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Kumar A, Ghotra GS, Raj S, Tiwari N, Ramamurthy HR. Low-Dose vasopressin and renal perfusion in pediatric cardiac surgery. Ann Card Anaesth 2023; 26:309-317. [PMID: 37470530 PMCID: PMC10451146 DOI: 10.4103/aca.aca_182_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/14/2023] [Accepted: 03/03/2023] [Indexed: 07/21/2023] Open
Abstract
Background Congenital heart surgeries are associated with post-bypass renal and cardiac dysfunctions. The use of low-dose vasopressin has been found to be beneficial in adult cardiac surgeries. Objective To assess the hemodynamic and renal effects of patients undergoing on-pump pediatric cardiac surgery under general anesthesia (GA) with low-dose vasopressin infusion. Design Prospective randomized controlled study. Setting Operation room and ICU, tertiary care teaching hospital. Patients Fifty-five pediatric cardiac patients undergoing repair for congenital heart diseases (CHD). Interventions Low-dose vasopressin infusion in the study group and placebo in the control group. Measurements and Main Results Renal near-infrared spectroscopy (NIRS), serum NGAL, and inflammatory mediators-IL6 and IL8 along with other renal and hemodynamic parameters in the perioperative period were recorded. Diastolic blood pressure (DBP) and cardiac index were significantly higher in the vasopressin group. Inflammatory markers were significantly high in the immediate postoperative period in all patients which later stabilized in the next 48 h but showed similar trends in both groups. Low-dose vasopressin infusion did not improve either renal perfusion or function. The duration of mechanical ventilation and length of hospital stay, the incidence of AKI development, and transfusion requirements were marginally lower in the vasopressin group, although not significant. Conclusion Low-dose vasopressin infusion improved hemodynamics and showed a decreased incidence of complications. However, it failed to show any benefit of renal function and overall outcome in pediatric cardiac surgery.
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Affiliation(s)
- Alok Kumar
- Department of Anaesthesia and Critical Care, Army Hospital (Research and Referral), Delhi Cantt, New Delhi, India
| | - Gurpinder S. Ghotra
- Department of Anaesthesia and Critical Care, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
| | - Sangeeth Raj
- Department of Anaesthesia and Critical Care, Army Hospital (Research and Referral), Delhi Cantt, New Delhi, India
| | - Nikhil Tiwari
- Department of Cardiothoracic Surgery, Army Hospital (Research and Referral), Delhi Cantt, New Delhi, India
| | - HR Ramamurthy
- Department of Paediatrics, Army Hospital (Research and Referral), Delhi Cantt, New Delhi, India
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Kumar A, Ghotra GS, Dwivedi D, Bhargava DV, Joshi A, Tiwari N, Ramamurthy HR. Common Inflammatory Markers and Outcome After Pediatric Cardiac Surgery With High Thoracic Epidural Anesthesia: A Randomized Controlled Study. World J Pediatr Congenit Heart Surg 2023; 14:334-344. [PMID: 36823972 DOI: 10.1177/21501351221151053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Background: High thoracic epidural analgesia (HTEA) plays a pivotal role in reducing stress and neuroendocrine response in cardiac surgeries. Aim: The primary objective is to assess the effect of HTEA, in pediatric cardiac surgery, on inflammatory markers (interleukin [IL]-6, IL-8, and tumor necrosis factor-α). The secondary objectives are to assess its effect on various organ systems, that is, pulmonary (PaO2, P/F ratio), renal (Creatinine clearance, somatic near infrared spectroscopy [NIRS], serum neutrophil gelatinase-associated lipocalin values), cardiac (cardiac index, serum Trop-I, and lactate levels), mechanical ventilation duration, and length of stay in hospital (LOS). Methods: The study included 188 pediatric patients, who underwent, on-pump cardiac surgery randomized into the Epidural Group (n = 92) and Non-Epidural Group (n = 96). After general anesthesia, a 23 G epidural catheter was placed at the T4-5 level with a Bupivacaine infusion while the Non-epidural Group received fentanyl infusion. Blood samples were collected at four-time points, T0(preop), T1(4 h), and on the first and second postoperative days (T2 and T3). Results: The inflammatory markers were reduced, while the outcomes variables of mechanical ventilation (MV) duration had lower values in the epidural group (19.5 h vs 47.3 h, P = .002). LOS was shorter (10.1 days vs 13.3 days, P = .016). pO2, PF ratio, and renal NIRS values were better in the Epidural Gp, while other parameters were comparable. Non-epidural Gp had more complications esp. Acute kidney injury requires RRT. Conclusion: HTEA use in pediatric, on-pump cardiac surgery offers a favorable profile in terms of reduction in the inflammatory markers and positive effect on the organ systems with lesser MV duration and the LOS.
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Affiliation(s)
- Alok Kumar
- Department of Anaesthesia & Critical Care, 521937Army Hospital (Research & Referral), New Delhi, India
| | - Gurpinder Singh Ghotra
- Department of Anaesthesia & Critical Care, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Deepak Dwivedi
- Department of Anaesthesia & Critical Care, Department of Anaesthesia & Critical Care, 30154Command Hospital (Eastern command), Kolkata, India
| | - D V Bhargava
- Department of Anaesthesia & Critical Care, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Ankur Joshi
- Department of Anaesthesia & Critical Care, 521937Army Hospital (Research & Referral), New Delhi, India
| | - Nikhil Tiwari
- Department of Cardiothoracic Surgery, 521937Army Hospital (Research & Referral), New Delhi, India
| | - H R Ramamurthy
- Department of Paediatrics, 521937Army Hospital (Research & Referral), New Delhi, India
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Kumar V, Kumar P, Chauhan L, Dwivedi A, Ramamurthy HR. Novel combination of FLNC (c.5707G>A; p. Glu1903Lys) and BAG3 (c.610G>A; p.Gly204Arg) genetic variant expressing restrictive cardiomyopathy phenotype in an adolescent girl. J Genet 2022. [DOI: 10.1007/s12041-022-01402-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Khera S, Ramamurthy HR, Ranjan R, Dwivedi A. Hypertrophic Obstructive Cardiomyopathy in an Infant with Neuroblastoma. Indian J Pediatr 2021; 88:836. [PMID: 34021863 DOI: 10.1007/s12098-021-03793-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/27/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Sanjeev Khera
- Department of Pediatrics, Army Hospital Research & Referral, Delhi, 110010, India.
| | - H Ravi Ramamurthy
- Department of Pediatrics, Army Hospital Research & Referral, Delhi, 110010, India
| | - Randhir Ranjan
- Department of Pediatrics, Army Hospital Research & Referral, Delhi, 110010, India
| | - Aradhana Dwivedi
- Department of Pediatrics, Army Hospital Research & Referral, Delhi, 110010, India
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Tiwari N, Ramamurthy HR, Kumar V, Kumar A, Dhanalakshmi B, Kumar G. The role of three-dimensional printed cardiac models in the management of complex congenital heart diseases. Med J Armed Forces India 2021; 77:322-330. [PMID: 34305286 DOI: 10.1016/j.mjafi.2021.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 01/17/2021] [Indexed: 01/07/2023] Open
Abstract
Background Three-dimensional printing is a process enabling computer-assisted conversion of imaging data from patients into physical "printed" replicas. This has been extrapolated to reconstructing patient-specific cardiac models in congenital heart diseases. The aim of this study was to analyze the impact of three-dimensional printing in surgical decision making in selected cases of complex congenital heart disease by creating patient-specific printed models. Methods Patients with complex congenital heart diseases with unresolved management decisions after evaluation by echocardiography, cardiac catheterization, and cardiac computed tomography were included with intent to aid in surgical decision making. Three-dimensional models were created from computed tomographic images by an outsourced firm using computer applications. All cases were reviewed by the same team before and after the cardiac models were prepared. The management decisions were grouped as either "corrective surgery" or "no surgery or palliation" The impact of the surgical decision pre and post three-dimensional cardiac model was analyzed by applying Cohen's kappa test of agreement. Results Ten patients were included, of which five were of increased pulmonary blood flow, and five were of decreased pulmonary flow. The commonest indication for three-dimensional printed models was to establish the routability of the aorta and pulmonary artery to their respective ventricles (in five patients). The nonagreement between the decision taken before and after the cardiac model was 80%, with kappa -0.37 and P value 0.98. Conclusions Three-dimensional printed cardiac models contribute to better decision making in complex congenital heart diseases enabling safer execution of any complex congenital heart surgery.
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Affiliation(s)
- Nikhil Tiwari
- Senior Advisor (Surgery) & Cardiothoracic Surgeon, Army Hospital (R&R), Delhi Cantt, India
| | - H Ravi Ramamurthy
- Senior Advisor (Paediatrics) & Pediatric Cardiologist, Army Hospital (R&R), Delhi Cantt, India
| | - Vivek Kumar
- Senior Advisor (Paediatrics) & Pediatric Cardiologist, Command Hospital (Air Force), Bangalore, India
| | - Alok Kumar
- Classified Specialist (Anaesthesia) & Cardiothoracic Anaesthesiologist, Army Hospital (R&R), Delhi Cantt, India
| | - B Dhanalakshmi
- Classified Specialist (Radiodiagnosis), Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Gaurav Kumar
- Professor & Director, Consultant Paediatric Cardiothoracic Surgeon, Fortis-Escorts Heart Institute, Okhla Road, New Delhi, India
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Abstract
A 16-month-old, healthy, asymptomatic male child presented with a diagnosis of dilated cardiomyopathy. Cardiovascular examination and chest radiograph were normal. ECG revealed sinus rhythm, and the augmented vector left lead showed raised ST segment, T wave inversion and q waves. Echocardiography showed a globular left ventricle with notched cardiac apex, abnormal echogenicity in the left ventricular apical myocardium, single papillary muscle and normal biventricular function. Cardiac MRI scan revealed a globular left ventricle with fibrofatty changes and retraction of the apex, the papillary muscles closely approximated, and the right ventricle wrapping around the apex of the left ventricle. This is described as isolated left ventricular apical hypoplasia. Diagnosis of this rare entity can be made by MRI, and it has been diagnosed largely in adults. The pathophysiology and long-term outcomes are unknown. We characterise the echocardiography findings of this rare anomaly in a child for the first time in the literature.
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Affiliation(s)
- H Ravi Ramamurthy
- Department of Pediatrics, Army Hospital (Research & Referral), Delhi, India,Department of Pediatric Cardiology & Grown Up congenital heart diseases, Narayana Institute of Cardiac Sciences, Bangalore, India
| | - Onkar Auti
- Department of Radiology, Ruby Hall Clinic, Pune, India
| | - Vimal Raj
- Department of Radiology, Mazumdar Shaw Medical Center, Narayana Health City, Bangalore, India
| | - Kiran Viralam
- Department of Pediatric and Grown-UpCongenital HeartDiseases, Narayana Institute of Cardiac Sciences, Bangalore, India
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Dwivedi A, Kumar V, Ramamurthy HR. Partial Trisomy 16q21-q24.3 with Novel Cardiac Manifestation of Left Ventricular Noncompaction Cardiomyopathy: A Case Report. J Pediatr Genet 2020; 10:326-330. [PMID: 34849281 DOI: 10.1055/s-0040-1714362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/07/2020] [Indexed: 10/23/2022]
Abstract
Partial trisomy 16q is most often a consequence of malsegregation from a balanced parental translocation involving chromosome 16q. It is characterized by nonspecific craniofacial dysmorphic features, hypotonia, developmental delay, psychomotor retardation, and systemic manifestations of cardiac defect, renal abnormalities, and lung abnormalities. The survival of these patients depends upon the extent and severity of the organs involved. The present literature was replete with cases of partial trisomy 16q having structural cardiac defects. However, in the present report we described a novel finding of myocardial disease in the form of left ventricular noncompaction (LVNC) cardiomyopathy associated with this genetic condition.
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Affiliation(s)
- Aradhana Dwivedi
- Department of Medical Genetics, Army Hospital (Research and Referral), New Delhi, India
| | - Vivek Kumar
- Department of Pediatric Cardiology, Army Hospital (Research and Referral), New Delhi, India
| | - H Ravi Ramamurthy
- Department of Pediatric Cardiology, Army Hospital (Research and Referral), New Delhi, India
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Sharma VK, Kumar G, Joshi S, Tiwari N, Kumar V, Ramamurthy HR. An evolving anesthetic protocol fosters fast tracking in pediatric cardiac surgery: A comparison of two anesthetic techniques. Ann Pediatr Cardiol 2019; 13:31-37. [PMID: 32030033 PMCID: PMC6979031 DOI: 10.4103/apc.apc_36_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/15/2019] [Accepted: 06/19/2019] [Indexed: 11/17/2022] Open
Abstract
Background: The past two decades have seen rapid development of new surgical techniques for repair as well as palliation of complex congenital heart diseases. For a better patient outcome, minimal postoperative ventilation remains one of the most important endpoints of an effectual perioperative management. Aims and Objectives: The aim of this randomized open-label trial was to compare postoperative extubation time and intensive care unit (ICU) stay when two different anesthetic regimens, comprising of induction with ketamine and low-dose fentanyl versus high-dose fentanyl, are used, in pediatric patients undergoing corrective/palliative surgery. Materials and Methods: Patients with congenital cardiac defects, under 14 years of age undergoing cardiac surgery under cardiopulmonary bypass (CPB) and epidural analgesia, were enrolled into two groups – Group K (ketamine with low-dose fentanyl) and Group F (high-dose fentanyl) – over a period of 10 months, starting from January 2018. The effect of both these drugs on postoperative extubation time and ICU stay was compared using Mann–Whitney U-test. Results: A total of 70 patients were assessed with equal distribution in both the groups. In Group K, 32 of 35 patients were extubated in the operation room, whereas extubation time in Group F was18.1 ± 11 h. Total ICU stay in Group K and Group F was 45.2 ± 30.1 and 60.1 ± 24.5 h, respectively (P = 0.02). Systolic blood pressure was significantly higher in Group K. Conclusion: Ketamine along with low-dose fentanyl, when used for anesthetic induction, in comparison to high-dose fentanyl, reduces postoperative extubation time and ICU stay, in pediatric patients undergoing corrective/palliative surgery under CPB and epidural analgesia for congenital cardiac defects.
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Affiliation(s)
- Vipul K Sharma
- Department of Cardio-Thoracic Anaesthesia, Army Hospital Research and Referral, New Delhi, India
| | - Gaurav Kumar
- Department of Cardio-Thoracic Surgery, Army Hospital Research and Referral, New Delhi, India
| | - Saajan Joshi
- Department of Cardio-Thoracic Anaesthesia, Army Hospital Research and Referral, New Delhi, India
| | - Nikhil Tiwari
- Department of Cardio-Thoracic Surgery, Army Hospital Research and Referral, New Delhi, India
| | - Vivek Kumar
- Department of Pediatric Cardiology, Army Hospital Research and Referral, New Delhi, India
| | - H Ravi Ramamurthy
- Department of Pediatric Cardiology, Army Hospital Research and Referral, New Delhi, India
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Ravi Ramamurthy H, Jaswal D, Chaturvedi V. “Travel travails” – Travel-related poisoning. Med J Armed Forces India 2013; 69:409. [DOI: 10.1016/j.mjafi.2013.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Indexed: 10/26/2022] Open
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Kanitkar M, Ramamurthy HR. Bed wetting - silent suffering: an approach to enuresis and voiding disorders in children. Indian J Pediatr 2013; 80:750-3. [PMID: 23893319 DOI: 10.1007/s12098-013-1103-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022]
Abstract
Bed wetting or nocturnal enuresis is a common problem among children. It is either monosymptomatic or may be associated with a voiding disorder. Many factors may contribute towards enuresis such as developmental delay, heredity, inappropriate nocturnal anti diuretic hormone secretion and reduced bladder capacity. Any child presenting with bed-wetting should be evaluated for any underlying bladder dysfunction before labeling as monosymptomatic enuresis. The evaluation consists of structured bowel and bladder history, detailed clinical examination, frequency volume record and appropriate investigations. The frequency volume diary is an indispensible component of evaluation and helps in establishing diagnosis and tailoring therapy. The treatment of monosymptomatic enuresis consists of positive psychological support, alarms and medication (desmopressin/ anticholinergics/ imiprammine). Children with features of underlying bladder dysfunction, anatomical anomalies and neurological disorders should be referred to a pediatrician without delay. The outcome of therapy is usually rewarding but varies, depending on the underlying etiology, motivation, compliance and family support. The cure rates with alarms are better than with desmopressin in monosymptomatic enuresis. Timely and appropriate therapy yields better outcomes. Thus, a thorough, scientific and evidence based approach is essential in children presenting with bed-wetting.
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Affiliation(s)
- Madhuri Kanitkar
- Department of Pediatrics, Base Hospital, Delhi Cantt, New Delhi 110010, India.
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Raju U, Shaw SC, Rana KS, Sharma M, Ramamurthy HR. Pompe's Disease in Childhood: A Metabolic Myopathy. Med J Armed Forces India 2011; 66:32-6. [PMID: 27365701 DOI: 10.1016/s0377-1237(10)80089-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Accepted: 08/24/2009] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Myopathy of metabolic origin in childhood occurs due to a variety of conditions. Pompe's Disease also known as Glycogen storage disease Type II, is a rare storage disorder with clinical presentation akin to spinal muscular atrophy. METHODS A series of patients with suspected metabolic myopathy were reviewed at a tertiary care service hospital over a period of three years. The diagnosis was confirmed by estimation of acid alpha glucosidase activity. RESULT At our centre, these cases presented with generalized hypotonia, organomegaly (hepatomegaly, cardiomegaly) and congestive cardiac failure. Infantile onset, the most severe form of Pompe's disease, was the commonest form accounting for 75% of the cases. Four of the babies with infantile onset Pompe's disease expired, three due to refractory heart failure and one to fulminant respiratory infection before 15 months of age. CONCLUSION Pompe's Disease is now being increasingly diagnosed, due to definitive enzyme estimation facilities. With the recent availability of enzyme replacement therapy with Myozyme, the prognosis is likely to change for the better.
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Affiliation(s)
- U Raju
- AOC, 7 Air Force Hospital, Kanpur Cantt
| | - S C Shaw
- Graded Specialist (Paediatrics), 164 Military Hospital, C/O 99 APO
| | - K S Rana
- Senior Advisor (Paediatrics & Neurology), Army Hospital R & R, Delhi Cantt
| | - M Sharma
- Senior Advisor (Paediatrics & Cardiology), Army Hospital R & R, Delhi Cantt
| | - H R Ramamurthy
- Graded Specialist (Paediatrics), Command Hospital (EC), Kolkata
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Ramamurthy HR, Kanitkar M, Raju U. Bartter's Syndrome Masquerading as a Neurometabolic Disorder. Med J Armed Forces India 2011; 63:282-3. [PMID: 27408019 DOI: 10.1016/s0377-1237(07)80157-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Accepted: 08/28/2006] [Indexed: 11/25/2022] Open
Affiliation(s)
- H R Ramamurthy
- Graded Specialist (Paediatrics), Command Hospital (Southern Command), Pune 411040
| | - M Kanitkar
- Professor and Head (Dept of Paediatrics), Armed Forces Medical College, Pune-411040
| | - U Raju
- Senior Advisor (Paediatrics & Neonatology), Command Hospital (Southern Command), Pune 411040
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Ramamurthy HR, Kanitkar M. Recurrent urinary tract infection and functional voiding disorders. Indian Pediatr 2008; 45:689-691. [PMID: 18723914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This study was carried out to determine the association of recurrent urinary tract infections with functional voiding disorders. Sixty eight children with suspected functional voiding disorders were prospectively evaluated clinically and by non-invasive urodynamics. Invasive urodynamics were carried out when indicated. Group I comprised 34 children with symptoms suggestive of functional voiding disorders and recurrent urinary tract infections (mean age 6.3+/-2 yr) and Group II comprised 34 children with symptoms suggestive of functional voiding disorders without recurrent urinary tract infections (mean age 6.7+/-2 yr). The underlying bladder abnormalities in Groups I and II were detrusor instability in 22 (64.7%) and 30 (88.2%), respectively (P>0.05) and dysynergic voiding in 10 (29.4%), and 1 (2.9%), respectively (P<0.05). Children with recurrent urinary tract infections are more likely to have a dysynergic voiding pattern than children presenting with other symptoms of functional voiding disorders.
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Affiliation(s)
- H Ravi Ramamurthy
- Department of Pediatrics, Armed Forces Medical College and Command Hospital, Pune 411040, India
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