTIVE: To elucidate our experience and outcome in the management of childhood encopresis, and to emphasize the factors that may predict successful management. METHODS: This prospective study was carried out between September 2003 and September 2011 in the Department of Pediatric Surgery, Al-Thoura Teaching Hospital, Al-Beida and Al-Butnan Medical Teaching Center, Tobruk, Libya. RESULTS: One hundred and thirty-two patients (117 male, 15 female) took part of the study. The male and female ratio was 7.8:1. The participants were patients aged 4-9 years. There were 30 (22.7%) patients between 4-5 years, 61 (46.2%) between 6-7 years, and 41 (31%) between 8-9 years. Nonretentive encopresis patients were 36 (27.2%) (Group I) and 96 (72.8%) patients had retentive encopresis (Group II). Patients with low fluid intake were 87 (65.9%) and low fiber diet were 91 (68.9%). Patients with delayed toilet training were 99 (75%). The total rate of successful conservative treatment was 70.5%. The rate of successful treatment in Group I was 94.4% and in Group II was 61.5%. We observed 18.2% of the patients had recurrence of encopresis. The factors found to predict good resolution rate after medical treatment included: cooperation of the parent and patient, female gender, ages above 5 years, and non-retentive encopresis. CONCLUSION: Encopresis remains a problem for the parents and the patients. Clinical evaluation is indispensable. Good outcome can be achieved effectively. Cooperative parents and patient, female gender, age above 5 years, and nonretentive encopresis are predictors for good response to medical treatment.

Encopresis: un problema que se oculta / Encopresis: a hidden problem

La encopresis es un problema común en la infancia que se presenta en escenarios pediátricos, psiquiátricos y psicológicos y tiene un impacto significativo en el funcionamiento social y emocional del niño y en su familia.

Early childhood risk factors associated with daytime wetting and soiling in school-age children.

OBJECTIVE: To examine the impact of a range of early childhood factors on the risk for daytime wetting and soiling. METHODS: This is a longitudinal study based on a UK population of over 10,000 children from age 4 to 9 years. Parents completed questionnaires on child development (at 18 months); child temperament (24 months); maternal depression/anxiety (21 months), and parenting behaviors (24 months). The analysis examined whether these risk factors distinguish between children with normal development of daytime bladder and bowel control and those with delayed acquisition of daytime continence; persistent daytime wetting/soiling, and relapse in wetting/soiling. RESULTS: Delayed development, difficult temperament, and maternal depression/anxiety were associated with an increase in the odds of experiencing problems with bladder and bowel control. CONCLUSIONS: The current findings provide evidence that risk factors in early childhood are associated with a subsequent increase in the odds of children experiencing daytime wetting and soiling at school age.

[Encopresis]. / Enkopresis.

Encopresis is defined as functional faecal incontinence at 4 years of age or older and affects 1-3% of all school children. The two most important subtypes are encopresis with and without constipation. In preschoolers toilet refusal syndrome can occur. Comorbid behavioural disorders and urinary incontinence are common. The current state-of-the-art regarding aetiology, assessment and therapy is presented in this overview. A symptom-oriented behavioural approach (toilet training) is most successful, with the addition of laxatives (polyethylene glycol) if constipation is present. Biofeedback is not effective. Other forms of psychotherapy are indicated only in case of comorbid behavioural disorders. The long-term outcome has been poor and needs improvement.

A United Kingdom population-based study of intellectual capacities in children with and without soiling, daytime wetting, and bed-wetting.

OBJECTIVE: The objective of this study was to examine differences in intellectual capacities between children with and without soiling, daytime wetting, and bed-wetting. METHODS: This study was based on a population of >6000 children (age range: 7 years 6 months to 9 years 3 months; median: 7 years 6 months) from the United Kingdom-based Avon Longitudinal Study of Parents and Children. Data on wetting and soiling were obtained from a questionnaire completed by parents. The Wechsler Intelligence Scale for Children-Third Edition was administered at a research clinic. RESULTS: Bed-wetting was associated with lower Wechsler Intelligence Scale for Children-Third Edition IQ scores compared with control subjects, particularly performance IQ. This difference remained after exclusion of children with an IQ of <70 and adjustment for gender, stressful life events, and sociodemographic background. There were fewer differences in IQ scores between children with and without soiling or daytime wetting. Co-occurring wetting and soiling were associated with lower IQ scores than isolated soiling, daytime wetting, or bed-wetting, but this was mostly attributable to an overrepresentation of children with an IQ of <70 in the co-occurrence group. CONCLUSIONS: It is hypothesized that the differences in intellectual capacities between children with and without bed-wetting are associated with maturational deficits of the central nervous system. There was less evidence for differences in intellectual capacities between children with and without soiling and daytime wetting. The central nervous system is involved to a lesser extent in soiling and daytime wetting, because peripheral influences from the bladder and gut play a greater role.

The relevance of fecal soiling as an indicator of child sexual abuse: a preliminary analysis.

Encopresis is typically characterized as resulting from chronic constipation with overflow soiling but has been portrayed as an indicator of sexual abuse. The predictive utility of fecal soiling as an indicator of sexual abuse status was examined. In a retrospective analysis of three comparison groups of 4-12 year olds, we studied 466 children documented and treated for sexual abuse; 429 psychiatrically referred children with externalizing problems and 641 normative children recruited from the community, with the latter two samples having abuse ruled out. Standardized parent report measures identified soiling status and sexual acting out behaviors. Multiple regression analysis was used to predict abuse status in each group. Reported soiling rates were 10.3% (abuse), 10.5% (psychiatric), and 2% (normative), respectively. The soiling rate in the abused group differed significantly from that of the normative group, but not from the psychiatric group. Similar rates of soiling were reported among abused children, with and without penetration, and the psychiatric sample. Rates of sexualized behavior were reported significantly more often by the abused group versus both the psychiatric and normative groups and were a better predictor of abuse status. The positive predictive value of soiling as an indicator of abuse was 45% versus 63% for sexual acting out. The psychiatric sample displayed significantly more dysregulated behavior than the sexually abused sample. The predictive utility of fecal soiling as an indicator of sexual abuse in children is not supported. Soiling seems to represent one of many stress-induced dysregulated behaviors. Clinicians should assume the symptom of soiling is most likely related to the typical pathology and treat accordingly.

[Functional constipation: prospective study and treatment response]. / Estreñimiento funcional: estudio prospectivo y respuesta al tratamiento.

OBJECTIVE: To assess the prevalence of functional constipation (FC) with and without encopresis, the factors involved in its onset, and treatment response. PATIENTS AND METHODS: A prospective study of 62 children was performed using a standard questionnaire (onset-age, regular toilet use, encopresis, complications, dietary habits and environmental and psychological factors) and physical and anthropometric assessment. FC was defined as a stool frequency of less than 3 bowel movements/week, with passage of large or scybalous stools, with or without 2 or more soiling episodes per week, without underlying disease. Treatment included demystification, behavioral modification and drugs (mineral oil and senna). Each child was periodically re-evaluated, and treatment was considered successful when the defecation rate was 3 or more bowel movements/week, discomfort was absent, and fecal soiling frequency was 2 or fewer episodes/ month. RESULTS AND CONCLUSIONS: FC accounted for 13 % of all first consultations (60 % boys, 40 % girls; mean age at diagnosis 6.1 years). The most frequent manifestations were painful defecation (60 %), rectorrhagia (42 %), obstructive episodes (34 %) and anal fissure or hemorrhoids (17 %); 19 patients (31 %) had encopresis. Nutritional assessment revealed that 84 % of the patients was well nourished and 16 % was overweight. Fiber intake was deficient in more than 60 %. Sixteen (26 %) patients underwent successful relief of impaction with senna (20-30 mg/dose) combined with mineral oil. Maintenance treatment included mineral oil (15-30 ml/day) and senna at the minimum effective dose (5-15 mg/day). Satisfactory results were achieved 1 month later in 32 % of the children, 3-6 months later in 71 %, and 6-12 months later in 85 %; successful response was closely related to regular toilet habits, dietary modification and a shift in the family's attitude.

[Encopresis--predictive factors and outcome]. / Enkopresis--Prognosefaktoren und Langzeitverlauf.

OBJECTIVES: comparison of diagnostic, clinical and therapeutic features and their predictive value for the outcome of encopresis in children and adolescents. METHODS: 85 children and adolescents (aged 9.6 +/- 3.2 years) with severe encopresis (ICD 10: F98.1) were investigated during inpatient treatment and 35 of them again 5.5 +/- 1.8 years later. Mentally retarded patients were excluded. Inpatient therapy consisted of treating constipation and/or stool regulation by means of laxatives, behavioural approaches, and the specific therapy of comorbid psychiatric disorders. RESULTS: During inpatient treatment 22% of the patients experienced total remission, 8% an unchanged persistence of symptoms. Of the 35 patients studied at follow-up 5.5 years later, 40% were symptom-free. As main result, prognostic outcome depended significantly on sufficient treatment of obstipation. Another important factor was the specific therapeutic approach to psychiatric comorbidity, especially to ADHD. The outcome for patients with comorbid ICD 10: F43 was significantly better than for the other patients. Those who were symptom-free at discharge had significantly better long-term outcomes. CONCLUSIONS: Decisive to the success of encopresis treatment were the stool regulation and the specific therapy of associated psychiatric illnesses, in particular of ADHD. Inpatient treatment revealed significantly better long-term outcomes where total remission had been achieved by the time of discharge from hospital.