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The Overactive Bladder
C. DEFOURNEY, E. VAN LAECKE, A. RAES, J. DEHOORNE, G. MOSIELLO, M.L. CAPITANUCCI, P. MASTRACCI, M. MOSCONI, Paediatric Uro- Nephrologic Centre (PUNC), Ghent University Pediatric Surgery, Urodynamic Unit, Bambino Gesù Children's LONG TERM OUTCOME OF TREATMENT OF NON NEUROPATHIC IS STOLLER AFFERENT NERVE STIMULATION (SANS) USEFUL AND BLADDER SPHINCTER DYSFUNCTION (NNBSD) IN GIRLS TOLERATED IN CHILDREN AFFECTED BY VESICO-SPHINCTER DYSFUNCTION? Does the treatment of NNBSD in girls leads to definite cure or do we learn them to live with their dysfunction. In order to answer this [Background] Stoller afferent nerve stimulation (SANS) has been question we re-evaluated bladder function in girls treated between proved to be effective in adults to treat bladder dysfunction (BD), while in pediatric age experience is still preliminary. Aims of our [Methods] A validated questionnaire was sent to 83 girls treated study were to define SANS tolerability in children and to verify its between January 1995 and July 1996. All girls were considered cured clinical efficacy in the treatment of BD.
at that time. They underwent urotherapy and pharmacotherapy. [Methods] 22 patients (12 female and 10 male), mean age 10.5 Bladder function was evaluated by a questionnaire and by a voiding years, have been treated by SANS. All patients presented lower urinary tract symptoms (LUTS) refractory to conventional [Results] 56 of 83 girls responded (67.5%). Mean age at treatment treatments(bladder training and/or drugs), related to non was 6.6 years, mean age at evaluation is 12.7 years. Most neuropathic BD in 17 cases and neurogenic bladder in 5. The first 10 remarkable results are: 75% of girls consider themselves as cured. patients were previously enrolled to a psychodiagnostic evaluation 30% still suffer some urine loss during day (minimal loss 10%, performing anxiety-depression test, visual analogue scale (VAS) and considerable loss 20%), 30% still suffer nighttime incontinence and questionnaire of pain(QUID). The SANS workup included 12 43% have nocturia, 10 % of patients still have urinary tract infections, treatments(1/week) and it was carried out using the standard Stoller 20% have urge during day and only 7% of patients are still under device. Stimu lation was done for 30 minutes with a fixed pulse of 200 ms and 20 Hz frequency, selecting within range of 1 to 10 mA. All [Conclusion] From these results we conclude that despite treatment 22 patients underwent voiding diary, standard urodynamic and still 30 % of girls have symptoms related to bladder sphincter clinical LUTS data evaluation, prior and after SANS.
dysfunction (6 years after successful treatment). Only a minority of [Results] Regarding tolerability the psycological behaviour was good them seeks medical help for these problems. It is therefore in 4/10 patients, VAS score resulted always normal and in all patients concluded that a lot of girls with NNBSD will carry this condition into QUID showed a statistically significant decrease in pain perception. Clinical symptoms improved in 13/22 patients, while iperactive detrusor contractions resolved in five patients and bladder capacity and residual urine improved in two and five patients respectively.
[Conclusions] SANS has been proved to be well tolerated by children and to be effective in the treatment of BD. Su bjective symptoms ameliorated more than urodynamics patterns.
P. HOEBEKE, C. RENSON, H. DE PAEPE, E. VAN LAECKE, A. RAES, J. VANDE WALLEDept of Pediatric Urology and Urogenital Reconstruction, Ghent University Hospital A. RAES, E. VAN LAECKE, J. DEHOORNE, P. HOEBEKE, PELVIC FLOOR SPASMS IN CHILDREN: AN UNKNOWN CONDITION Departments of paediatric nephrology and urology, UZG GentGhent, Belgium [Objective] During the last 5 years 21 children are seen for nighttime pelvic pain. These children typical wake up in the middle of the night with severe lower abdominal pain. During day they suffer urge syndrome. During urodynamic investigation in these children we Instable detrusor and small bladder syndrome may benefit from a found extremely high pelvic floor activity as recorded by high treatment with anticholinergic drugs together with a urethral pressure. We therefore started pelvic floor relaxation bladdervolume-training and urotherapy. Because there is a known co-morbidity between ADHD-syndrome and bladderdysfunction, [Methods] All children diagnosed with pelvic floor spasms anticholinergics may also be prescribed in this patients. With underwent biofeedback pelvic floor relaxation therapy in order to oxybutynin however we have seen in the past many side-effects. learn them to counteract pelvic pain due to these spasms. In those Tolterodine has definitely less side-effects in normal children, but if girls in whom detrusor hyperactivity was seen on urodynamics this is also the case in ADHD children is not known. Over the last concomitant anticholinergic treatment was given (oxybutynin).
years the drug has been prescribed in such patients, despite of the [Results] Between January 1998 and January 2002 symptomatic non-registration in children, because of the unacceptable high pelvic floor spasms were diagnosed in 21 children (19 girls / 2 boys). frequency of side-effects of oxybutynin.
Pelvic floor relaxation biofeedback was successful for treatment of [Aim of the study] Comparative study between Tolterodine this condition in 17 of 21 children. Mean duration of therapy was 3 (2mg/day) and oxybutynin (15mg/day) in children with ADHD.
months (12 weekly sessions) and on long term follow up relaps was [Methods] Case-control-study. Patients were matched for age and seen in 3 of 17 successfully treated children. 10 of 17 successfully sex. Registration of side-effects and effect (during 3 month's) treated children received anticholinergics.
[Study-population] Age 5-14y, 30 children in each group, [Conclusion] Pelvic floor spasms in children (which can be secondary to detrusor hyperactivity) respond well to pelvic floor relaxation [Results] In the oxybutynin group 12 patients stopped the drug <3m, because of side-effects (hypernervositas, concentration-disorder). In 9 other patients there was significant worsening of the ADH-symptoms according to the parents. In the detrusitol-group 5 children interrupted therapy < 3 m: 2 for the price, 1 for accomodation-problems, 2 for worsening of ADHD-symptoms. Only in 3 other patients there was suspicion of more ADHD-symptoms. There was no difference in effect on the bladder-function.
The Overactive Bladder
[Conclusion] The side-effect-ratio between Tolterodine and Central nervous system disorders (81%) were the most common oxybutynin is definitely in favour of Tolterodine in children with adverse events, 26.2% showed flushing, 12.2% had abnormal visual accomodation and 25.2 %had gastrointestinal complaints (constipation, diarrhoea, abdominal pain). Withdrawal of the non-selective antimuscarinic drug resulted in total recovery from adverse events. The remaining 39.6% of group 1 switched to tolterodine due to lack improvement in micturition variables. Introduction of tolterodine in group I and II caused no serious adverse D. BATINIC , G. MÜRTZ , F. MARTIN , F. SCHNABEL , T. GRAMATTÈ , events. Nine patients (3.5%) reported side effects and only 2 discontinued treatment. There were no reports of flushing, 1Childrens University Hospital Salata, Zagreb, Croatia hyperpyrexia and troubles of visual accomodation. In group 1 we observed a mean decrease in urgency by 38.7 %, a mean increase in 3Institute of Clinical Pharmacology, Technical University Dresden maximal bladdercapacity by 33.6% and the number of incontinence episodes decreased by 64.8%. In group 2 we observed equivalent values with a significant (p<0.001) change in maximal EFFICACY AND TOLERABILITY OF PROPIVERINE IN CHILDREN bladdercapacity (49.7%), incontinence episodes (64.8%) and SUFFERING FROM OVERACTIVE BLADDER - A DOUBLE-BLIND, RANDOMIZED, CLINICAL TRIAL VERSUS OXYBUTYNIN AND PLACEBO [Conclusions] The results of this retrospective analysis suggest that tolterodine is well tolerated in children and offers an effective [Aim of the study] C omparison of efficacy and tolerability of treatment for urinary symptoms due to overactive bladder. propiverine, oxybutynin and placebo in children with overactive Tolterodine is superior to non-selective antimuscarinic drugs, with bladder (enuresis diurna, diurna et nocturna, nocturna with urge).
respect to adverse events, allowing more compliance and more [Methods] 266 children (propiverine 85; oxybutynin 91; placebo 90) were recruited. 10 mg propiverine b.i.d., 5 mg oxybutynin b.i.d. or placebo were administered during a treatment period of 12 weeks. Efficacy was assessed by micturition diaries. In a subpopulation (n = 100) bladder capacity at maximal urge was evaluated. Tolerability was assessed by directly questioning of adverse events.
[Results] Efficacy: The weekly enuretic events decreased for U. GRIGOLEIT , S. LASCHKE , M. SCHULDT , G. MÜRTZ , propiverine (pre 11.2; post 6.4) and oxybutynin (pre 10.9; post 6.3). Due to placebo effects (pre 11.6; post 7.5) no significanct treatment 1Department of Urology, Berufsgenossenschaftliche Unfallklinik, differences resulted. However, bladder capacity at maximal urge increased significantly with propiverine (pre 133.9; post 162.8; 2Department of Urology, University Heidelberg p<0.05) and oxybutynin (pre 138.3; post 167.4; p<0.05), but not with 3Department of Paediatric Surgery, University Greifswald Tolerability: The frequency of adverse events was significantly 5Department of Urology and Children Urology, Klinikum higher in the oxybutynin compared to the propiverine or placebo [Conclusions] The study demonstrated a superior tolerability of propiverine compared to oxybutynin. Enuretic events decreased EFFICACY AND SAFETY OF PROPIVERINE HYDROCHLORIDE IN comparably in all three groups. However, urodynamic data CHILDREN WITH CONGENITAL OR TRAUMATIC DETRUSOR demonstrated propiverine and oxybutynin being equally effective in the treatment of overactive bladder in children. [Aims of the study] Clean intermittent catheterization (CIC) and anticholinergics are established therapeutic strategies in children with detrusor hyperreflexia (DH). Efficacy and safety of propiverine hydrochloride, an anticholinergic with additional spasmolytic effect on the smooth muscle cell, were evaluated in these children.
A. RAES, G. PHILIPPE, E. VAN LAECKE, J. DEHOORNE, [Methods] In four clinics, specialised in treatment of children with DH, the patient files were scrutinised for propiverine treatment. Urodynamic parameters before and after treatment and adverse events were recorded retrospectively. [Results] 74 children (40 boys, 34 girls; age range 11 months 19.9 RETROSPECTIVE ANALYSIS OF EFFICACY AND TOLERABILITY OF years) suffering from DH mainly of congenital (myelomeningocele, TOLTERODINE IN CHINLREN WITH OVERACTIVE BLADDER tethered cord) or traumatic (spinal cord injury) aetiology were analyzed. The average treatment duration was 31 months. [Objective] To evaluate the efficacy and tolerability of tolterodine Altogether 172 patient years of propiverine treatment were in children with an overactive bladder, treated in a single enuresis documented, individual daily dosages varied (5 - 75 mg propiverine; [Materials and methods] We performed a retrospective analysis of a Efficacy: Urodynamic parameters improved significantly during database of a total of two hundred and fifty-six patients (175 boys propiverine treatment (explorative paired t-tests): Maximum and 81 girls, age range 3 years to 17 years, mean age 8,33 years) with bladder capacity pre 161.2 ( 97), post 252.2 ( 117) ml; p 0.001; urodynamically confirmed bladder overactivity. The children maximum detrusor pressure pre 43.8 ( 39), post 27.1 ( 26) cm H O; received tolterodine tartrate (dose range of 0.5 mg - 4 mg orally) p=0.002; compliance pre 7.6 ( 6), post 17.0 ( 16) ml / cm H O; p0.001.
replacing anticholinergic drugs (oxybutynin chloride or Safety: Due to the retrospective character of the analysis the oxyfencyclimine-hydrochloride n =205, group 1) or as initial therapy frequency of adverse events was lower than in prospective clinical (n =51, group 2). Tolerability was assessed from adverse events by a trials: 1/74 patients reported accommodation disorders and nausea. standardised questionnaire. Efficacy assessment was based on [Conclusions] Propiverine is effective and well tolerated in children micturition diary variables, mean change of maximum bladder suffering from DH, even under long term treatment. capacity and number of incontinent episodes/24h.
[Results] The mean treatment time was 9.32 months with a range from 1.5 months to 23.4 months. The final dose was 0.1 mg /kg orally daily, divided into two doses.
In group 1, 60.4% switched to tolterodine due to serious adverse events during treatment with non-selective antimuscarinic drugs. The Overactive Bladder
A.D. MARSCHALL-KEHREL , G. MÜRTZ , G. Kramer Departments of Urology and Physiology , College of Medicine, 1Urology Consultant, Vorstadt 20, Oberursel 3Berufsgenossenschaftliche Unfallklinik MurnauGermany THE EFFECTS OF BOTULINUM TOXIN A ON THE DETRUSOR MUSCLE IN RATS AN EMPIRICAL TREATMENT ALGORITHM FOR INCONTINENT CHILDREN [Purpose] There is little data on the effects of botulinum toxin A (BoTx A) on detrusor muscle in the literature. An experimental study [Aims of the study] Response rates of monotherapeutic strategies of was conducted to investigate the effect of BoTx A on the detrusor incontinent children evidence limited success only. This retrospective analysis was performed to test whether [Materials and Methods] Sprague-Dawley rats were used to make the complementary therapies in incontinent children might improve detrusor muscle strip (length: 8mm, width: 2mm). An isometric force transducer in the physiologic salt solution was used to measure [Methods] Patient records of 457 enuretic or incontinent children the contraction and relaxation of this muscle strip. A contraction (1998 - 2001) were scrutinized. Children were investigated was induced by acetylcholine (ACh) and electrical field stimulation according to ICCS-standards (1). Primary endpoint was the (40V, 20Hz, 3sec), and relaxation was induced by verapamil and achievement of continence, secondary endpoint the improvement of sodium nitroprusside. The BoTx A concentration was 0.1U/ml. The functional bladder capacity (FBC). Seventy incontinent children (2) relaxation and contraction of the detrusor muscle in the BoTx A- were treated with propiverine (0.8 mg/kg/day; Mictonetten) and treated group were analyzed and compared with those in the control reevaluated after four weeks (period 1). In non-responders and partial responders complementary therapies were initiated for 12 [Results] The time to the maximum contraction induced by weeks (period 2). These therapies were chosen on an empirical electrical field stimulation was lengthened and the time of recovery basis: selective alpha-blocker in functional bladder neck to the basal state after terminating electrical field stimulation was obstruction, DDAVP in excessive nocturnal urine production and also increased by BoTx A (p<0.05). However, the contractile reaction biofeedback for increased pelvic floor activity during micturition.
induced by ACh and the relaxing reaction induced by verapamil and [Results] Demography: 70 patients; 22 girls, 48 boys; age range 5 14 sodium nitroprusside after maintaining the maximum contraction induced by ACh 10 M was not influenced by BoTx A.
Results of the different treatment strategies (tab. 1): [Conclusions] The results of this experimental study suggest that the time delay of the maximum contraction induced by electrical field stimulation occurred by blocking ACh release at the neuronal endings and the time delay of the recovery to the basal state after terminating electrical field stimulation occurred by reducing [Conclusions] Propiverine monotherapy in incontinent children is 1Department of Molecular and Clinical Medicine, Division of In partial and non-responders tailored complementary therapies induce further improvements (3). Therefore combination therapies for partial and non-responders appear promising.
Faculty of Health Sciences Linköping, Sweden THE BLADDER COOLING TEST IN CHILDREN WITH NON-NEUROGENIC BLADDER PROBLEMS [Background] The bladder cooling test, BCT, activates a primitive neonatal reflex that becomes suppressed by descending signals in older children. The aim of this study was to evaluate the BCT in children with non-neurogenic bladder problems.
[Methods] The BCT was evaluated in a consecutive series of 265 children (169 girls and 96 boys, 1 month - 18 years) with non-neurogenic bladder problems. The test was performed at the end of an ordinary cystometry by a rapid infusion of body-warm saline (about a third of the cystometric capacity) followed by the same volume of cold saline (4-8°C). The test was considered positive if a detrusor contraction above 30 cm/H O was evoked by the cold fluid but not by the warm.
[Results] Most children <4 years (24/30) had VUR (IV-V), the rest a history of UTIs. The BCT was positive in 14/15 below 1 year and in 9/12 below 2 years. All but one test (1/12) was negative between 2-4 years. Seven of these negative tests were repeats in children with positive BCT before 2 years. Most older children (>4 years) had urge incontinence and/or dysfunctional voiding. The frequency of positive BCT was highest (57%) in the interval 4-6 years with a gradual decline to 12 years. Only 1/35 older than 12 years had a positive test. [Conclusion] The conversion of positive to negative BCTs at 2-4 years presumably represents normal maturation. Positive tests in older children with urge incontinence suggest delayed maturation of the central control of the bladder.

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