Diffusion-weighted magnetic resonance imaging is more sensitive than dimercaptosuccinic acid scintigraphy in detecting parenchymal lesions in children with acute pyelonephritis: A prospective study

Introduction Static renal scintigraphy is the gold standard for detection of inflammatory changes in the renal parenchyma in acute pyelonephritis. Our aim was to determine whether diffusion-weighted magnetic resonance imaging (DW-MRI) was comparable with static renal scintigraphy (DMSA-SRS) to demonstrate acute renal parenchymal lesions. Objective To compare Tc-99m-dimercaptosuccinic acid static renal scintigraphy (DMSA-SRS) with diffusion-weighted magnetic resonance imaging (DW-MRI) for detecting acute inflammatory changes in the renal parenchyma in children with febrile urinary tract infection. Methods Thirty-one children (30 girls) aged 3-18 years with a first episode of febrile UTI without a previously detected congenital malformation of the urinary tract, were prospectively included. DMSA-SRS and DW-MRI were performed within 5 days of diagnosis to detect renal inflammatory lesions. The DW-MRI examination was performed without contrast agent and without general anesthesia. Late examinations were performed after 6 months using both methods to detect late lesions. Results DW-MRI confirmed acute inflammatory changes of the renal parenchyma in all 31 patients (100%), mostly unilateral. DMSA-SRS detected inflammatory lesions in 22 children (71%; p = 0.002). The lesions were multiple in 26/31 children (84%) on DW-MRI and in 9/22 (40%) on DMSA-SRS. At the control examination, scarring of the renal parenchyma was found equally by DW-MRI and DMSA-SRS in five patients (16%), three of whom were the same patients. The overall concordance of positive and negative late findings occurred in 87% of patients. There was correspondence in the anatomical location of acute and late lesions. Discussion The clinical significance of acute and late parenchymal findings on DWI-MR is yet to be determined. A limitation of our study is the age of the patients (older than 3 years) who are less sensitive to scar development; therefore, a smaller number of patients with scars could be analyzed during control examination. Further studies using the DW-MRI should confirm its reliability to detect acute and late lesions in younger children and infants and determine the clinical consequences. Conclusion DW-MRI has higher sensitivity for detecting acute renal inflammatory lesions and multifocal lesions than DMSA-SRS. The incidence of scars was low and corresponded with the anatomical location of acute and late lesions.Web of Science143art. no. 269.e

Urinary tract infections in children: EAU/ESPU guidelines

Context: In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract. Objective: To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI. Evidence acquisition: The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low. Evidence synthesis: UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded. Conclusions: The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage. Patient summary: In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24 h and later vesicoureteral reflux, if indicated. (C) 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved

EAU guidelines on vesicoureteral reflux in children

Context: Primary vesicoureteral reflux (VUR) is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal of treatment, which necessitates identification of patients requiring early intervention. Objective: To present a management approach for VUR based on early risk assessment. Evidence acquisition: A literature search was performed and the data reviewed. From selected papers, data were extracted and analyzed with a focus on risk stratification. The authors recognize that there are limited high-level data on which to base unequivocal recommendations, necessitating a revisiting of this topic in the years to come. Evidence synthesis: There is no consensus on the optimal management of VUR or on its diagnostic procedures, treatment options, or most effective timing of treatment. By defining risk factors (family history, gender, laterality, age at presentation, presenting symptoms, VUR grade, duplication, and other voiding dysfunctions), early stratification should allow identification of patients at high potential risk of renal scarring and urinary tract infections (UTIs). Imaging is the basis for diagnosis and further management. Standard imaging tests comprise renal and bladder ultrasonography, voiding cystourethrography, and nuclear renal scanning. There is a well-documented link with lower urinary tract dysfunction (LUTD); patients with LUTD and febrile UTI are likely to present with VUR. Diagnosis can be confirmed through a video urodynamic study combined with a urodynamic investigation. Early screening of the siblings and offspring of reflux patients seems indicated. Conservative therapy includes watchful waiting, intermittent or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with LUTD. The goal of the conservative approach is prevention of febrile UTI, since VUR will not damage the kidney when it is free of infection. Interventional therapies include injection of bulking agents and ureteral reimplantation. Reimplantation can be performed using a number of different surgical approaches, with a recent focus on minimally invasive techniques. Conclusions: While it is important to avoid overtreatment, finding a balance between cases with clinically insignificant VUR and cases that require immediate intervention should be the guiding principle in the management of children presenting with VUR. (C) 2012 European Association of Urology. Published by Elsevier B. V. All rights reserved

Limity ochrany biodiverzity ve fragmentované krajině

Cílem řešení projektu je ve vybraném pilotním území definovat závislost vývoje lokálních populací zvláště chráněných a nebo vzácných a nebo ohrožených druhů na strukturálních charakteristikách krajiny a na velikosti a tvaru fragmentovaných lesních celků. Předmětem výzkumu je populační dynamika invazních a expanzních rostlin. Základním přístupem je stanovení základních charakteristik fragmentované krajiny, stanovení vhodných indikátorů pro tyto charakteristiky, definování limitní hodnoty těchto charakteristik a limitní hodnoty indikátorů. Projekt popisuje modifikaci látkových toků související s fragmentací krajiny, chemismus půd ve vztahu k vlastnostem fragmentů, flóru a vegetaci fragmentů, mykologii a edafon. Zabývá se historickou dynamikou krajinných struktur jako významného vysvětlujícího faktoru. Zpráva popisuje studovanou oblast a výzkumné plochy, modifikaci látkových toků souvisejících s fragmentací krajiny, modifikaci klimatických jevů souvisejících s fragmentací krajiny, flóru a vegetaci fragmentů, diverzitu makromycet, diverzitu edafonu, diverzitu vybraných skupin bezobratlých a diverzitu ptáků. Proběhl mykologický monitoring, v jehož rámci bylo nalezeno 820 druhů makromycet, z nichž 67 druhů je zařazeno do Červeného seznamu makromycet ČR