[ ISSN : 2573-3680 ]
Micturating cystourethrogram; Urinary tract infection; Vesicoureteric reflux; Posterior urethral valves
Although the micturating cystourethrogram is included in the radiological evaluation of Jamaican children with urinary tract infections, there has never been a formal local study evaluating abnormal findings from this investigation. The aim of this paper is to document in a cohort of Jamaican children < age 12 years with urinary tract infections, the pattern of urological pathology identified by the micturating cystourethrogram. Radiological reports of micturating cystourethrogram findings in children with urinary tract infection investigated at the Bustamante Hospital for Children between October 2008 and January 2012 were identified and information on age, sex, and urological pathology recorded. Of the 523 children undergoing micturating cystourethrography, 458 fulfilled inclusion criteria. Males outnumbered females both in number (male: female 2.5:1) and in the frequency of abnormalities (13% of males and 7% of females). MCUG were abnormal in 54 children (11.8%). The commonest pathologies were vesicoureteric reflux (29%) followed by bladder /urethral abnormalities (28%). Posterior urethral valves were identified in 4 patients (1.2% of all males). In this study of a predominantly black population of children, the frequency of abnormal MCUG was less than in international studies, primarily due to the low frequency of VUR. However, the incidence of posterior urethral valves and bladder abnormalities is similar. As posterior urethral valves remain a major cause of chronic renal failure in Jamaican children, the micturating cystourethrogram is an important investigation. Financial constraints mandate local clinical research to establish more selective criteria for micturating cystourethrography.
Urinary tract infections are one of the most common infections in childhood, with international prevalence documented to be between 2.9-11.6% in infants less than 24 months [1-3] and between 6.4-9% in children less than 19 years [4,5]. The investigation of UTI involves the use of KUB ultrasound, MCUG and renal scan.
The main reason for investigation of UTI is to ensure early identification of urological pathology, which, if left untreated, may lead to ESRD [6-9]. Internationally in developed countries, CAKUT and hereditary nephropathies account up to 66% of all cases of CKD [6]. The situation is similar in Jamaica where CAKUT accounts for 41-44% of cases of CRF [7,8]. Posterior urethral valves are the most common cause of obstructive uropathy in Jamaica, accounting for 27% of all cases of CRF [8]. Children with VUR are significantly more likely to develop pyelonephritis and renal scarring compared with children with no VUR and those with VUR grades III or higher are more likely to develop scarring than children with lower grades of reflux [9].
In recent years, there have been changes in the investigation of urinary tract infection worldwide, with a trend towards less aggressive investigation internationally [10,11]. Local guidelines recommend that all first UTIs be investigated, with the choice of investigation depending on age. For children 5years old, a KUB ultrasound is done with MCUG investigation in all male children and in females with an abnormal ultrasound or examination or history suspicious of a voiding disorder.
The indications for renal scan are as for the younger child [12]. In Jamaica, antenatal ultrasounds are not performed routinely and in some cases locally, infants with normal fetal ultrasounds have been shown to have abnormalities on investigation of UTI post delivery. The American Academy of Pediatrics 2011 guidelines recommend that KUB ultrasonography be performed on all children between the ages of 2-24 months with first UTI, and MCUG reserved for those in whom the KUB ultrasound is abnormal or UTI recurs [10]. The National Institute for Health and Clinical Excellence (NICE) British guidelines recommend the MCUG in infants On the other hand, there are numerous studies which challenge this worldwide conservative trend and document that the omission of this study will result in significant missed diagnoses [13-15].
Analysis of CRF data in Jamaican children reveals that since the first application of the local UTI investigative guidelines in 1985, all cases of obstructive uropathy in the years 2001-2006 were diagnosed before age 5 years [8] as opposed to 43% in the years 1984-2000 [7]. Additionally CRF secondary to PUJ obstruction is no longer seen and posterior urethral valves are virtually now the only obstructive urological pathology causing CRF [8]. It is against this background that the local protocol [12] including the use of MCUG has been maintained.
The incidence of VUR in Caucasian populations with UTI ranges from 22% in Italy [16] to 41% in USA [14]. In USA it is reported that VUR is less common in black than Caucasian populations [17]. West, et al. documented VUR in 10% of Jamaican children in whom MCUG was performed for various reasons including UTI [18].
There is however, no literature on urological abnormalities in Jamaican children specifically investigated for only UTI. This study documents the frequency and types of urological pathology found on MCUG evaluation of a cohort of Jamaican children investigated for UTI. The information so obtained will add to the body of knowledge on local uropathology, and contribute objective data which may be useful in determining future local investigative protocols for childhood UTI.
This was a retrospective study documenting the yield of MCUG following investigation for UTI. Patients were identified from the electronic radiological records of the Bustamante Hospital for Children-the only stand-alone children’s hospital in the English speaking Caribbean. This hospital serves the Kingston and St Andrew areas of Jamaica, and receives referrals from other parishes island wide. It was selected as the setting because it was the only public hospital that offered MCUG services to children at minimal or no cost during the study period, thus providing a large cohort of patients for investigation. Bustamante Hospital for Children is a solely paediatric hospital with no antenatal unit so antenatal ultrasonography is not performed here.
All MCUG’s reported between October 2008 and January 2012 were evaluated. Only those in which the indication for study was UTI were included. The UTI diagnosis was based solely on the electronic radiology records and not by bacteriological conformation from a medical records search. Information recorded included: date of study, date of birth, age, sex and urological pathology. The pathology was divided into the following major categories: VUR, PUV, anterior urethral valves, bladder abnormalities, urethral abnormalities, and other findings. VUR was further subdivided into Grades 1-5 according to the International Classification [19]. Bladder abnormalities were sub-grouped into: diverticulum, trabeculation, ureterocoele, spinning top bladder, elongated bladder and dilated bladder base. Urethral abnormalities were sub-classified as: diverticulum dilated proximal urethra and filling defects. If VUR was bilateral, the highest grade was used and recorded as a solitary entity / patient). Only primary VUR was evaluated. A single radiologist reported on all MCUG. Pathology was analyzed independently as a function of age in twoyear categories up to age <12 years.
As this was a purely radiological study there was no verification by chart review that the MCUG analyzed was in fact the MCUG for the first UTI, however it is likely that this would have been the case since only the first MCUG on record was evaluated and MCUG performed for previously documented abnormalities excluded.
The inclusion criteria were the first recorded MCUG in patients of the Bustamante Hospital for Children who were under the age of 12 years at the time of investigation, had no co morbidities, and in whom the MCUG was performed only for UTI investigation and not for evaluation of known structural urological abnormalities or recurrent UTI. Patients whose age and sex were unrecorded on the radiological request were excluded. If any child had more than one MCUG report, only the first was evaluated.
SPSS version 20 was used for statistical analysis. Ethical approval was obtained from the University Hospital of the West Indies / University of the West Indies Ethics Committee and the Ethics Committee of the South East Regional Health Authority.
523 MCUG reports were identified between October 2008 and January 2012. After the exclusion criteria were applied, (Figure 1) the remaining 458 reports were recorded and analyzed.
Figure 1: Patient selection process
Age and Sex Distribution of Total Cohort (Figure 2)
Of 458 who had MCUG for investigation of UTI 326 (71%) were males and 132 (29%) were female. Sixty-four percent (294) of the patients were less than 2 years old. Of this group 121 (40%) were age <6 months. There was a male predominance in most age groups. The median age was 16.4 months and the interquartile range was 9.3-34.6 months (Figure 2).
Figure 2: Age and sex distribution of 458 children undergoing MCUG for UTI.
Age and Sex Distribution of Children with Abnormal MCUG
Pathology was identified in 54 children (11.8% of the total). The majority (81.5%) were males. Some patients had more than one abnormality. Children < age 2 years were the largest group (64%) and of these, 47% were infants 6-12 months old. Males were twice more likely to have an abnormal MCUG (44/326-13%) than females (10/132 or 7%).
Figure 3: Age and sex distribution of children with abnormal MCUG.
Urological Abnormalities (Figure 4), (Table 1)
Table 1: Age related urological abnormalities.
Figure 4: Gender distribution of urological abnormalities on MCUG.
Our study is limited by the fact that it was purely a radiological one. As the diagnosis of UTI was made from the radiology records and not verified with microbiological data, we cannot guarantee that all the children sent for MCUG had a truly bacteriologically confirmed UTI. Additionally, the frequency of VUR was documented as an occurrence per patient not in terms of renal units so by other classifications this may have understated the frequency of VUR. Although by our selection process, the UTI investigation is likely to have been the first, this was not validated by a medical records search.
Within our cohort of 458 patients there was a predominance of male children (71%) and children < age 2 years (65%). This was to be expected as studies have shown that UTI is 2-3 times more common in males than females < 3 months old [20,21] and also more frequent in children under age 2 years [4,20]. As the local guidelines for females > 5 years recommend routine MCUG with first UTI only in those with an abnormal KUB ultrasound or suspicious clinical findings, [12] it is not unexpected to find few children between the ages of 6-12 years represented in this cohort.
In the present study the yield of pathology from MCUG following UTI was 11%. This is less than the international experience in which rates of detection vary from 60% in Iran [22], to 38-41% in the USA [14,23], 34% in England [24], 27% in Finland [25] and 22% in Italy [16].
The difference in yield is due mainly to frequency of VUR within given populations. Internationally VUR is responsible for 65-100% of abnormal MCUG and is reported in 22-41% of patients investigated for UTI [14,22]. The incidence of VUR is lower in Italy 22% [16] and Finland 27% [25] but higher in USA 41% [14] and Iran 39% [22]. This is in stark contrast to our local study in which VUR, although being the commonest pathology, accounted for only 36% of abnormal MCUG’s and 4% of patients investigated for UTI. VUR is reportedly infrequent in black races [18,26]. Within black populations there is also variation in the frequency of VUR from a high of 13% in black populations in the USA [17] to a low of 0% in Nigerian children [26]. Although Jamaica is multiracial, the population in general [27] and the children attending the study hospital (the Bustamante Hospital for Children) in particular, are predominantly black so a lower incidence of VUR was expected. However, there are racial minorities that contribute to the Jamaican population as a whole, and data regarding VUR and other urological abnormalities may be different in Caucasian mixed race children who are more likely to have had their MCUG done privately.
Although a firm diagnosis of PUV was made only in four boys, (0.7% of all males studied) the potential exists that more cases may have been subsequently diagnosed following clinical correlation of suspicious urethral findings on MCUG. The relative infrequency of PUV detection appears to be international: 0.2% in Finland [25] and USA [14] and 3% in England [24].
The frequency of non VUR urological pathology (most commonly dilated proximal urethra and bladder trabeculation) in our series (7%) falls in between that of USA (2.2%) [14] and Iran 39% [22]. The second comparable pathological group was a subcategory classified by Hannula et al. as “bladder abnormalities” [25] which include bladder wall trabeculation, diverticulum, marked residual urine and widened posterior urethra. The frequency with which these bladder abnormalities were detected was similar locally (4%) to Finland (5%) [25], but was greater than in USA (2%) [14]. Bladder abnormalities accounted for 36% of the total abnormalities in the present study but only 12 % and 4% in the Finnish [25] and American (14) studies respectively.
Local guidelines (12) include the MCUG in the investigation of first UTI in all children < 5 years old, all males, and children > 5 years with abnormal renal ultrasound, renal scan, recurrent UTI or symptoms suggestive of voiding disorders. Since the 1985 introduction of this protocol congenital abnormalities have been diagnosed earlier and obstructive urological disease causing CRF is virtually limited to posterior urethral valves [8]. Overall, PUV remains an important cause of CRF in Jamaican children (26-28%) [7,8] and MCUG is the gold standard of diagnosing this pathology. Antenatal ultrasonography is not routine in Jamaica, and is not always accurate in diagnosing lower tract anomalies in our population.
Current guidelines by the AAP [10] and Britain (NICE guidelines) [11] recommend that the MCUG be excluded from investigation of first UTI because of the perceived ineffectiveness of antibiotic prophylaxis in the management of VUR – the primary reason for performing the MCUG in those countries. The RIVUR trial [28] found prophylaxis to significantly reduce the risk of febrile UTI in children with VUR and recommended re-evaluation of the AAP guidelines. In Jamaica the problem is not VUR but PUV which can only be conclusively diagnosed with the MCUG, making a case for the continued use of the MCUG.
In this predominantly black cohort of children, VUR occurs infrequently. However, the use of MCUG in the detection of lower tract abnormalities is undeniably important as the percentage of PUV and other urethral abnormalities found following UTI is similar to that seen internationally. In a resource poor country such as ours the low overall yield of MCUG documented in this study mandates further local research to identify clinical and laboratory features which select children at greater risk of having underlying urological pathology and make our local guidelines for MCUG use more cost effective.
We wish to acknowledge the following individuals who assisted in the preparation of this paper: Dr. M. Antoine, Dr. O. Olugbuyi, Dr. H. Trotman-Edwards, Dr. J. Mullings and the Medical Records Department of the Bustamante Hospital for Children.
Gomes N, Miller M and Lawrence M. Micturating Cystourethrogram Findings in Children with Urinary Tract Infections: A Five Year Review. SM J Clin Med. 2016; 2(2): 1017.
The purpose of this statement is none other than to highlight the importance of ethical standards and quality required in basic and applied research currently being done so we can subsequently inform health care professionals of new developments that are taking place in this area.
Ma. Esperanza Rodríguez-van Lier*
Chemotherapy is commonly used in cancer treatment. So far, chemotherapy agents can be categorized into three types: classical chemotherapeutic drugs, molecular target agents and cellular machineries target drugs.
Ziyou Wang1,2 and Zunnan Huang1,2*
Blood transfusion can cause some transfusion adverse reactions. In order to understand the incidence of adverse transfusion reactions, we performed a meta-analysis in Chinese hospitals. Of 809 literatures, seven studies involving a total of 211, 050 patients with blood transfusion treatment were included in this meta-analysis. Meta-analysis showed that the total incidence of adverse reactions was 0.4% [95% CI (0.2, 0.9), P < 0.0001]. Further subgroup analysis showed that the incidence of febrile and allergic reactions was 0.2% [95% CI (0.1, 0.5), P < 0.0001] and 0.2% [95% CI (0.1, 0.3), P < 0.0001], respectively. The common blood components caused adverse reactions were red blood cell, plasama, and platelet in clinical practice.
Yulu Gao1 , Qinyun Li2 , Zongshuai Gao2 , Yunxia Zhu4 , Yanqiu Liao5 , Changtai Zhu2 *# , Yongning Sun3 *#
Background: CT scanning remains one of the most routinely used diagnostic tools in a setting of Interstitial Lung Disease (ILD). New and improved technologies, such as High Resolution Computer Tomography (HRCT) have revolutionized the quality of imaging, leading to a prominent increase in number of incidental findings that may or may not be of any clinical significance. The aim of this study was to evaluate the prevalence of incidental findings on thoracic CT and their clinical significance.
Methods: Retrospective analysis was conducted on a cohort of 84 patients referred to our academic center as cases of ILD. Patients were referred for further evaluation between January 2000 and January 2014 and were followed over the disease course. CT scans were done annually as part of clinical management and patients were screened for any incidental findings. All incidental findings were reviewed, recorded in a clinical database and followed up on subsequent visits.
Results: 25 (30%) patients were found to have incidental findings. Liver abnormalities were found in 12 (14.29 %) patients. 11(13.10 %) patients were reported to have coronary artery calcifications. 5 (5.95 %) and 3 (3.57%) patients had thyroid abnormalities and renal cysts, respectively. A malignant lesion was found in 1 patient each in liver and thyroid abnormality subgroup.
Conclusion: Incidental findings are common on thoracic CT scans providing valuable and unexpected findings which warrant investigation by health care providers to exclude malignant processes.
Sonu Sahni1,2*, Sameer Verma1,2, Reeju S Thomas1 , Barbara Capozzi3 and Arunabh Talwar1,2
Hepatitis C Virus infection (HCV) is an increasing public health concern with an estimated 184 million people infected worldwide and approximately 350.000 yearly deaths from HCV-related complications.
Nesrine Gamal and Pietro Andreone*
We report a case of large cell undifferentiated lung carcinoma in a middle aged patient with previously treated tuberculosis and scarring. 20 pack years of smoking history was noted. He presented with metastasis at multiple sites including trochanter, liver and acute bilateral lateral rectus palsy. Chest radiography showed fibrosis of right upper zone with homogenous opacity. Sputum examination for AFB was negative. Computerized tomography of the thorax showed an irregular heterogeneously enhancing mass involving right upper lobe with cavitation, necrosis along with lymph node involvement and the erosion of the 4th rib with liver metastasis. Radiography of hip joint was suggestive of lesser trochanteric metastasis. MRI brain was suggestive of mass at base of brain in parasellar area. Fine needle aspiration cytology and CT guided biopsy confirmed undifferentiated large cell carcinoma of lung. Tuberculosis and smoking may increase the risk of lung scarring and malignancy and pulmonary scarring may be associated with increased lung carcinoma in ipsilateral lung. Clinician needs to be more sensitive to look for malignancy association particularly in patient with or previously treated for tuberculosis and even more emphasis to be laid if scarring of lung is observed.
Sreenivasa Rao Sudulagunta1 *, Shyamala Krishnaswamy Kothandapani2 , Mahesh Babu Sodalagunta3 , Hadi Khorram2 , Mona Sepehrar4 and Zahra Noroozpour1
Systemic Sclerosis (SSc) is a connective tissue disease characterized by fibrosis of the skin and internal organs, pronounced alterations in the microvasculature and frequent cellular and humoral immunity abnormalities. The rheumatic involvement of SSc is polymorphic and can reveal the disease or may appear during the course of its progression. Musculoskeletal involvement is dominated by non specific arthralgia, polyarthritis, and bony resorption especially acro-osteolysis. The diagnosis of these rheumatic manifestations is generally based on x rays examination. Musculoskeletal involvement in SSc is generally relieved with Non Steroidal Anti-Inflammatory Drugs (NSAID) or low dose of corticotherapy. The immunosuppressive therapy is used in corticoid-resistant or corticoid-dependent forms such us méthotrexate. The aim of our review is to presents an overview of the different osteoarticular and muscular involvement in SSc, their diagnosis and management.
Nessrine Akasbi*, Fatima Ezzahra Abourazzak and Taoufik Harzy
Sedigheh Mirhashemi1 , Mohammad Hosein Kalantar Motamedi1 *, Amir Hossein Mirhashemi2 and Hamid Reza Rasouli1
We encountered two autopsy cases of huge cardiomegaly with over 1000g in weight. Histochemical characteristics were examined using conventional staining including HE and Azan stains and immunohistochemical staining using antibodies against Complement Component 9 (CC9), RNA Binding Protein Motif 3(RBM3), Endothelial Type NO Synthase (eNOS) and Hypoxic Inducible Factor1α (HIF1). The reactive area with anti CC9 antibody, which presumed to be a marker of hypoxic change of myocardium, overlapped with eosinophilic area by HE and basophilic one by Azan. Although the reactive area with anti CC9 antibody showed relatively weak in the cytoplasm by anti eNOS antibody and no in the nucleus of cardiocytes with anti RBM3 antibody, outside of the reactive area with anti CC9 antibody there were intensive reactivity with anti eNOS antibody in cytoplasm and in a nucleus with anti RBM3 antibody. Anti HIF1 antibody showed weak reactivity with cytoplasm of endocardial cardiocytes and no with cytoplasm of cardiocytes in another area. The results obtained from the present cases revealed that the hypoxic change was equivalent even though the cause of cardiomegaly was deferred between two cases, and conventional staining such as HE and Azan utilized to detect hypoxic change in the heart and immunohistochemical studies seemed to be a useful tool for clarifying the cascade of hypoxic changes in the myocardium.
Satoshi Furukawa1,2*, Mayumi Kataoka1 , Satomu Morita1,2, Akari Uno2 , Masahito Hitosugi2 , Hiroshi Matsumoto1,3 and Katsuji Nishi1,2
A 45-year-old woman with multiple sclerosis was admitted to our hospital after out of hospital cardio-pulmonary resuscitation. The first ECG showed ventricular fibrillation. Following direct current defibrillation and mechanical reanimation, spontaneous circulation was restored and the ECG unremarkable without any signs of ischemia. Coronary angiography showed unobstructed coronary arteries Figure 1, (Panel A). Left ventriculography revealed apical wall obstruction, suggestive of apical aneurysm (Panel B, supplementary videos). Transthoracic echocardiography and Cardiac Magnetic Resonance Imaging (CMR) eventually lead to the diagnosis of a rare case of Apical Hypertrophic Cardiomyopathy (AHC) with ace of spades-form (Panel C,D). The patient underwent Cardioverter-Defibrillator Implantation (ICD) and amiodarone medical therapy for secondary prophylaxis. Patient’s family history and screening for HCM were unsuspicious.
Wiedemann S# *, Heidrich FM# , Speiser U and Strasser RH