Vesicoureteral Reflux as a Well Known Heterogeneous Disease - Essay Example

?Research PROPOSAL PROJECT Incidence of urinary tract infection in vesico-ureteral reflux Grade 111 INTRODUCTION: Vesicoureteral reflux (VUR) is a well known heterogeneous disease. It can be described as a disease process coupled with an anatomical abnormality at the ureterovesical junction. It can also be described as an abnormal urinal flow from the bladder to the upper urinary tract. VUR is usually categorized into either primary or secondary reflux. Of the two, primary reflux is the most common. It is as a result of an incompetent ureterovesical junction. Under normal circumstances, ureter passes through the detrusor muscle and ends at the ureteral hiatus thus the intramural ureter has an oblique direction and during process of micturition it closes in a flap valve mechanism.(Hunzikar, Kutasi, D’atsa, Puri,2011) If intramural ureter is short and incompetent then it results into failure of the flap-valve mechanism(Aappublications.org, 2011). Secondary VUR is associated with abnormal high pressure build up in the bladder. It follows that a flap-valve mechanism failure at the intramural ureter is due to this high pressure. Posterior urethral valves and neurogenic bladder are normally associated with clinical conditions that lead to secondary reflux. The retrograde flow of urine is checked as the intramural ureter is passively compressed while the bladder fills. The disorder has been subjected to great scrutiny especially in relation to the general importance of the disorder as a clinical entity in renal development and function. Vesicoureteral reflux may present before birth as hydronephrosis or dilatation of ureter which leads to urinary tract infection or acute pyelonephritis. New borns may be lethargic with faltering growth while infants and young children may present with symptoms of urinary tract infection like fever, dysuria, frequent urination and malodorous urine or GI symptoms. An international classification for grading of VUR has been developed. According to this classification, grade 1 VUR is reflux into non dilated ureter, grade 2 is reflux into non dilated renal pelvis and calyces, grade 3 is reflux into mild to moderately dialated renal pelis, calyces and ureter with mild blunting of fornices, grade 4 id dilatation of renal pelvis and calyces with moderate ureteral tortuosity, grade 5 is gross dilatation of ureter, renal pelvis, calyces, ureteral tortuosity, loss of papillary impressions. It is a matter of debate that which grade of VUR is associated with greater risk of complications. Statistics reveal that 1% of normal children are usually affected by this disorder Approximately 30-50% of children with urinary tract infections are also affected (Aappublications.org., 2011). It should also be noted that 10% of children with prenatally diagnosed hydronephrosis have been reported to have the disorder. Chances of renal damage especially in children over one year of age can be reduced through management and identification of VUR. When a child has UTI in close proximity with VUR prevalence then he or she is likely to contract pyelonephritis and UTI. Renal scarring is a clear indicator of pyelonephritis.(Mahant, freedman, 2002).A child is more disadvantaged when he or she has both pyelonephritis and VUR as compared to when he or she only has pyelonephritis. Diagnosis of VUR is based on voiding cystourethregram. The risk of permanent renal injury and morbidity of acute pyelonephritis can be lowered by administering VUR treatment. Three most common methods of treating VUR include curative interventions, continuous antibiotic prophylaxis and observation (Medicaltalking.com, 2011) Endoscopic subureteral injection is a technique which is used to treat VUJ abnormalities. It was first described in 1981 and further supported by O’Donell and Puri in 1984. Several studies have been done that shows its effectiveness, simplicity, safety and 70-90% cure rate. In a study, it was found that 47.4% patients cured after a single injection and 52% after second injection.(Tarcan, Tiney, Temiz, Simsek, 2007). Treatment of vesicoureteral reflux (VUR) with endoscopic suburetral injection is known as an alternative to open anti-reflux surgery for patients with high-grade VUR, also it is an alternative to prophylactic antibiotics for patients with lower-grade VUR. A study shows that patients of vesicoureteric reflux are at risk of developing repeated urinary tract infections and acute graft pyelonephritis. In such patients subureteric injection of polydimethylsiloxane reduces the incidence of pyelonephritis. According to study, overall success rate was 63%. The success rate of PDS treatment differed with the VUR grade (50% in grade 1, 33% in grade 2, 75% in grade 3, and 67% in grade 4). The success rate in the first trial was 67% and in the second it was 50%.(Song, Hwang, Yoon, Kim, Choi, Kim, Yang, 2011). However, its treatment has since remained to be clouded with a lot of controversies in pediatric urology in addition to the fact that it represents one of the most significant risk factors for acute pyelonephritis in children. Paediatric nephrologists, pediatric urologists and pediatricians in general, have frequently encountered VUR. This has led to the conclusion that VUR is a prevalent disorder. This study is being conducted to know the frequency of UTI in VUR patients and which grade of VUR is more problematic. In this study, effects of different variables on results are also going to be studied. HYPOTHESIS BEING EXAMINED: [Due in the First Draft] The research proposed in this study will examine the following hypothesis(es): Null: Knowing demographic characteristics (gender, race/ethnicity, age), medical history (circumcision), injection and VUR grade does not predict the odds of developing recurrent UTI’s Alternative: Knowing demographic characteristics (gender, race/ethnicity, age), medical history (circumcision), injection and VUR grade does predict the odds of developing recurrent UTIs The variables of interest are: Dependent Variable(s): Occurrence of recurrent UTI’s Independent variable(s): Age Gender Race/Ethnicity Circumcision (Yes/No) Injection (antibiotic prophylaxis and endoscopic subureteral) VUR grade(definition/ high versus low) METHODS: A thorough literature review should be conducted to facilitate generation of evidence tables. This has been facilitated by collection of data in a hospital where study is going to be conducted. Data collection can be retrospective or prospective. Study period of 5 years have been decided. All children between ages 0-15 years who have an ultrasound or voiding cystourethrogram previously will be included in the data base and their medical records will be checked. All patients younger than 15 years will be included if they have their first ultrasound done due to community acquired urinary tract infection. Children with known urinary tract abnormality or those with some other medical condition responsible for their UTI will be excluded from the study. Diagnosis of UTI will be based on finding of bacteria in urine culture. In a survey population, incidence of UTI in males versus females and their age groups will be studied. Also race and ethnicity will be considered. Status of circumcision in boys, prior treatment they received, and grade of vesicoureteral reflux is also considered (NIH, vesicoureteral reflux, 2011). Prior use of antibiotics as a prophylactic or therapeutic measure will be asked in a questionnaire.(Pannesi, Travan, 2008). The method of collection of urine for culture is also considered as it affects results. Urine can be collected from urine bag, freshly voided urine and via suprapubic catheterization. The reoccurrence of UTI in a sample population will also be considered. UTI is confirmed when results of two freshly void samples shows more than 105 bacteria per sample. Aspects of occurrences, recurrence and prevalence will then be obtained from this kind of information. Information can also be gathered from literature review and journal articles but it has few barriers. Medicaltalking.com (2011) reveals that a common outcome is that just a few of the articles provide original and reliable data. The articles should then be organized and arranged in order bearing in mind their significance. All this initiatives will definitely result into development of a model that is based on evidence. The major elements are quantitative outcomes obtained from the relevant literature. The existing literature should be subjected to a meta-analysis process. The literature usually describes the results of the surgical and non operative management of VUR. (Cooper, 2009). Ultrasound and other imaging modalities findings will also be gathered from the study of literature.(Gleeson & Gordon, 1991). These are used to grade VUR. (Moyer & Elliot, 2004).Questions about prior use of antibiotics or subureteral injection will also be asked. Patient response to these maneuvers is also important for future considerations.(Herz, Hafiz, Baqli, 2001). Finally, the third group of questions relates to the results of curative therapies that will be prescribed to the patient.(Oh, Kim, 2008). There are so many literature resources available. Only the relevant ones should be selected for the study. It is expected that the final recommendation will be obtained by the evidence gathered. It is for this reason that the methodologist will rate the evidence as good, fair, strong or opinion/consensus. A comprehensive description of all the methods that should be used is generated. This should be recorded in a technical final report. Outline of Analysis Plan: All data gathered via this process is being evaluated on SPSS version 16 and StatDirect version 2.7.2. the Pearson x2 test will be used to compare patient characteristics and urinary tract abnormalities in different patients. The linear association between age and VUR will be examined by trend test. Relative risks of VUR and ultrasound abnormalities in the proven and false UTI and their confidence intervals will be calculated. Age differences between patients of different grades of VUR will be tested by variance test with Tukey’s post hoc correction. A multivariate logistic analysis will be performed to study influence of reliability of UTI diagnose on the risk of VUR after adjusting possible confounding variables.(age, gender and patients with recurrent history). The results of multivariate analysis will be given as odd’s ratio with 95% confidence intervals. Plan for Reporting of Results: As mentioned earlier, a final technical report that has detailed entries should be generated. The report should capture everything in the study. According to Medscape.com (2010) a good report gives a clear impression of the conducted study. The report should therefore be organized to enhance easy retrieval of vital information. The results of the study will be brought to the attention of the public through the media (newspapers, national radio and television) and a dedicated website. Various presentations should also be done during conferences and annual meetings in addition to the various publications about the study. Conclusion: In conclusion, UTI and VUR are disorders that should be taken seriously because they can result in potential fatal By studying frequency of development of UTI in VUR patients and its relation to other variables like age, gender, circumcision, VUR grade etc, we will be able to develop a good strategic plan of prevention and early treatment for such patients. The results of the study will also guide the researchers for future studies and study the effects of these and few other variables on the incidence of UTI. This study will also enhance awareness of both doctors, therapists and even relatives of the patients regarding disease. REFERENCES: Aappublications.org. (2011). Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children. Retrieved 6th Oct. 2011 from http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/4/843#SEC1. Medicaltalking.com. (2011). Management of vesicoureteral reflux in the child over one year of age. Retrieved 5th Oct. 2011 from http://www.medicaltalking.com/vesicoureteral-reflux/21025-management-vesicoureteral-reflux-child-over-one-year-age.html. Medscape.com. (2010). Vesicoureteral Reflux. Retrieved 6th Oct. 2011 from http://emedicine.medscape.com/article/439403-overview. Moyer, V. & Elliot, E. (2004). Evidence based Pediatrics and Child Health. London: BMJ Cooper, C S (2009). Diagnosis and management of vesicoureteral reflux in children. Nature. Reviews Urology, VOL. 6, 481-489 Gleeson, FV, Gordon, I (1991). Imaging in urinary tract infection, Arch. Dis. Child, vol. 66, pp. 1282-1283 Herz, D, Hafez, A, Baqli, D et al (2001). Efficacy of endoscopic subureteral polydimethylsiloxane injection for treatment of vesicoureteral reflux in children: a North American clinical report, J.Urol., Vol. 166, No. 5, pp. 1880-6. Mahant, S, Friedman,J & MacArthur,C (2002). Renal ultrasound findings and vesicoureteral reflux in children hospitalised with urinary tract infection, Arch. Dis. Child, Vol. 86, pp. 419-421 NIH, "Vesicoureteral Reflux", Retrieved October 10, 2011 from: http://kidney.niddk.nih.gov/kudiseases/pubs/vesicoureteralreflux/ Oh, M M, Kim, H C, Bae, J H et al (2008).Technical Considerations of Endoscopic Subureteral Injection for the Treatment of Vesicoureteral Reflux, Chonnam Medical Journal, Vol.44, No. 1, pp. 17-22 Pennesi, M, Travan, L, Peratoner, L et al (2008). Is Antibiotic Prophylaxis in Children With Vesicoureteral Reflux Effective in Preventing Pyelonephritis and Renal Scars? A Randomized, Controlled Trial, Pediatrics, Vol. 121, No. 6, pp.e1489- e 1494 Hunzikar, M Kutasi,B. D’atsa, F. Puri, P. (2011). Urinary tract abnormalities associates with high garde primary vesicoureteral reflux abnormalities. Paediatric Surgery International. (Epub ahead of print). Tarcan, T. Tiney, I. Temiz, Y. Simsek, F.(2011). Long term results of endoscopic treatment of vesicoureteral reflux with subureteral injection of calcium hydroxyapatite. International Urology and Nephrology. 39(4): 1011-4. Song, J.C. Hwang, H.S. Yoon, H.E. Kim, J.C. Choi, B.S. Kim, Y.S. Yang, C.W. (2011). Endoscopic subureteral polydimethylsiloxane injection and prevention of recurrent acute graft pyelonephritis. Nephron. Clinical Practice. 117(4): c385-9. Read More