Oral steroids for reducing kidney scarring in young children with febrile urinary tract infections: the contribution of Bayesian analysis to a randomized trial not reaching its intended sample size

Background: This study aimed to evaluate the effect of oral dexamethasone in reducing kidney scars in infants with a first febrile urinary tract infection (UTI). Methods: Children aged between 2 and 24 months with their first presumed UTI, at high risk for kidney scarring based on procalcitonin levels ( 651 ng/mL), were randomly assigned to receive dexamethasone in addition to routine care or routine care only. Kidney scars were identified by kidney scan at 6 months after initial UTI. Projections of enrollment and follow-up completion showed that the intended sample size could not be reached before funding and time to complete the study ran out. An amendment to the protocol was approved to conduct a Bayesian analysis. Results: We randomized 48 children, of whom 42 had a UTI and 18 had outcome kidney scans (instead of 128 planned). Kidney scars were found in 0/7 and 2/11 patients in the treatment and control groups respectively. The probability that dexamethasone could prevent kidney scarring was 99% in the setting of an informative prior probability distribution (which fully incorporated in the final inference the information on treatment effect provided by previous studies) and 98% in the low-informative scenario (which discounted the prior literature information by 50%). The probabilities that dexamethasone could reduce kidney scar formation by up to 20% were 61% and 53% in the informative and low-informative scenario, respectively. Conclusions: Dexamethasone is highly likely to reduce kidney scarring, with a more than 50% probability to reduce kidney scars by up to 20%. Trial registration number: EudraCT number: 2013-000388-10; registered in 2013 (prospectively registered) Graphical Abstract: [Figure not available: see fulltext.

Updated Italian recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children

Aim: Our aim was to update the recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children, which were endorsed in 2012 by the Italian Society of Pediatric Nephrology. Methods: The Italian recommendations were revised on the basis of a review of the literature published from 2012 to October 2018. We also carried out an ad hoc evaluation of the risk factors to identify children with high-grade vesicoureteral reflux or renal scarring, which were published in the previous recommendations. When evidence was not available, the working group held extensive discussions, during various meetings and through email exchanges. Results: Four major modifications have been introduced. The method for collecting urine for culture and its interpretation has been re-evaluated. We have reformulated the algorithm that guides clinical decisions to proceed with voiding cystourethrography. The suggested antibiotics have been revised, and we have recommended further restrictions of the use of antibiotic prophylaxis. Conclusion: These updated recommendations have now been endorsed by the Italian Society of Pediatric Nephrology and the Italian Society for Pediatric Infectivology. They can also be used to compare other recommendations that are available, as a worldwide consensus in this area is still lacking

L\u2019approccio al dolore nel bambino: primi dati nell\u2019ospedale di Treviso

Introduzione: Il dolore \ue8 parte integrante dell\u2019approccio quotidiano al bambino malato: pi\uf9 dell\u201980% dei ricoveri pediatrici \ue8 dovuto a patologie che presentano anche dolore. Non esistono limiti di et\ue0 alla percezione del dolore, vi \ue8 una \u201cmemoria\u201d dello stesso sin dall\u2019et\ue0 neonatale ed il dolore non trattato in et\ue0 evolutiva \ue8 associato ad aumentata morbidit\ue0 e mortalit\ue0 con effetti sulla maturazione del sistema algico. Un\u2019adeguata terapia antalgica accelera la guarigione dei bambini malati e riduce i giorni di degenza. Nonostante le ormai ampie conoscenze sull\u2019analgesia pediatrica non corrisponde ancora oggi una pratica clinica adeguata. Obiettivo: valutare l\u2019approccio al dolore nell\u2019Ospedale di Treviso nel setting della degenza e del Pronto Soccorso (PS). Metodi: distribuzione di tre diversi questionari dal 14.11.2011 al 17.02.2012 ai capireparto, agli operatori sanitari, ai bambini (ai genitori se bambino di et\ue0 inferiore a 7 anni) nei reparti di Pediatria, Chirurgia Pediatrica, Patologia Neonatale e Pronto Soccorso. Sono stati esclusi i neonati ricoverati presso la patologia neonatale per il ridotto tempo di assistenza da parte dei genitori. Risultati: ha risposto il 100% dei capireparto ed il 56% degli operatori sanitari. Il 50% dei medici e il 68% degli infermieri ha seguito corsi sul dolore, di durata inferiore a 4 ore nel 72,7% dei casi. Dei 212 bambini reclutati (range di et\ue0 0-18 anni) 108 bambini presentano dolore. La valutazione \ue8 stata eseguita nell\u201981,4% dei casi, con % pi\uf9 alte per i bambini degenti. La valutazione \ue8 stata eseguita da entrambi gli operatori nel 54,3% dei casi, nei restanti da un solo operatore. La scala FLACC \ue8 stata usata nello 0,1% dei casi, la scala di Wong-Baker nell'1%, la scala VAS nel 29,5%, la descrizione verbale della quantit\ue0 di dolore \ue8 la pi\uf9 usata (73,8%). Il 56,4% dei bambini con dolore non \ue8 stato trattato, in particolare il 91,7% di quelli visti nel PS generale. Il 91,8% dei trattati ha avuto beneficio dalla terapia eseguita. Il paracetamolo \ue8 usato dall\u201986,8% degli operatori, seguito dai FANS (67,9%). La morfina ed il tramadolo sono usati rispettivamente dal 15,1% e dal 12,3% degli operatori sanitari. Conclusioni: la valutazione del dolore viene eseguita maggiormente nel bambino ricoverato ma la misurazione non viene eseguita con metodi validati nel 73,8% dei casi in entrambi i setting (degenza/PS). Il dolore \ue8 ipotrattato soprattutto nei bambini accolti in PS e gli oppioidi sono poco usati nella pratica clinica