Background Newborns sleep about 80% of the time. Gastroesophageal reflux (GER) disease is prevalent in about 10% of NICU infants. Concurrent polysomnography and pH-impedance studies clarify relationship of GER with sleep. Aims To characterize spatio-temporal and chemical characteristics of impedance-positive GER and define symptom associations in sleep and wake states in symptomatic neonates. We hypothesized that frequency of impedance-positive GER events and their association with cardiorespiratory symptoms is greater during sleep. Methods Eighteen neonates underwent concurrent polysomnography with pH-impedance study. Impedance-positive GER events (weakly acidic or acidic) were categorized between sleep vs. wake states: Symptom Index = # of symptoms with GER/total symptoms*100, Symptom Sensitivity Index = # of GER with symptoms/Total GER*100 and Symptom Association Probability = [(1-Probability of observed association between reflux and symptoms)*100]). Results We analyzed 317 GER events during 116 hours of polysomnography. During wake vs. sleep respectively, the median (interquartile range) frequency of impedance-positive GER was 4.9(3.1–5.8) vs. 1.4(0.7–1.7)events/hour (P<0.001), proximal migration was 2.6(0.8–3.3) vs. 0.2(0.0–0.9)events/hour (P<0.001); Symptom Index for cardiorespiratory symptoms for impedance-positive events was 22.5 (0–55.3) vs. 6.1(0–13), P=0.04 while Symptom Sensitivity Index was 9.1(0–23.1) vs. 18.4 (0–50), P=0.04 though Symptom Association Probability was similar, (P=0.68). Conclusions Contrary to our hypothesis, frequency of GER in sleep is lesser; however, spatio-temporal and chemical characteristics of GER and symptom generation mechanisms are distinct. For cardiorespiratory symptoms during sleep, lower Symptom Index entails evaluation for etiologies other than GER disease, higher Symptom Sensitivity Index implies heightened esophageal sensitivity and similar Symptom Association Probability indicates other mechanistic possibilities.

The past 30 years have seen broad changes in the diagnosis and management of vesicoureteral reflux (VUR). Recently, a clinical debate has generated an open discussion in academic circles. New evidence has shifted treatment patterns away from widespread surgical management and recently brought into question some pharmacologic treatments. VUR is usually not hazardous by itself but is a significant risk factor for urinary tract infection (UTI) and less commonly, renal scarring and insufficiency. Given the costs and morbidity of UTI as well as the potential for significant renal injury, our approach remains conservative. Careful follow-up, parental education about pathophysiology and management of VUR and UTI, and management of bowel and bladder dysfunction (BBD) when present, are the foundation of treatment. Additionally, though we recognize the limitation of continuous antibiotic prophylaxis (CAP), we believe the benefits outweigh the risks and costs for many patients. Careful observation can be considered in patients with a single medical home, parental understanding of what UTI signs and symptoms are, low grade VUR, no history of complicated UTIs and close follow-up. Surgical management remains a relevant option for select patients who fail conservative measures with breakthrough UTIs or failure to resolve. Minimally invasive surgical options are available with acceptable outcomes though open ureteroneocystostomy still carries the highest success rate.

Low sociocultural status of the mother within the family is significantly associated with having a LBW-SGA baby. Further studies are warranted to study this risk factor.

IntroductionVesicoureteral reflux is a common disorder in children but can result in kidney scarring following acute pyelonephritis. The gold standard diagnostic to detect renal scars in children is 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy. DMSA has a number of limitations including radiation exposure, need for sedation, and radiotracer supply shortages. Contrast-enhanced ultrasound (CEUS) is a technique whereby biocompatible microspheres of inert gas are administered i.v. that reflect ultrasonography sound waves and do not involve radiation. Because the contrast agent is rapidly cleared, contrast images must be obtained within minutes of administration. CEUS has been used in a variety of organ systems, but its use in pediatric kidney diseases is limited.MethodsIn this study, we performed CEUS in 7 children with documented renal scars by radiographic imaging consistent with reflux nephropathy.ResultsIn all subjects, CEUS detected all previously known radiologic abnormalities as well as detecting new areas of hypoenhancing renal parenchyma. None of the patients experienced any serious adverse events.DiscussionThis study represents the first report of using CEUS to characterize renal scars in children with reflux nephropathy. We conclude that CEUS is a highly sensitive, rapid, and cost-effective diagnostic imaging modality for detecting and monitoring renal scars in children with vesicoureteral reflux.

Objectives To describe the pattern of gastro-esophageal reflux (GER) events in wake and sleep states with increasing acid reflux index (ARI) in neonates and to test the hypothesis that GER-related symptoms are frequent in ARI> 7% in wake-state. Study design Infants underwent 24-hour pH-impedance studies with 6-hour concurrent video-polysomnography studies. Data were stratified based on the 24-hr ARI (% duration that esophageal pH is <4) into ARI<3% (normal), ARI 3≥ to ≤7% (intermediate) and ARI>7% (abnormal). GER frequency, clearance mechanisms and symptoms were distinguished during wake-state and sleep-state. Results Total wake and sleep duration was similar (p≥ 0.2) in all ARI groups. Acidic events were frequent with increasing ARI in wake-state vs. sleep-state (p≤ 0.03). The Symptom Index increased with increasing ARI (p≤ 0.02) in both wake-state and sleep-state. Acid clearance time increased with increasing ARI in wake-state (p≤ 0.02). In ARI>7% vs. ARI≤7%, frequency of acidic GER events was higher (p≤0.02) in wake-state and sleep-state; proximal migration of acid (p=0.03) and acid clearance time were higher in wake-state (p=0.0005) only. Symptom index was higher in ARI>7% vs. ARI≤7% in wake-state (p<0.0001), comparable in normal vs. intermediate (p=0.4) and higher in abnormal vs. intermediate (p=0.0004) groups. Conclusions Severe esophageal acid exposure (ARI>7%) is associated with increased reflux-associated symptoms in wake-state. Sleep-state appears to be protective regardless of ARI, likely due to greater chemosensory thresholds. Attention to posture and movements during wake-state can be helpful. Scrutiny for non-GER etiologies should occur for infants presenting with life-threatening symptoms.

The first method developed to translate customer requirements into software specification was the Quality Function deployment (QFD) and the second approach to the identification of software specification comes from the software engineering. Requirements may be defined as a demand or need. In software engineering, a requirement is a description of what a system should do. System may have dozen to thousands of requirements.Software requirements stipulate what must be accomplished, transformed, produced or provided. It is well documented that requirement engineering saves money. There are several techniques to elicit the software requirements like JAD, misuse, RAD, Web Surveys etc. In this paper we have used the Web Surveys approach to elicit the software requirements for a railway projects. The main objective of this paper is to improve the effectiveness and the efficiency of the freight transportation between source and destination using optimization algorithm.

Urinary tract infections (UTI), associated with vesicoureteral reflux (VUR), can lead to chronic kidney disease. Genetic alterations in the innate immune defenses contribute to UTI risk. We investigated a novel gene, Dachsous Cadherin-Related 1 ( DCHS1), in children with UTI. We determined absolute DNA copy number (CN) of DCHS1 in children with UTI. In this case-control study, we utilized multiple complementary methods to determine the genomic CN of DCHS1. Children with ( n = 370) and without ( n = 71) VUR from two well-phenotyped clinical trials of UTI were copy-typed and compared to 491 healthy controls with no known history of VUR or UTI. Less than 1% of controls had a single copy of DCHS1, while 31% of children with UTI and no VUR and 7% of children with UTI and VUR had a single copy of the DCHS1 gene. Using immunostaining, we localized expression postnatally to the bladder and renal epithelia. Mice were also challenged with two uropathogenic Escherichia coli strains, and Dchs1 mRNA was quantified. This study represents the first report of DCHS1 in association with pediatric UTI. We hypothesize that its role in innate immunity is critical to lower urinary tract defense. Further investigation is required to determine the role of DCHS1 in innate immunity.

AimTo find the trend in patient’s visits to our centers for vesicoureteral reflux (VUR). We hypothesize that VUR diagnosis and hence possible nephropathy recognition may be diminishing because of changing practice patterns.MethodsData were extracted from electronic medical records for new and follow-up patients aged 0–18 years with ICD-9/10 codes to correspond with VUR, VUR unilateral, VUR bilateral, and VUR with reflux nephropathy, as well as new patients with diagnoses of urinary tract infections (UTI) and pyelonephritis at two major pediatric centers from 2012 to 2015. Figures and statistics to reflect absolute clinic visits and annual trends were created with SPSS 2010. Linear regression was applied.ResultsAnnually, Le Bonheur Children’s Hospital and Nationwide Children’s Hospital experienced an average decrease of 13 and 17% in total VUR visits, and an average decrease of 22 and 27% in VUR nephropathy visits, respectively, for each institution. Patient visits for UTIs were reduced an average of 16% annually in both centers. Linear regression demonstrated that number of patients (patients/year ± SE) decreased annually 69 ± 19 (P = 0.02), 7 ± 2 (P = 0.02), and 67 ± 25 (P = 0.04) for VUR, VUR nephropathy, and UTI, respectively.ConclusionWe conclude that the decreased number of VUR and VUR nephropathy cases identified in subspecialty clinics (Nephrology/Urology) at two major children’s hospitals reflect a possible decreased identification of VUR. This trend may also be due to decreased referral of low grade cases of VUR. We cannot conclude that “undifferentiated UTI” referrals increased concomitantly to account for the decreased VUR as our data reflects a decreased trend in those visits as well. We suggest that clinicians following the American Academy of Pediatrics guidelines ensure that all UTI are accounted for and surveillance is appropriately escalated for recurrent UTI or abnormal imaging results.