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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610. Review/Other-Dx N/A To revise the American Academy of Pediatrics practice parameter regarding the diagnosis and management of initial urinary tract infections (UTIs) in febrile infants and young children. Diagnosis is made on the basis of the presence of both pyuria and at least 50,000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen of urine. After 7 to 14 days of antimicrobial treatment, close clinical follow-up monitoring should be maintained to permit prompt diagnosis and treatment of recurrent infections. Ultrasonography of the kidneys and bladder should be performed to detect anatomic abnormalities. Data from the most recent 6 studies do not support the use of antimicrobial prophylaxis to prevent febrile recurrent UTI in infants without vesicoureteral reflux (VUR) or with grade I to IV VUR. Therefore, a voiding cystourethrography (VCUG) is not recommended routinely after the first UTI; VCUG is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy and in other atypical or complex clinical circumstances. VCUG should also be performed if there is a recurrence of a febrile UTI. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of care; variations may be appropriate. Recommendations about antimicrobial prophylaxis and implications for performance of VCUG are based on currently available evidence. As with all American Academy of Pediatrics clinical guidelines, the recommendations will be reviewed routinely and incorporate new evidence, such as data from the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. 4
2. Koyle MA, Elder JS, Skoog SJ, et al. Febrile urinary tract infection, vesicoureteral reflux, and renal scarring: current controversies in approach to evaluation. Pediatr Surg Int. 2011; 27(4):337-346. Review/Other-Dx N/A A review on the ideal approach to the radiological evaluation of children with UTI. No results stated in abstract. 4
3. Lim R. Vesicoureteral reflux and urinary tract infection: evolving practices and current controversies in pediatric imaging. AJR Am J Roentgenol. 2009; 192(5):1197-1208. Review/Other-Dx N/A Review recent evolution and controversies in the management of UTI and VUR. Multi-technique imaging of UTI and VUR is complex and controversial. Evolution in practice patterns is motivated by the desire to rationally minimize unnecessary interventions and radiation exposure. Ongoing evidence-based research is needed to further improve practice guidelines. 4
4. Merguerian PA, Sverrisson EF, Herz DB, McQuiston LT. Urinary tract infections in children: recommendations for antibiotic prophylaxis and evaluation. An evidence-based approach. Curr Urol Rep. 2010; 11(2):98-108. Review/Other-Dx N/A Review imaging protocols and use of antibiotic prophylaxis in children with UTI. Risk of developing long-term complications after a UTI is extremely low, and evidence suggests selective imaging to a select group of children at risk. Finding those at risk for long-term complications is yet to be determined. 4
5. Williams GJ, Hodson EH, Isaacs D, Craig JC. Diagnosis and management of urinary tract infection in children. J Paediatr Child Health. 2012; 48(4):296-301. Review/Other-Dx N/A To review and summarize recent primary studies, systematic reviews and guidelines on the diagnosis and management of UTI in children. No results stated. 4
6. Ismaili K, Wissing KM, Lolin K, et al. Characteristics of first urinary tract infection with fever in children: a prospective clinical and imaging study. Pediatr Infect Dis J. 2011; 30(5):371-374. Observational-Dx 209 children To provide the clinical characteristics, uropathogen frequencies, and antimicrobial resistance rates of first UTI diagnosed in febrile Belgian children. The ability of noninvasive US to detect renal abnormalities and VUR in these patients was also assessed. Among these children, 63% were females and 37% were males, and 75% of them had their first UTI before the age of 2 years. The most common causative agent was Escherichia coli (91% of cases) with high rate resistance to ampicillin (58%) and trimethoprim/sulfamethoxazole (38%). Of these children, 25% had evidence of VUR (15 boys and 38 girls). VUR was of low grade in 85% of cases. The overall performance of renal US as a diagnostic test to detect significant uropathies excluding low-grade VUR was excellent; the sensitivity attained 97% and the specificity 94%. Girls represent 63% of cases with first UTI. For 91% of UTIs, Escherichia coli is held responsible with a high rate of resistance to ampicillin and trimethoprim/sulfamethoxazole. US is an excellent screening tool that allows avoidance of unjustified VCUG studies. 3
7. Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics. 2010; 126(6):1084-1091. Meta-analysis 33 studies To review the prevalence of acute and chronic renal imaging abnormalities in children after an initial UTI. Among children with an initial episode of UTI, 57% (95% CI: 50-64) had changes consistent with acute pyelonephritis on the acute-phase DMSA renal scan and 15% (95% CI: 11-18) had evidence of renal scarring on the follow-up DMSA scan. Children with VUR were significantly more likely to develop pyelonephritis (RR: 1.5 [95% CI: 1.1-1.9]) and renal scarring (RR: 2.6 [95% CI: 1.7-3.9]) compared with children with no VUR. Children with VUR grades III or higher were more likely to develop scarring than children with lower grades of VUR (RR: 2.1 [95% CI: 1.4-3.2]). The pooled prevalence values provided from this study provide a basis for an evidence-based approach to the management of children with this frequently occurring condition. M
8. Baracco R, Mattoo TK. Diagnosis and management of urinary tract infection and vesicoureteral reflux in the neonate. Clin Perinatol 2014;41:633-42. Review/Other-Dx N/A To diagnose and manage urinary tract infection and vesicoureteral reflux in the neonate. No results stated in the abstract 4
9. Goldman M, Lahat E, Strauss S, et al. Imaging after urinary tract infection in male neonates. Pediatrics. 2000; 105(6):1232-1235. Review/Other-Dx 45 male neonates <8 weeks old To assess the frequency of urinary tract anomalies in male neonates <8 weeks old who presented with UTI, and to evaluate a suitable imaging approach after the initial infection. Urinary tract abnormalities were observed in 22/45 male neonates. 19 had VUR, 1 had VUR and a double collecting system, 1 had VUR and a posterior urethral valve, and 1 had an ureteropelvic junction stricture. Renal atrophy or scars, as demonstrated by DMSA scan, were detected almost exclusively in neonates with VUR grade 3 and above. Only 1 neonate with VUR grade 1 had a pathologic DMSA, and the US of this male also demonstrated renal atrophy. Escherichia coli was the pathogen in 62% (28/45), and 9 boys had bacteremia. Authors suggest that US and VCUG should be performed routinely after the initial UTI in male neonates. Renal scan should be reserved for those cases in which the US suggests renal parenchymal damage or when VCUG detects VUR grade 3 and above. 4
10. Milas V, Puseljic S, Stimac M, Dobric H, Lukic G. Urinary tract infection (UTI) in newborns: risk factors, identification and prevention of consequences. Coll Antropol 2013;37:871-6. Review/Other-Dx 1200 newborns To study the identification of urinary tract infections (UTI) and urinary tract anomalies (UTA) already in the perinatal period. The frequency of a UTI in the perinatal period amounted to 4.5%. A UTA was found in 29.6% of the examinees. The infection was more likely to appear among newborns with a UTA in their families, a UTI, pre-eclampsia and a febrile infection in mother, intrauterine growth retardation, premature rupture of membranes (RVP), umbilical cord strangulation, jaundice, cyanosis, breathing difficulties, seizures and asphyxia. 4
11. Santoro JD, Carroll VG, Steele RW. Diagnosis and management of urinary tract infections in neonates and young infants. Clin Pediatr (Phila) 2013;52:111-4. Review/Other-Dx N/A To review the diagnosis and management of urinary tract infections in neonates and young infants. No abstract available 4
12. Sastre JB, Aparicio AR, Cotallo GD, Colomer BF, Hernandez MC. Urinary tract infection in the newborn: clinical and radio imaging studies. Pediatr Nephrol. 2007; 22(10):1735-1741. Observational-Dx 301 neonates in 28 neonatal units community-acquired UTI, n=250; nosocomial UTI, n=51 Multicenter study to assess clinical characteristics and results of radio imaging studies and compare community-acquired UTI with nosocomial UTI in neonates with UTI consecutively admitted to neonatal units in Spain over 3 years. Abnormal renal US was present in 37.1% of cases (34% in community-acquired UTI and 54.5% in nosocomial UTI, P<0.01). VCUG showed VUR in 27% of cases (23.8% in community-acquired UTI and 48.6% in nosocomial UTI, P<0.01). In patients with abnormal renal US and VUR, renal scan with DMSA performed early after UTI revealed cortical defects in 69.5% of cases. However, in patients with abnormal renal US and normal VCUG, DMSA also revealed cortical defects in 39% of cases. Absence of VUR in neonates with UTI and abnormal renal US does not exclude the presence of cortical defects suggestive of pyelonephritis. 3
13. Mori R, Lakhanpaul M, Verrier-Jones K. Diagnosis and management of urinary tract infection in children: summary of NICE guidance. BMJ 2007;335:395-7. Review/Other-Dx N/A To summarize the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on how to provide consistent clinically and cost effective practice for the diagnosis, treatment, and further management of urinary tract infection in childhood. No abstract available. 4
14. Tekgul S, Riedmiller H, Hoebeke P, et al. EAU guidelines on vesicoureteral reflux in children. Eur Urol 2012;62:534-42. Review/Other-Dx N/A To present a management approach for vesicoureteral reflux (VUR) based on early risk assessment. 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. 4
15. Piepsz A, Blaufox MD, Gordon I, et al. Consensus on renal cortical scintigraphy in children with urinary tract infection. Scientific Committee of Radionuclides in Nephrourology. Semin Nucl Med. 1999; 29(2):160-174. Review/Other-Dx 30 experts 30 experts provided guidance by questionnaire on renal cortical scintigraphy in children with UTI. Consensus reached whenever 75% or more of the experts agreed on a given matter. Consensus reached by 89% that DMSA was the most appropriate tracer for renal cortical imaging. DMSA most appropriate radiotracer for renal cortical imaging in children with UTI. 4
16. Urinary tract infection in under 16s: diagnosis and management. National Institute for Health and Clinical Excellence.  Available at: http://www.nice.org.uk/nicemedia/pdf/CG54NICEguideline.pdf. Review/Other-Dx N/A To cover diagnosing and managing first or recurrent upper or lower urinary tract infections in infants, children and young people. It aims to achieve more consistent clinical practice, based on accurate diagnosis and effective management. No results stated in the abstract. 4
17. Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract infection in febrile infants. J Pediatr 1993;123:17-23. Observational-Dx 945 infants This study assessed (I) the prevalence of urinary tract infection (UTI) in febrile infants (temperature =38.3°C) with differing demographic and clinical characteristics and (2) the usefulness of urinalysis in diagnosing UTI. We diagnosed UTI in 50 (5.3%) of 945 febrile infants if we found =10,000 colony-forming units of a single pathogen per milliliter in aurine specimen obtained by catheterization. Prevalences were similar in (I) infants aged =2 months undergoing examination for sepsis (4.6%), (2) infantsaged >2 months in whom UTI was suspected, usually because no source of fever was apparent (5.9%), and (3) infants with no suspected UTI, most of whom hadother illnesses (5.1%). Female and white infants had significantly more UTIs, respectively, than male and black infants. In all, 17% of white female infants withtemperature =39° C had UTI, significantly more (p <0.05) than any other grouping of infants by sex, race, and temperature. Febrile infants with no apparentsource of fever were twice as likely to have UTI (7.5%) as those with a possible source of fever such as otitis media (3.5%) (p =0.02). Only I (1.6%) of 62 subjectswith an unequivocal source of fever, such as meningitis, had UTI. As indicators of UTI, pyuria and bacteriuria had sensitivities of 54% and 86% and specificitiesof 96% and 63%, respectively. In infants with fever, clinicians should consider UTI a potential source and consider a urine culture as part of the diagnostic evaluation. 3
18. Pauchard JY, Chehade H, Kies CZ, Girardin E, Cachat F, Gehri M. Avoidance of voiding cystourethrography in infants younger than 3 months with Escherichia coli urinary tract infection and normal renal ultrasound. Arch Dis Child. 102(9):804-808, 2017 09. Observational-Dx 102 infants To investigate, in infants aged 0–3 months, if the presence of Escherichia coli versus non-E. coli bacteria and/or normal or abnormal renal ultrasound (US) could avoid the use of voiding cystourethrography (VCUG). One hundred and twenty-two infants with a first febrile UTI were enrolled. High-grade VUR was defined by the presence of VUR grade =III. The presence of high-grade VUR was recorded using VCUG, and correlated with the presence of E. coli/non-E. coli UTI and with the presence of normal/abnormal renal US. The Bayes theorem was used to calculate pretest and post-test probability. 3
19. Unver T, Alpay H, Biyikli NK, Ones T. Comparison of direct radionuclide cystography and voiding cystourethrography in detecting vesicoureteral reflux. Pediatr Int. 2006; 48(3):287-291. Observational-Dx 41 patients (82 kidney ureter units) Direct radionuclide cystography compared to fluoroscopic VCUG for detection of VUR in children with UTI or antenatal hydronephrosis. 18 refluxing ureters detected by radionuclide cystography, 22 by VCUG, and 14 by both methods. The two methods were concordant in 85% of kidney ureter units. VUR missed by VCUG in 4 units and by radionuclide cystography in 8 units. Good correlation between radionuclide cystography and VCUG in evaluation of VUR. 3
20. American College of Radiology. ACR–ACNM–SNMMI–SPR Practice Parameter for the Performance of Radionuclide Cystography. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=93+&releaseId=2 Review/Other-Dx N/A Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. No abstract available. 4
21. Bonadio W, Maida G. Urinary tract infection in outpatient febrile infants younger than 30 days of age: a 10-year evaluation. Pediatr Infect Dis J. 2014;33(4):342-344. Review/Other-Dx 670 febrile neonates To determine the prevalence of outpatient-diagnosed urinary tract infection (UTI) in consecutive febrile neonates </= 30 days of age and correlate demographic, laboratory and radiographic imaging results with infectious etiology. Of 670 febrile neonates </= 30 days of age evaluated for sepsis, urine culture was obtained in 651 cases (97%). Of 100 patients with UTI (15.4%), 73% were male; the most common uropathogens were Escherichia coli (71%), Enterococcus (10%) and Klebsiella sp. (10%). In all, 39% had a maximum documented fever >/= 102 degrees F, and 40% had CBC total white blood cells count >/= 15,000/mm(3). Urine dipstick test was positive for leukocyte esterase or nitrite in 79%. Renal ultrasound performed in 95 patients (95%) showed anatomic abnormalities in 47%; 5/26 (24%) with hydronephrosis had vesicoureteral reflux on voiding cystourethrogram. Four patients had urosepsis; none had bacterial meningitis and no patients died. 4
22. Chang PW, Abidari JM, Shen MW, et al. Urinary Imaging Findings in Young Infants With Bacteremic Urinary Tract Infection. Hosp. pediatr.. 6(11):647-652, 2016 11. Observational-Dx 257 infants To describe renal ultrasound (RUS) and voiding cystourethrogram (VCUG) findings and determine predictors of abnormal imaging in young infants with bacteremic urinary tract infection (UTI). Of the 276 infants, 19 were excluded. Of the remaining 257 infants, 254 underwent a RUS and 224 underwent a VCUG. Fifty-five percent had =1 RUS abnormalities. Thirty-four percent had =1 VCUG abnormalities, including vesicoureteral reflux (VUR, 27%), duplication (1.3%), and infravesicular abnormality (0.9%). Age <1 month, male sex, and non-Escherichia coli organism predicted an abnormal RUS, but only non-E coli organism predicted an abnormal VCUG. Seventeen of 96 infants (17.7%) with a normal RUS had an abnormal VCUG: 15 with VUR (Grade I-III = 13, Grade IV = 2), 2 with elevated postvoid residual, and 1 with infravesical abnormality. 3
23. Guedj R, Escoda S, Blakime P, Patteau G, Brunelle F, Cheron G. The accuracy of renal point of care ultrasound to detect hydronephrosis in children with a urinary tract infection. Eur J Emerg Med. 22(2):135-8, 2015 Apr. Observational-Dx 433 patients (262 female, 171 male) To investigate the accuracy of renal point of care ultrasound (POCUS) for the detection of hydronephrosis in children with a urinary tract infection (UTI). We calculated the accuracy of POCUS to detect hydronephrosis (renal pelvis enlargement =10 mm). We included 433 UTI visits, and 382 (88.2%) POCUS were performed. The sensitivity and the specificity were 76.5% (95% confidence interval: 58.1-94.6%) and 97.2% (95.2-99.2%), respectively. The positive and the negative predictive values were 59.1% (36.4-79.3%) and 98.8% (97.7-99.9%), respectively. 2
24. Gordon ZN, McLeod DJ, Becknell B, Bates DG, Alpert SA. Uroepithelial Thickening on Sonography Improves Detection of Vesicoureteral Reflux in Children with First Febrile Urinary Tract Infection. Journal of Urology. 194(4):1074-9, 2015 Oct. Observational-Dx 226 patients To determine if the finding of uroepithelial thickening indicates greater risk of high grade vesicoureteral reflux and whether uroepithelial thickening improves the screening value of renal and bladder ultrasound. Of 226 patients 143 (63%) had vesicoureteral reflux, of whom 37 (26%) had high grade reflux. On multivariable analysis uroepithelial thickening was a significant independent predictor of high grade vesicoureteral reflux (OR 5.41, 95% CI 1.74-16.79, p = 0.004). When hydronephrosis and hydroureter were considered the only abnormal renal and bladder ultrasound findings warranting voiding cystourethrography, sensitivity of renal and bladder ultrasound for high grade reflux was 84%, and 6 children with high grade and 82 with low grade reflux would have been missed. When uroepithelial thickening was also considered an abnormal finding, the sensitivity increased to 97%, and only 1 child with high grade and 57 with low grade reflux would have been missed. 3
25. Downs SM. Technical report: urinary tract infections in febrile infants and young children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics. 1999; 103(4):e54. Review/Other-Dx 432 articles Comprehensive review and analysis of literature for diagnosis and management of febrile UTI in children under 2 years of age. Recommendations for the management of UTI are presented. Gold standard definition of a UTI is growth on a culture of a urine specimen obtained from a tap. PPV of a positive culture from a bagged urine specimen is 15%.Sensitivity and specificity of positive catheterization urine culture is 95% and 99% respectively. Prevalence of VUR drops from ~0.5 to ~0.3 from age 0 to ~2, plateaus at ~0.3 from age ~2 to ~7, and then drops precipitously at age ~7 (based on meta-analysis of 54 studies of VUR in children with UTI). Higher grade of VUR correlates with higher risk of renal scarring (based on meta-analysis of 48 studies). Renal US has low sensitivity for low-grade VUR, but relatively higher sensitivity for high-grade VUR. Renal US alone is an inadequate imaging evaluation for children under age 2 with a febrile UTI. VCUG must also be performed. 4
26. Foresman WH, Hulbert WC, Jr., Rabinowitz R. Does urinary tract ultrasonography at hospitalization for acute pyelonephritis predict vesicoureteral reflux? J Urol. 2001; 165(6 Pt 2):2232-2234. Observational-Dx 184 patients Retrospective study to determine if US findings during acute pyelonephritis episode in children predict presence or grade of VUR at follow-up VCUG. 77/184 (42%) US exams during clinical acute pyelonephritis episode were abnormal. 139/184 (76%) patients underwent follow-up VCUG 39 days later. 35% of normal US patients demonstrated reflux, and 36% of abnormal US patients demonstrated reflux. No correlation between US findings during acute pyelonephritis episode and presence or absence of reflux on follow-up VCUG. 3
27. Kenney IJ, Negus AS, Miller FN. Is sonographically demonstrated mild distal ureteric dilatation predictive of vesicoureteric reflux as seen on micturating cystourethrography? Pediatr Radiol. 2002; 32(3):175-178. Observational-Dx 285 renal units in 144 patients To evaluate whether the diameter of the distal ureter on US is predictive of the presence of VUR on VCUG in children. Distal ureter diameter of >3.5 mm on US has a sensitivity of 0.63 and specificity of 0.78 for presence of VUR, and 0.78 and 0.77 respectively for grade 3 or higher VUR. In this study, with a prevalence of VUR of 0.19, this yields a PPV of 0.41 and NPV of 0.90. The NPV of a distal ureter diameter of <3.5 mm in excluding dilating reflux was 0.96. Absence of distal ureteral dilation on US cannot reliably exclude VUR. 3
28. Mahant S, Friedman J, MacArthur C. Renal ultrasound findings and vesicoureteral reflux in children hospitalised with urinary tract infection. Arch Dis Child. 2002; 86(6):419-420. Observational-Dx 162 patients 6 reviewers Retrospective study to determine the sensitivity, specificity, and predictive values of US for VUR in children under 5 admitted for first febrile UTI. Prevalence of VUR was 22%. Sensitivity, specificity, PPV and NPV for renal US suggesting VUR was 40%, 76%, 32%, and 82% respectively. Renal US is neither sensitive nor specific for VUR in children with a first UTI. 3
29. Moorthy I, Wheat D, Gordon I. Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standard. Pediatr Nephrol. 2004; 19(2):153-156. Observational-Dx 930 kidneys To determine how US performs in comparison to DMSA scan (gold standard) in detection of post-infectious renal scarring in children. Sensitivity, specificity, PPV and NPV for US detection of focal renal scarring was 5.2%, 98.3%, 50%, and 75.8%, respectively. Sensitivity, specificity, PPV and NPV for US detection of diffuse renal scarring was 47.2%, 91.8%, 60.8%, and 86.6%, respectively. US cannot be substituted for DMSA in the evaluation of renal scarring. 3
30. Muensterer OJ. Comprehensive ultrasound versus voiding cysturethrography in the diagnosis of vesicoureteral reflux. Eur J Pediatr. 2002; 161(8):435-437. Observational-Dx 205 patients 407 renal units reviewed Retrospective study to assess the accuracy of comprehensive renal US in detecting dilating VUR (grade 3 or higher) when abnormal age-adjusted renal length was taken into consideration along with pelvic dilatation and cortical thinning, compared to VCUG. When taking abnormal kidney length into account, as well as traditional markers such as pelvic dilatation and cortical thinning, dilative VUR (grade 3 or higher) was detected with sensitivity and specificity of 91% and 67% respectively with US. 99% NPV. Much poorer results when not considering abnormal renal length. US cannot accurately diagnose VUR by morphological changes alone. When taking abnormal renal length into consideration, in addition to traditional morphologic changes, a normal US exam makes the presence of dilative VUR highly unlikely. 3
31. Nelson CP, Johnson EK, Logvinenko T, Chow JS. Ultrasound as a screening test for genitourinary anomalies in children with UTI. Pediatrics. 2014;133(3):e394-403. Observational-Dx 3,995 clinical encounters To determine test characteristics and predictive values of RBUS for VCUG findings in this setting. We identified 2259 patients age <60 months who had UTI as the indication for imaging. RBUS was reported as "normal" in 75%. On VCUG, any vesicoureteral reflux (VUR) was identified in 41.7%, VUR grade >II in 20.9%, and VUR grade >III in 2.8%. Sensitivity of RBUS for any abnormal findings on VCUG ranged from 5% (specificity: 97%) to 28% (specificity: 77%). Sensitivity for VUR grade >III ranged from 18% (specificity: 97%) to 55% (specificity: 77%). Among the 1203 children aged 2 to 24 months imaged after a first febrile UTI, positive predictive value of RBUS was 37% to 47% for VUR grade >II (13% to 24% for VUR grade >III); negative predictive value was 72% to 74% for VUR grade >II (95% to 96% for VUR grade >III). 3
32. Berrocal T, Gaya F, Arjonilla A, Lonergan GJ. Vesicoureteral reflux: diagnosis and grading with echo-enhanced cystosonography versus voiding cystourethrography. Radiology. 2001; 221(2):359-365. Observational-Dx 216 patients 440 kidney units To evaluate the usefulness of echo-enhanced cystosonography compared with VCUG for detecting and grading VUR. VUR was detected in 123 kidney units at cystosonography and in 104 at VCUG. In 401 kidney units, there was concordance between results at cystosonography and at VCUG regarding the presence or absence of VUR. 94 kidney units showed VUR with both methods. 77/94 refluxing units were depicted with the same grade of VUR with both modalities, and in 17 the VUR grade was greater at cystosonography than at VCUG. 29/94 units showed VUR at only cystosonography, and 10 units at only VCUG. The McNemar test showed that cystosonography depicted a significantly (P=.003) higher number of units with VUR. By patient, VUR was depicted with both studies in 67 and with only one study in 25. VUR was seen at only cystosonography in 16 patients and at only VCUG in nine. The McNemar test for patients showed no significant difference between the two tests in detection of VUR. Cystosonography with SH U 508A appears comparable to VCUG in the depiction of VUR. 2
33. Darge K. Voiding urosonography with US contrast agents for the diagnosis of vesicoureteric reflux in children. II. Comparison with radiological examinations. Pediatr Radiol 2008;38:54-63; quiz 126-7. Review/Other-Dx N/A To analyze studies comparing voiding urosonography (VUS) with voiding cystourethrography (VCUG) and direct radionuclide cystography (DRNC) and discuss the presented detailed tables demonstrating the diagnostic values and grading of vesicoureteric reflux (VUR). Comparative studies of DRNC were too few and did not allow definite conclusions. Using VCUG as the reference, the results of VUS were as follows: sensitivity 57–100%, specificity 85–100%, positive/negative predictive values 58–100%/87–100%, respectively, and diagnostic accuracy 78–96%. With the exception of two studies the diagnostic accuracy reported was 90% and above. In 19% of pelviureteric units (PUUs) the diagnosis was made only by VUS and in 10% only by VCUG. Thus in 9% of PUUs more refluxes were detected using VUS. In 73.6% the reflux grades were concordant in VUS and VCUG. Reflux grade was found to be higher with VUS than with VCUG in 19.6% of PUUs. In 71.2% of PUUs with grade I reflux on VCUG, the reflux was found to be grade II and higher on VUS. The common selection criteria for VUS as the primary examination for VUR currently include (a) follow-up studies, (b) first examination for VUR in girls, and (c) screening high-risk patients. 4
34. Darge K, Troeger J, Duetting T, et al. Reflux in young patients: comparison of voiding US of the bladder and retrovesical space with echo enhancement versus voiding cystourethrography for diagnosis. Radiology. 1999; 210(1):201-207. Observational-Dx 188 patients To compare the usefulness of voiding US of the bladder and retrovesical space with echo enhancement with that of VCUG for diagnosis of VUR and to assess patient tolerance of the echo-enhancing agent. VUR was detected in 80 of the units with one (n = 18) or both (n = 62) methods. All grades of reflux were identified. In 15 units, reflux diagnosed at voiding US was not observed at VCUG; the reverse was true in three units. In 208 (92%) of the 226 kidney-ureter units, there was concordance between the two methods regarding the diagnosis or exclusion of VUR. The echo-enhancing agent was well tolerated. SH U 508 A enhanced voiding US is as good as VCUG in the detection or exclusion of VUR and thus will make it possible to reduce the number of children having to be exposed to ionizing radiation. 2
35. Duran C, Beltran VP, Gonzalez A, Gomez C, Riego JD. Contrast-enhanced Voiding Urosonography for Vesicoureteral Reflux Diagnosis in Children. [Review]. Radiographics. 37(6):1854-1869, 2017 Oct. Review/Other-Dx N/A To study the structure of the urinary tract after the administration of intravesical contrast material for contrast-enhanced voiding urosonography (ceVUS) is a dynamic imaging technique. Initially, ceVUS was indicated mainly to study vesicoureteral reflux (VUR); however, since the ability of ceVUS to depict the structure of the urethra was demonstrated in both sexes, ceVUS is now indicated for examination of the entire urinary tract. The main benefit of ceVUS is that it does not use ionizing radiation. In recent years, fundamental changes have occurred in the understanding of VUR. The lessening effect of VUR and the low rate of occurrence of urethral pathologic conditions have given rise to changes in the indications for tests for these conditions. In addition to being able to help confirm a diagnosis of VUR, the ceVUS technique can be used to depict obstructive and nonobstructive urethral pathologic conditions, as well as normal variants, on high-quality images. Furthermore, ceVUS enables real-time assessment of voiding function. For these reasons, ceVUS should be not only an alternative to voiding cystourethrography, but also the technique of choice for the study of the entire urinary tract in pediatric patients. 4
36. Duran C, del Riego J, Riera L, Martin C, Serrano C, Palana P. Voiding urosonography including urethrosonography: high-quality examinations with an optimised procedure using a second-generation US contrast agent. Pediatr Radiol. 2012;42(6):660-667. Observational-Dx 307 VUS examination in 295 children To evaluate the quality of images of the entire urinary tract when using a second-generation US contrast agent and a modified VUS technique. Three criteria were used for quality assessment of the bladder image: (1) progressive incorporation of contrast material in the bladder, (2) homogeneous bladder-filling to maximum capacity, and (3) visualisation of the posterior bladder wall. RESULTS: Criterion 1 was fulfilled in 305 (99.3%), criterion 2 in 304 (99%) and criterion 3 in 304 (99%) studies. In children who underwent VUS with both contrast agents, the concordance between the two techniques was moderate for findings in the bladder (Cohen K = 0.487; P < 0001) and perfect for findings in the male urethra. 4
37. Kljucevsek D, Battelino N, Tomazic M, Kersnik Levart T. A comparison of echo-enhanced voiding urosonography with X-ray voiding cystourethrography in the first year of life. Acta Paediatr. 2012;101(5):e235-239. Experimental-Dx 66 children To compare VUS with X-ray voiding cystourethrography (VCUG) and to evaluate the predictive value of pelvicalyceal dilatation for detecting VUR in the first year of life. According to VCUG, VUR was present in 16/132 (12%) renal units. VUS confirmed all these and additionally revealed VUR in 26 renal units (all together 42/132 (32%) renal units with VUR). It should be noted that all VUR detected only with VUS and missed by VCUG were of grades II and III. In 27/92 (29%) US normal and in 15/40 (37%) renal units with pelvicalyceal dilatation, VUR was detected by VUS. 2
38. McCarville MB. Contrast-enhanced sonography in pediatrics. Pediatr Radiol. 2011;41 Suppl 1:S238-242. Review/Other-Dx N/A To discuss several proven and potential pediatric applications of contrast-enhanced sonography. No result stated in abstract 4
39. Papadopoulou F, Ntoulia A, Siomou E, Darge K. Contrast-enhanced voiding urosonography with intravesical administration of a second-generation ultrasound contrast agent for diagnosis of vesicoureteral reflux: prospective evaluation of contrast safety in 1,010 children. Pediatr Radiol. 44(6):719-28, 2014 Jun. Observational-Tx 1010 children To evaluate the safety of intravesical administration of a second-generation ultrasound (US) contrast agent for the diagnosis of vesicoureteral reflux in children. No case of serious adverse event was recorded. Minor events were reported in 37 children (3.66% of the study population). These included dysuria (n = 26, 2.57%), urinary retention (n = 2, 0.2%), abdominal pain (n = 2, 0.2%), anxiety (n = 1, 0.1%) and crying (n = 1, 0.1%) during micturition, blood and mucous discharge (n = 1, 0.1%), increased frequency of micturition (n = 1, 0.1%), vomiting (n = 1, 0.1%), perineal irritation (n = 1, 0.1%), and an episode of urinary tract infection 10 days after ce-VUS (n = 1, 0.1%). Of these adverse events, 91.9% were subacute in onset and 8.1% were delayed. All events were self-limited and none required hospitalization. 2
40. Wozniak MM, Wieczorek AP, Pawelec A, et al. Two-dimensional (2D), three-dimensional static (3D) and real-time (4D) contrast enhanced voiding urosonography (ceVUS) versus voiding cystourethrography (VCUG) in children with vesicoureteral reflux. Eur J Radiol. 85(6):1238-45, 2016 Jun. Observational-Dx 69 patients To analyze if three-dimensional static (3DUS)/ four-dimensional static (4DUS) bring additional information leading to an increased detection rate or change in the grading of reflux compared to Two-dimensional (2DUS) and voiding cystouretrography. 2DUS and 3DUS/4DUS urosonography diagnosed 10 more refluxes (7.25%) than cystourethrogra-phy and in 3 refluxes (2.17%) detected a higher grade. In 9 refluxes (6.52%) 3DUS/4DUS urosonography andcystourethrography diagnosed a higher grade than 2DUS. There was a statistically significant differencebetween cystourethrography and 3DUS/4DUS urosonography when the number of detected refluxes anddifferences in grading were compared. 4DUS enabled a better visualization of reflux than 3DUS. 3
41. SUBCOMMITTEE ON URINARY TRACT INFECTION. Reaffirmation of AAP Clinical Practice Guideline: The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile Infants and Young Children 2-24 Months of Age. Pediatrics. 138(6), 2016 12. Review/Other-Dx N/A To reaffirm the 2011 urinary tract infection (UTI)  clinical practice guidelines (CPGs)  and provide an updated review of the supporting evidence by the American Academy of Pediatrics. No abstract available. 4
42. Bisset GS, 3rd, Strife JL, Dunbar JS. Urography and voiding cystourethrography: findings in girls with urinary tract infection. AJR Am J Roentgenol. 1987; 148(3):479-482. Review/Other-Dx 523 examinations2 independent readers Retrospective study to evaluate the usefulness of VCUG and excretory urogram in girls with UTI. Higher grades of VUR had higher rates of parenchymal scarring: 3/37 (8%) grade 1, 13/114 (11%) grade 2, 12/32 (37%) grade 3, 5/5 (100%) grade 4. 0 of 523 females had urethral anomalies. VUR grade associated with renal scarring. VCUG has significantly higher ovarian radiation dose than radionuclide. Single spot film of urethra is sufficient. 4
43. Hoberman A, Greenfield SP, Mattoo TK, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med. 2014;370(25):2367-2376. Experimental-Tx 607 children To determine whether long-term antimicrobial prophylaxis is effective in preventing febrile or symptomatic recurrences and reducing the likelihoodof renal scarring, and the extent to which it contributes to bacterial resistance. Recurrent urinary tract infection developed in 39 of 302 children who received prophylaxis as compared with 72 of 305 children who received placebo (relative risk, 0.55; 95% confidence interval [CI], 0.38 to 0.78). Prophylaxis reduced the risk of recurrences by 50% (hazard ratio, 0.50; 95% CI, 0.34 to 0.74) and was particularly effective in children whose index infection was febrile (hazard ratio, 0.41; 95% CI, 0.26 to 0.64) and in those with baseline bladder and bowel dysfunction (hazard ratio, 0.21; 95% CI, 0.08 to 0.58). The occurrence of renal scarring did not differ significantly between the prophylaxis and placebo groups (11.9% and 10.2%, respectively). Among 87 children with a first recurrence caused by Escherichia coli, the proportion of isolates that were resistant to trimethoprim-sulfamethoxazole was 63% in the prophylaxis group and 19% in the placebo group. 1
44. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev. 2011; (3):CD001534. Meta-analysis 12 studies; 1,557 children To determine the efficacy and harms of long-term antibiotics to prevent recurrent UTI in children. 6 (5 analyzed, 1,069 children) of 12 studies compared antibiotics with placebo/no treatment. Compared to placebo/no treatment, when all studies were included, antibiotics did not appear to reduce the risk of symptomatic UTI (RR 0.75, 95% CI, 0.36 to 1.53) however, when authors evaluated the effects of antibiotics in studies with low risk of bias, there was a statistically significant reduction (RR 0.68, 95% CI, 0.48 to 0.95). The effect was similar in children with VUR (RR 0.65, 95% CI, 0.39 to 1.07) compared to those without VUR (RR 0.56, 95% CI, 0.15 to 2.12). There was no consistency in occurrence of adverse events. 3 studies reported antibiotic resistance, showing a nonsignificant increased risk for resistance to the antibiotic in the active treatment groups (RR 2.4, 95% CI, 0.62 to 9.26). 5 studies (4 analyzed, 367 children) compared one antibiotic with another but all compared different combinations or different outcomes and studies were not pooled. Two studies reported microbial resistance, nitrofurantoin having a significantly lower risk of resistance than cotrimoxazole (RR 0.54, 95% CI, 0.31 to 0.92).One study compared alternate with every day cefadroxil treatment. Long-term antibiotics appear to reduce the risk of repeat symptomatic UTI in susceptible children but the benefit is small and must be considered together with the increased risk of microbial resistance. M
45. Shaikh N, Hoberman A, Rockette HE, Kurs-Lasky M. Identifying children with vesicoureteral reflux: a comparison of 2 approaches. J Urol 2012;188:1895-9. Observational-Dx 309 children 1 to 24 months old To compare the sensitivities of the top-down ((99m)technetium dimercaptosuccinic acid renal scan to screen) and biomarker based (C-reactive protein level at presentation) approaches in identifying children with vesicoureteral reflux. The top-down and C-reactive protein based approaches missed 33% and 29% of cases of high grade vesicoureteral reflux, respectively. 3
46. Majd M, Nussbaum Blask AR, Markle BM, et al. Acute pyelonephritis: comparison of diagnosis with 99mTc-DMSA, SPECT, spiral CT, MR imaging, and power Doppler US in an experimental pig model. Radiology. 2001; 218(1):101-108. Observational-Dx 35 piglets (70 kidneys) To compare Tc-99m DMSA SPECT, spiral CT, MRI, and power Doppler US for the detection and localization of acute pyelonephritis in piglets using histology as the standard of reference. 38/70 kidneys had pyelonephritis by histology. Sensitivity and specificity: 92% and 94% for SPECT DMSA. Sensitivity and specificity: 90% and 88% for MRI. Sensitivity and specificity: 87% and 88% for CT. Sensitivity and specificity: 74% and 57% for Doppler US. SPECT DMSA, MRI, and CT are equally sensitive and reliable for the detection of acute pyelonephritis. Doppler US is significantly less accurate. 2
47. Ataei N, Madani A, Habibi R, Khorasani M. Evaluation of acute pyelonephritis with DMSA scans in children presenting after the age of 5 years. Pediatr Nephrol. 2005; 20(10):1439-1444. Observational-Dx 52 patients Prospective study to assess the occurrence of renal parenchymal lesions using DMSA in children over 5 years admitted with a first-time symptomatic UTI. 41/52 (79%) had renal lesion demonstrated via DMSA in acute phase of illness. 16/41 (39%) with positive DMSA also had abnormal US. 9/32 (28%) who underwent repeat DMSA had persistent lesions. 23/32 (72%) who underwent repeat DMSA showed partial regression of the lesions. Older children are not less susceptible to renal parenchymal scarring than younger children. Findings suggest in children over 5 years DMSA may be more appropriate than VCUG. 2
48. Craig JC, Wheeler DM, Irwig L, Howman-Giles RB. How accurate is dimercaptosuccinic acid scintigraphy for the diagnosis of acute pyelonephritis? A meta-analysis of experimental studies. J Nucl Med. 2000; 41(6):986-993. Meta-analysis 7 studies; 242 animals Meta-analysis of experimental studies to evaluate the performance of DMSA in the diagnosis of acute pyelonephritis and to compare planar DMSA with SPECT DMSA. Most studies of planar DMSA clustered in a range of sensitivity values around 80% and specificity around 95%. SPECT DMSA studies demonstrate both higher true-positive and false-positive rates than planar DMSA. Planar DMSA performs well for diagnosis of acute pyelonephritis. SPECT DMSA results in a larger number of false-positives. M
49. Hitzel A, Liard A, Vera P, Manrique A, Menard JF, Dacher JN. Color and power Doppler sonography versus DMSA scintigraphy in acute pyelonephritis and in prediction of renal scarring. J Nucl Med. 2002; 43(1):27-32. Observational-Dx 57 patients (mean age, 5 +/- 3 years) US – one blinded reviewer DMSA – 2 blinded reviewers Prospective study to assess the value of color and power Doppler US for diagnosing pyelonephritis and for predicting the development of renal scars in comparison with DMSA (gold standard). Using DMSA as the gold standard, color/power Doppler US had a sensitivity and specificity of 80% and 81% respectively for diagnosis of pyelonephritis. US had PPV and NPV of 57% and 75% respectively for predicting scarring after infection, compared to 62% and 100% for DMSA. No scars developed in children with a normal acute phase DMSA. Doppler/power US is relatively reliable in the acute phase for detection of acute pyelonephritis, but it cannot predict scarring well. 2
50. Lin KY, Chiu NT, Chen MJ, et al. Acute pyelonephritis and sequelae of renal scar in pediatric first febrile urinary tract infection. Pediatr Nephrol. 2003; 18(4):362-365. Review/Other-Dx 216 patients To investigate the incidence of acute pyelonephritis and renal scarring in children with febrile UTI. 19/216 (88%) children with their first episode of UTI received Tc-99m DMSA renal SPECT. =1 year old (149 in group) – 82/131 (63%) had acute pyelonephritis on DMSA and 16/72 (22%) had VUR on VCUG. 1-5 years (33 in group) – 25/29 (86%) had acute pyelonephritis on DMSA and 11/16 (69%) had VUR on VCUG. 5-17 years (34 in group) – 26/34 (84%) had acute pyelonephritis on DMSA and 8/18 (44%) had VUR on VCUG. Totals (216 total patients) – 133/191 (70%) had acute pyelonephritis on DMSA and 35/106 (33%) had VUR on VCUG. 61 patients had follow up DMSA scan >6 months with 35 (57%) demonstrating renal scarring. 70% incidence of acute pyelonephritis in children with first febrile UTI and over half develop renal scar. 4
51. Preda I, Jodal U, Sixt R, Stokland E, Hansson S. Normal dimercaptosuccinic acid scintigraphy makes voiding cystourethrography unnecessary after urinary tract infection. J Pediatr. 2007; 151(6):581-584, 584 e581. Observational-Dx 290 consecutive children Prospective study to determine the frequency at which dilating VUR occurs when acute DMSA is normal in infants with first UTI. 27/290 children had dilating VUR. DMSA abnormal in 26/ 27 of these patients. VCUG does not need to be performed routinely in infants with UTI and a normal acute DMSA scan. 2
52. Tseng MH, Lin WJ, Lo WT, Wang SR, Chu ML, Wang CC. Does a normal DMSA obviate the performance of voiding cystourethrography in evaluation of young children after their first urinary tract infection? J Pediatr. 2007; 150(1):96-99. Observational-Dx 142 patients 10-year retrospective review to determine if a normal DMSA scan during an acute first UTI can obviate the need for VUR evaluation with VCUG. 70% of patients had evidence of pyelonephritis on DMSA scan. 30% of children with first UTI had VUR. 67% of children with pyelonephritis did not have VUR. No child with a normal DMSA had high-grade VUR, only 5 had low-grade VUR. Children with a negative DMSA during their first UTI rarely have VUR, and may never have high-grade VUR. 3
53. Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. 2008; 122(5):1064-1071. Experimental-Tx 338 children aged 2 months to <7 years Multicenter, open-label, randomized controlled multicenter trial to determine whether no prophylaxis is similar to antimicrobial prophylaxis for 12 months in reducing the recurrence of febrile UTI in children after a first febrile UTI. Intention-to-treat analysis showed no significant differences in the primary outcome between no prophylaxis and prophylaxis: 12 (9.45%) of 127 vs 15 (7.11%) of 211. In the subgroup of children with reflux, the recurrence of febrile UTI was 9 (19.6%) of 46 on no prophylaxis and 10 (12.1%) of 82 on prophylaxis. No significant difference was found in the secondary outcome: 2 (1.9%) of 108 on no prophylaxis vs 2 (1.1%) of 187 on prophylaxis. Bivariate analysis and Cox proportional hazard model showed that grade III reflux was a risk factor for recurrent febrile UTIs. Whereas increasing age was protective, use of no prophylaxis was not a risk factor. For children with or without primary nonsevere reflux, prophylaxis does not reduce the rate of recurrent febrile UTIs after the first episode. 1
54. Pennesi M, Travan L, Peratoner L, et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics. 2008; 121(6):e1489-1494. Experimental-Tx 100 patients Multicenter, open-label, randomized, controlled trial to assess the effectiveness of antibiotic prophylaxis in preventing recurrence of pyelonephritis and avoiding new scars in a sample of children who were younger than 30 months and VUR. The baseline characteristics in the 2 study groups were similar. There were no differences in the risk for having at least 1 pyelonephritis episode between the intervention and control groups. At the end of follow-up, the presence of renal scars was the same in children with and without antibiotic prophylaxis. Continuous antibiotic prophylaxis was ineffective in reducing the rate of pyelonephritis recurrence and the incidence of renal damage in children who were younger than 30 months and had VUR grades II through IV. 1
55. Rosenberg AR, Rossleigh MA, Brydon MP, Bass SJ, Leighton DM, Farnsworth RH. Evaluation of acute urinary tract infection in children by dimercaptosuccinic acid scintigraphy: a prospective study. J Urol. 1992; 148(5 Pt 2):1746-1749. Review/Other-Dx 65 children evaluated; 34 had abnormal DMSA scans A prospective study examining the incidence of DMSA abnormalities in children at the time of acute UTI, the progression of these abnormalities following treatment and their correlation with the presence of VUR is reported. DMSA scans performed within 72 hours of presentation in 65 previously healthy children with acute UTI were abnormal in 34 (52%).The scan appearances of 30/36 (83%) initially abnormal kidneys improved or became normal on the repeat DMSA study performed at 3 to 6 months after the acute UTI. A cystogram demonstrated significant VUR in 11/45 cases (24%). Of these 11 cases 10 had abnormal DMSA studies and 1 had dilated upper tracts on US. The incidence of DMSA abnormalities at the time of acute UTI is high but these abnormalities tend to resolve with time. An abnormal DMSA study at the time of UTI identifies most children with significant VUR, and in the series a combination of US and DMSA identified all cases. This study may have major implications for the clinical investigation of children with UTI. 4
56. Mantadakis E, Vouloumanou EK, Georgantzi GG, Tsalkidis A, Chatzimichael A, Falagas ME. Acute Tc-99m DMSA scan for identifying dilating vesicoureteral reflux in children: a meta-analysis. Pediatrics. 2011; 128(1):e169-179. Meta-analysis 13 cohort studies Meta-analysis was performed to evaluate the accuracy of acute-phase DMSA scanning in identifying dilating (grades III through V) VUR documented by VCUG in children with a first febrile UTI. Pooled (95% CI) sensitivity and specificity rates of DMSA scanning were 79% and 53%, respectively, for the patient-based analysis (8 studies) and 60% and 65% for the renal unit-based analysis (5 studies). The respective areas under the hierarchical summary receiver operating curves were 0.71 and 0.67. Marked statistical heterogeneity was observed in both analyses, as indicated by I(2) test values of 91% and 87%, respectively. Acute-phase DMSA renal scanning cannot be recommended as replacement for VCUG in the evaluation of young children with a first febrile UTI. M
57. Zhang X, Xu H, Zhou L, et al. Accuracy of early DMSA scan for VUR in young children with febrile UTI. Pediatrics. 133(1):e30-8, 2014 Jan. Observational-Dx 523 children To evaluate the accuracy of an acute (99m)Tc-dimercaptosuccinic acid (DMSA) scan in predicting dilating vesicoureteral reflux (VUR) among young children with a febrile urinary tract infection (UTI). A total of 523 children were included in this study, of whom 397 children (75.9%) had abnormal DMSA results and 178 children (34.0%) were identified as VUR on micturating cystourethrography (MCU). Among all the patients, the number of children with dilating VUR was 151 (28.9%). The rate of abnormal results on DMSA for the dilating VUR group was significantly higher than the rates for the non-VUR and low-grade VUR groups (P < .01). In the <6 months age group and >/= 6 months age group, the sensitivities of DMSA in predicting dilating VUR were 96.15% and 100.0%, respectively, the negative predictive values were 97.26% and 100.0%, respectively, and the negative likelihood ratios were 0.0911 and 0.0000, respectively. 3
58. Polito C, Rambaldi PF, Signoriello G, Mansi L, La Manna A. Permanent renal parenchymal defects after febrile UTI are closely associated with vesicoureteric reflux. Pediatr Nephrol. 2006; 21(4):521-526. Observational-Dx 206 patients with primary VUR and 77 without VUR Prospective study to analyze the occurrence of DMSA detected renal scarring in children with febrile UTI in patients with and without VUR as detected by direct radionuclide cystography. In patients with VUR, 40% had renal defects on DMSA, compared to 6% of patients without VUR. Most permanent renal defects in children with UTI are associated with VUR. Direct radionuclide cystography should be the first-line investigation in children with febrile UTI. 2
59. Lee JH, Son CH, Lee MS, Park YS. Vesicoureteral reflux increases the risk of renal scars: a study of unilateral reflux. Pediatr Nephrol. 2006; 21(9):1281-1284. Observational-Dx 48 patients To assess the impact of VUR after the first pyelonephritis on renal scar following acute pyelonephritis by comparing refluxing renal units with nonrefluxing renal units in children under age 5 with unilateral primary VUR. 34/48 (70.8%) refluxing units had positive DMSA on initial scan – dropped to 23/48 (47.9%) at 6 month follow-up DMSA. 13/48 (27.1%) of nonrefluxing units had a positive DMSA on initial scan – dropped to 7/48 (14.6%) at 6 month follow-up DMSA. No significant variance in scarring with VUR grade. VUR increases risk of post-pyelonephritic renal scars in children under age 5. 2
60. Orellana P, Baquedano P, Rangarajan V, et al. Relationship between acute pyelonephritis, renal scarring, and vesicoureteral reflux. Results of a coordinated research project. Pediatr Nephrol. 2004; 19(10):1122-1126. Review/Other-Dx 269 patients Prospective study to determine the incidence of permanent renal damage in children after pyelonephritis and its relationship to VUR and demographic and clinical data. 150/269 children with UTI had VUR. 170/269 children with UTI had permanent renal damage. Of children with VUR, 72% had permanent renal damage compared with 52% of children without VUR. DMSA should be performed if it will change patient management, particularly in those patients with recurrent UTI, VUR, and older age. 4
61. Peters CA, Skoog SJ, Arant BS, Jr., et al. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children. J Urol. 2010; 184(3):1134-1144. Review/Other-Dx 131 articles 17,972 patients To summarize the existing evidence pertaining to children with diagnosed reflux including those young or older than 1 year without evidence of bladder and bowel dysfunction and those older than 1 year with evidence of bladder and bowel dysfunction. Meta-analysis identified increasing frequency of UTI, increasing grade of VUR and presence of bladder and bowel dysfunction as unique risk factors for renal cortical scarring. The efficacy of continuous antibiotic prophylaxis could not be established with current data. However, its purported lack of efficacy, as reported in selected prospective clinical trials, also is unproven owing to significant limitations in these studies. Reflux resolution and endoscopic surgical success rates are dependent upon bladder and bowel dysfunction. The lack of robust prospective randomized controlled trials limits the strength of these guidelines but they can serve to provide a framework for practice and set boundaries for safe and effective practice. As new data emerge, these guidelines will necessarily evolve. 4
62. Brandstrom P, Neveus T, Sixt R, Stokland E, Jodal U, Hansson S. The Swedish reflux trial in children: IV. Renal damage. J Urol. 2010; 184(1):292-297. Experimental-Tx 203 total patients; 128 girls and 75 boys younger than 2 years with grade III-IV reflux Multicenter randomized trial to compare the development of new renal damage in small children with dilating VUR randomly allocated to antibiotic prophylaxis, endoscopic treatment or surveillance as the control group. New renal damage in a previously unscarred area was seen in 13 girls and 2 boys. 8/13 girls were on surveillance, 5 received endoscopic therapy and none were on prophylaxis (P=0.0155). New damage was more common in children with than without febrile recurrence (11/49 or 22% vs 4/152 or 3%, P<0.0001). In boys the rate of new renal damage was low. It was significantly higher in girls and most common in the control surveillance group. There was also a strong association between recurrent febrile UTI and new renal damage in girls. 1
63. Dalirani R, Mahyar A, Sharifian M, Mohkam M, Esfandiar N, Ghehsareh Ardestani A. The value of direct radionuclide cystography in the detection of vesicoureteral reflux in children with normal voiding cystourethrography. Pediatric Nephrology. 29(12):2341-5, 2014 Dec. Observational-Dx 35 children To assess the value of direct radionuclide cystography (DRNC) in the detection of Vesicoureteral reflux (VUR) in children with urinary tract infection (UTI) and a normal voiding cystourethrography (VCUG). The results were statistically analyzed. Among the 70 ureters studied, 33 (49.1 %) were observed to have VUR. Of these, 17 (51.5 %) had mild, 14 (42.4 %) moderate, and 2 (6.1 %) severe reflux. A significant relationship was observed between DRNC results and dimercaptosuccinic acid (DMSA) renal scan findings (P < 0.05). 3
64. Valavi E, Nickavar A, Parsamanesh M. Reliability of Sonography for the Prediction of Vesicoureteral Reflux in Children With Mild Hydronephrosis. JDMS 2021;37:353-57. Observational-Dx 248 children The objective of this study was to identify the significance of mild postnatal hydronephrosis (HN) as a marker of vesicoureteral reflux (VUR) and its severity. The majority of patients had mild (67.8%) HN, followed by moderate (27.6%) and severe (4.6%) HN. VUR was identified in 14.7% of patients with mild HN, 18.5% of patients with moderate HN, and 18.7% of patients with severe HN. About 11.44% of patients with mild HN had low-grade VUR, followed by moderate (45.71 %) and severe grades (42.85%). 3
65. Lee HY, Soh BH, Hong CH, Kim MJ, Han SW. The efficacy of ultrasound and dimercaptosuccinic acid scan in predicting vesicoureteral reflux in children below the age of 2 years with their first febrile urinary tract infection. Pediatr Nephrol. 2009; 24(10):2009-2013. Observational-Dx 220 children with first febrile UTI Retrospective study to evaluate the efficacy of DMSA scan and US in comparison with VCUG in predicting VUR in children below the age of 2 years. Among 220 children with their first febrile UTI, VUR was detected in 67 (30.4%). The detection rate of VUR by US was 41.7% and 86% in the low (I, II) and high grade (III~IV) groups, respectively. Detection rate of VUR by DMSA scan was 37.5% and 88.4% in the low and high grade groups, respectively. Combining US and DMSA scan, authors found that the detection rate of high grade VUR was 95.3% and that of low grade was 62.5%. During follow up, most of the low grade VURs with normal DMSA and US scans resolved or were downgraded. Most high grade VURs could be detected by US and DMSA scan, but the prediction rate was not as high in low grade VURs. 3
66. Quirino IG, Silva JM, Diniz JS, et al. Combined use of late phase dimercapto-succinic acid renal scintigraphy and ultrasound as first line screening after urinary tract infection in children. J Urol 2011; 185(1):258.-263. Observational-Dx 553 children To evaluate the diagnostic accuracy of DMSA renal scintigraphy and renal US in identifying high grade VUR in children after a first episode of UTI. 246 patients had reflux, of whom 144 (27%) had high grade (III to V) disease. Sensitivity, NPV and diagnostic OR of US for high grade reflux were 83.3%, 90.8% and 7.9, respectively. DMSA scan had the same sensitivity as US but a higher NPV (91.7%) and diagnostic OR (10.9). If both tests were analyzed in parallel by using the OR rule, ie, a negative diagnosis was established only when both test results were normal, sensitivity increased to 97%, NPV to 97% and diagnostic OR to 25.3. Only 9 children (6.3%) with dilating reflux had an absence of alterations in both tests. Findings support the idea that US and DMSA scan used in combination are reliable predictors of dilating VUR. 2
67. Biggi A, Dardanelli L, Pomero G, et al. Acute renal cortical scintigraphy in children with a first urinary tract infection. Pediatr Nephrol. 2001; 16(9):733-738. Observational-Dx 101 patients Prospective study to evaluate the diagnostic value of clinical, biological, and US parameters in detecting children with acute renal infection documented by DMSA scintigraphy. CRP is significantly higher in patients with severe kidney involvement than those with mild/moderate 151 vs 92 (P<0.015). WBC is significantly higher in patients with severe kidney involvement than those with mild/moderate 15k vs 20k (P<0.013). Sensitivity and specificity of CRP was 85% and 20%. Sensitivity and specificity of WBC was 77% and 18%. US detected abnormal cortical echogenicity in 2/70 (3%) of kidneys with abnormal DMSA scan. US detected collecting system dilatation in 17/70 (24%) of kidney with abnormal DMSA scan. Clinical, biological, and US parameters do not accurately distinguish cystitis from pyelonephritis in children with UTI and do not identify children with severe renal damage. DMSA should be added to initial workup of children with UTI. 2
68. Christian MT, McColl JH, MacKenzie JR, Beattie TJ. Risk assessment of renal cortical scarring with urinary tract infection by clinical features and ultrasonography. Arch Dis Child. 2000; 82(5):376-380. Observational-Dx 990 patients 404 children had upper tract UTI and 586 lower tract UTI To determine if renal cortical scarring in children with history of UTI would be missed if US were used in lieu of DMSA scan. 127/204 (62%) abnormal kidneys by DMSA had a normal US. 22% sensitivity for US detection of renal scarring. Risk of missing DMSA scarring by US between 0.4% and 11.1% depending on age of child and lower vs upper tract infection. US should not replace DMSA for detection of post-UTI scarring in children. 3
69. Giorgi LJ, Jr., Bratslavsky G, Kogan BA. Febrile urinary tract infections in infants: renal ultrasound remains necessary. J Urol. 2005; 173(2):568-570. Observational-Dx 282 consecutive patients Retrospective review to determine whether US has a role in the diagnosis and treatment of infants (<6 months old) with febrile UTI. 32/203 (16%) infants with normal VCUG had an abnormal US. 9 out of these 32 cases resulted in change in management/parental counseling. Renal/bladder US is recommended in the evaluation of febrile UTI in infants younger than 6 months. 3
70. Jahnukainen T, Honkinen O, Ruuskanen O, Mertsola J. Ultrasonography after the first febrile urinary tract infection in children. Eur J Pediatr. 2006; 165(8):556-559. Observational-Dx 155 patients 2 reviewers Retrospective study to determine whether US detects significant non-VUR upper tract abnormalities in hospitalized children with first febrile UTI and whether these findings alter management. 23/155 (14.8%) patients had an abnormal US during acute first febrile UTI. 81% of these patients were under age 2. 9/23 (39%) with abnormal US had a normal VCUG, 4 of whom underwent surgery. 9/23 (39%) patients with abnormal US had management changed. US performed after first febrile UTI can play a major role as a primary imaging tool and can affect management. 3
71. Temiz Y, Tarcan T, Onol FF, Alpay H, Simsek F. The efficacy of Tc99m dimercaptosuccinic acid (Tc-DMSA) scintigraphy and ultrasonography in detecting renal scars in children with primary vesicoureteral reflux (VUR). Int Urol Nephrol. 2006; 38(1):149-152. Observational-Dx 62 patients To compare the efficacy of DMSA and US in detecting renal scars in children with primary VUR. DMSA detected renal scars in 57% of reflexive units while US detected only 34%. All scars identified by US were also identified by DMSA. 21/51 (40%) of cases where DMSA demonstrates renal scarring were missed by US. DMSA detected scars in 35% of kidneys reported normal on US. US is an inappropriate study in the detection of renal parenchymal scars regardless of reflux grade. 3
72. Zamir G, Sakran W, Horowitz Y, Koren A, Miron D. Urinary tract infection: is there a need for routine renal ultrasonography? Arch Dis Child. 2004; 89(5):466-468. Observational-Dx 255 patients Prospective study to assess the yield of renal US in the management of children under 5 hospitalized with first uncomplicated febrile UTI. Sensitivity, specificity, PPV, and NPV of abnormal renal US for detecting VUR were 17.7%, 87.6%, 23.5%, and 83.2% respectively. Renal US did not cause a change in the management of any children during and following the admission. 3
73. Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med. 2003; 348(3):195-202. Experimental-Dx 309 patients; 2 independent reviewers Prospective study to assess the value of routine imaging studies after the diagnosis of first febrile UTI in children less than 2 years of age. US and an initial renal scan were obtained within 72 hours after diagnosis, contrast VCUG was performed one month later, and renal scanning was repeated six months later. Study was part of a multicenter, randomized clinical trial. 272/309 (88%) of patients had normal US during acute episode. The identified US abnormalities did not alter management. Renal US at the time of the acute illness is of limited value because it does not modify management. Routine performance of renal US after the diagnosis of first febrile UTI is not recommended in children who have undergone prenatal US after 30-32 weeks gestation. 2
74. Halevy R, Smolkin V, Bykov S, Chervinsky L, Sakran W, Koren A. Power Doppler ultrasonography in the diagnosis of acute childhood pyelonephritis. Pediatr Nephrol. 2004; 19(9):987-991. Observational-Dx 62 patients Comparative study to determine if power Doppler US is as sensitive as radionuclide scans in detecting childhood pyelonephritis. Power Doppler US had sensitivity of 87% and specificity of 92.3%. It does not require radiation; therefore, it may be a practical tool for the diagnosis of acute pyelonephritis in children. 1
75. Stogianni A, Nikolopoulos P, Oikonomou I, et al. Childhood acute pyelonephritis: comparison of power Doppler sonography and Tc-DMSA scintigraphy. Pediatr Radiol. 2007; 37(7):685-690. Observational-Dx 74 patients 147 kidneys To compare the predictive value of power Doppler US with DMSA in the diagnosis of pyelonephritis in possible UTI within the first 48 hours after symptom onset. Pyelonephritis was diagnosed by power Doppler US in 46 kidneys. Using DMSA as the gold standard, sensitivity and specificity for power Doppler were 74% and 86% respectively. Power Doppler US has acceptable specificity and sensitivity if performed within the first 48 hours. 2
76. Basiratnia M, Noohi AH, Lotfi M, Alavi MS. Power Doppler sonographic evaluation of acute childhood pyelonephritis. Pediatr Nephrol. 2006; 21(12):1854-1857. Observational-Dx 34 children with mean age of 2.8 +/- 2.7 years Prospective study to assess the role of power Doppler US for diagnosis of acute pyelonephritis compared with Tc-99m DMSA scan. According to the patient's number, sensitivity, specificity, PPV and NPV, and accuracy of power Doppler US were 89%, 53%, 70%, 80%, and 74%, respectively, but based on the renal units, changed to 66%, 81%, 46%, 91%, and 79%, respectively. Although power Doppler US has the potential for identifying acute pyelonephritis in children, it is still soon to replace DMSA scan. 2
77. Bykov S, Chervinsky L, Smolkin V, Halevi R, Garty I. Power Doppler sonography versus Tc-99m DMSA scintigraphy for diagnosing acute pyelonephritis in children: are these two methods comparable? Clin Nucl Med. 2003;28(3):198-203. Observational-Dx 40 patients (78 kidneys) Prospective study to assess the role of renal power Doppler US to detect acute pyelonephritis in hospitalized children under aged 6 with first time febrile UTI and clinically suspected pyelonephritis, and to determine if power Doppler US can replace Tc-99m DMSA in children. 27/78 (35%) kidneys appeared abnormal on DMSA. In 7/27 (26%) of these kidneys, power Doppler was normal. 51/78 (65%) kidneys appeared normal on DMSA. In 3/51 (6%) of these kidneys, power Doppler demonstrated apparent disease. Sensitivity, specificity, PPV and NPV for power Doppler US was 87%, 74%, 87% and 87% respectively. When considering lesions, power Doppler missed 16 lesions in 27 kidneys detected by DMSA (26% false negative rate; sensitivity 58%). A positive power Doppler renal US should obviate the use of DMSA in children with clinically suspected pyelonephritis. However, it cannot replace DMSA in the diagnosis of acute pyelonephritis in children. 1
78. Keren R, Carpenter MA, Hoberman A, et al. Rationale and design issues of the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. Pediatrics. 2008; 122 Suppl 5:S240-250. Review/Other-Dx 600 children aged 2 to 72 months will be recruited To determine if antimicrobial prophylaxis with trimethoprim/sulfamethoxazole prevents recurrent UTI and renal scarring in children who are found to have VUR after a first or second UTI in an ongoing Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. The primary outcome is recurrence of UTI. Secondary outcomes include time to recurrent UTI, renal scarring (assessed by DMSA scan), treatment failure, renal function, resource utilization, and development of antimicrobial resistance in stool flora. The RIVUR study will provide useful information to clinicians about the risks and benefits of prophylactic antibiotics for children who are diagnosed with VUR after a first or second UTI. The data and specimens collected over the course of the study will allow researchers to better understand the pathophysiology of recurrent UTI and its sequelae. (The trial is still recruiting study subjects and results are not available yet.) 4
79. Mazzola BL, von Vigier RO, Marchand S, Tonz M, Bianchetti MG. Behavioral and functional abnormalities linked with recurrent urinary tract infections in girls. J Nephrol. 2003;16(1):133-138. Review/Other-Dx 141 girls To determine if predisposing behavioral and functional abnormalities: infrequent voiding, inadequate fluid intake, stool retention, poor genital hygiene and voiding dysfunction are associated with recurrent urinary tract infections. A total of 141 girls aged 3.9 to 18 years were evaluated between 1996 and 1999; 212 abnormalities were noted in 120 patients: infrequent voiding (isolated, 16; combined with other abnormalities, 47), poor fluid intake (isolated, 10; combined, 50), functional stool retention (isolated, 5; combined, 25), inadequate hygiene or toilet habits (isolated, 3; combined, 24), dysfunctional voiding (isolated, 15; combined, 10), bladder overactivity (isolated, 5; combined, 2). 4
80. Cheng CH, Tsai MH, Su LH, et al. Renal abscess in children: a 10-year clinical and radiologic experience in a tertiary medical center. Pediatr Infect Dis J. 2008; 27(11):1025-1027. Observational-Dx 45 children To compare the demographic data and clinical results of patients with different US admission indications for subsequent CT confirmation at 2 different regimes (1997–2003 and 2004–2006). CT image analysis revealed that 43 patients presented radiologic features of acute lobar nephronia in addition to renal abscesses in the affected kidneys. Statistical analysis revealed no significant differences in the gender distribution, age, VUR, clinical symptoms, WBC count, serum CRP, E. coli percentage in urine culture, and the preadmission fever duration between the first (18 patients) and second (27 patients) study periods. However, longer fever continuation after antibiotic treatment was noted in the first study period (14.1-7.1 vs 7.8-6.1 day; P=0.01). In addition, for patients in the first study period, it took longer to have the final CT confirmation after the onset of the symptoms and signs (11.9-4.2 vs 7.8-4.0 days; P=0.01). Experiences gained from this 10-year study on patients with CT-proved diagnosis include the varied clinical presentations and use of sonographic marked nephromegaly and focal mass as indications for further CT diagnosis. 3
81. Cheng CH, Tsau YK, Lin TY. Is acute lobar nephronia the midpoint in the spectrum of upper urinary tract infections between acute pyelonephritis and renal abscess? J Pediatr. 2010;156(1):82-86. Review/Other-Dx 115 patients To examine acute lobar nephronia (ALN) in the spectrum of upper urinary tract infections between acute pyelonephritis (APN) and renal abscess. The study included 21 patients with APN, 85 with ALN (63 simple ALN, 22 complicated ALN), and 9 with renal abscesses. The volume fraction of CT lesions correlated well with duration of fever before and after treatment in patients with APN or simple ALN, and only the correlation between fever duration after treatment and CT lesions was significant in patients with complicated ALN or renal abscess. 4
82. Comploj E, Cassar W, Farina A, et al. Conservative management of paediatric renal abscess. J Pediatr Urol. 2013;9(6 Pt B):1214-1217. Review/Other-Dx 6 children To describe the conservative management of renal abscesses without percutaneous drainage in 6 children In all patients, the abscesses were solitary, unilateral and located in the right kidney. The median abscess diameter was 38 mm. The diagnosis was made by ultrasonography. All 6 children were treated conservatively with a urinary catheter or suprapubic catheter and broad-spectrum antibiotics. None of the renal abscesses were surgically or percutaneously drained. 4
83. Schmidt B, Copp HL. Work-up of Pediatric Urinary Tract Infection. [Review]. Urol Clin North Am. 42(4):519-26, 2015 Nov. Review/Other-Tx N/A To discuss the work up of a pediatric patient with urinary tract infections. No results stated in the abstract. 4
84. De Palma D, Manzoni G. Different imaging strategies in febrile urinary tract infection in childhood. What, when, why? Pediatr Radiol. 2013;43(4):436-443. Review/Other-Dx N/A To critically analyze and give to the reader a complete, up-to-date and flexible overview recommendations of published guidelines and strengths and weaknesses of the available biochemical and imaging tools No results stated in abstract 4
85. Swerkersson S, Jodal U, Sixt R, Stokland E, Hansson S. Urinary tract infection in small children: the evolution of renal damage over time. Pediatric Nephrology. 32(10):1907-1913, 2017 10. Observational-Dx 103 patients To analyze the evolution of kidney damage over time in small children with urinary tract infection (UTI) and factors associated with progression of renal damage. Of 103 children, 20 showed progression, 20 regression, and 63 remained unchanged. There were no differences between groups regarding gender or age. In the progression group, 16/20 (80%) children had vesicoureteral reflux (VUR) grade III-V and 13 (65%) had recurrent UTI. In multivariable regression analysis, both VUR grade III-V and recurrent UTI were associated with progression. In the regression group, 16/20 (80%) had no VUR or grade I-II, and two (10%) had recurrent UTI. 3
86. Kocyigit A, Yuksel S, Bayram R, Yilmaz I, Karabulut N. Efficacy of magnetic resonance urography in detecting renal scars in children with vesicoureteral reflux. Pediatric Nephrology. 29(7):1215-20, 2014 Jul. Observational-Dx 49 children (10 boys, 39 girls) The aim of our study was to compare the efficacy of unenhanced magnetic resonance urography (MRU) and Tc-99m dimercaptosuccinic acid (Tc-DMSA) scintigraphy to dectect renal scars. The renal scar detection rate of Tc-DMSA scintigraphyand unenhanced MRU in kidneys with VUR was 32.4and 25.9 %, respectively. The sensitivity and specificity ofMRU in the detection of renal scars was 80 and 82.6 % inkidneys with VUR, respectively. There was no statisticallysignificant difference in lesion detection between MRU andTc-DMSA scintigraphy (P>0.05).MRU and Tc-DMSA scintigraphyshowed good agreement (?=0.60). 3
87. Kocaoglu M, Bulakbasi N, Ilica AT, Gok F, Tayfun C, Somuncu I. Intravenous contrast-enhanced dynamic MR urography: diagnosis of vesicoureteral reflux during bladder filling with time-signal intensity curves. J Magn Reson Imaging 2006;24:349-55. Observational-Dx 26 patients (15 females, 11 males) To evaluate the time-signal intensity (SI) curves generated from intravenous (IV) gadodiamide-enhanced dynamic magnetic resonance (MR) urographic scans for identifying vesicoureteral reflux (VUR) during bladder filling. Twelve ureterorenal units of eight patients (four bilateral and four unilateral) had VUR during bladder filling on VCUG. The time-SI curves of these patients showed intermittent (N = 8 ureterorenal units), and constantly increasing (N = 4 ureterorenal units) SI peaks consistent with VUR. One patient also had bilateral abnormal time-SI curves suggesting VUR despite the normal VCUG study. In the control group, 25 units had normal triphase time-SI curves, six renal units had urinary dilatation with good washout after diuretic injection, and four renal units had upper urinary dilatation without contrast washout, while five renal units did not show any function. None of the patients in the control group revealed distortion in the time-SI curve. The differences in time-SI curves patterns between the control group and patients with VUR during bladder filling were statistically significant (P < 0.001). 3
88. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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