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Martin rГјther

Martin RГјther

AKH Wien, WГ¤hringer GГјrtel , Wien e-mail: [email protected] Abstract Dr. W RГјther В° OrthopГ¤dische Klinik Wiesbaden, Direktor: Prof.

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Martin RГјther Video

Prevention of recurrent urinary infections in women: a comparative trial between nitrofurantoin and methenamine hippurate.

J Urol Jul; 1 Long-term prophylaxis of urinary infections in women: comparative trial of trimethoprim, methenamine hippurate and topical povidoneiodine.

J Urol Dec; 6 The incidence of UTI varies depending on age and sex. In the first year of life, mostly the first 3 months, UTI is more common in boys 3.

Paediatric UTI is the most common cause of fever of unknown origin in boys less than 3 years. The clinical presentation of a UTI in infants and young children can vary from fever to gastrointestinal, lower or upper urinary tract symptoms.

The objective is to rule out the unusual occurrence of obstruction, vesicoureteric reflux VUR and dysfunctional voiding, e.

Chronic pyelonephritic renal scarring develops very early in life due to the combination of a UTI, intrarenal reflux and VUR.

It sometimes arises in utero due to dysplasia. Although rare, renal scarring may lead to severe long-term complications such as hypertension and chronic renal failure.

Vesicoureteric reflux is treated with long-term prophylactic antibiotics GR: B. Surgical re-implantation or endoscopic treatment is reserved for the small number of children with breakthrough infection GR: B.

In the treatment of a UTI in children, short courses are not advised and therefore treatment is continued for days and longer GR: A. If the child is severely ill with vomiting and dehydration, hospital admission is required and parenteral antibiotics are given initially GR: A.

It represents the most common bacterial infection in children less than 2 years of age 1 LE: 2a. The outcome of a UTI is usually benign, but in early infancy it can progress to renal scarring, especially when associated with congenital anomalies of the urinary tract.

Delayed sequelae related to renal scarring include hypertension, proteinuria, renal damage and even chronic renal failure, requiring dialysis treatment in a significant number of adults 2 LE: 2a.

The incidence is different for children under 3 months of age, when it is more common in males. The incidence of asymptomatic bacteriuria is 0.

The incidence of symptomatic bacteriuria is 0. Hospital-acquired infections show a wider pattern of aggressive organisms, such as Klebsiella, Serratia and Pseudomonas spp.

Groups A and B streptococci are relatively common in the newborn 6. There is an increasing trend towards the isolation of Staphylococcus saprophyticus in UTIs in children, although the role of this organism is still debatable 7.

Retrograde ascent is the most common mechanism of infection. Nosocomial infection and involvement as part of a systemic infection are less common 8.

Obstruction and dysfunction are among the most common causes of urinary infection. Enterobacteria derived from intestinal flora colonize the preputial sac, glandular surface and the distal urethra.

Among these organisms are strains of E. A wide variety of congenital urinary tract abnormalities can cause UTIs through obstruction, e.

More mundane but significant causes of UTIs include labial adhesion and chronic constipation 7. Dysfunctional voiding in an otherwise normal child may result in infrequent bladder emptying aided by delaying manoeuvres, e.

Neuropathic bladder dysfunction spina bifida, sphincter dyssynergia, etc may lead to postvoid residual urine and secondary VUR 4.

The link between renal damage and UTIs is controversial. The mechanism in obstructive nephropathy is self-evident, but more subtle changes occur where there is VUR.

These must all work together in early childhood when the growing kidney is likely to be susceptible to parenchymal infection.

Later on in childhood, the presence of bacteriuria seems irrelevant to the progression of existing scars or the very unusual formation of new scars.

Another confounding factor is that many so-called scars are dysplastic renal tissue which developed in utero Epididymoorchitis is extremely unusual.

With scrotal pain and inflammation in a boy, testicular torsion has to be considered. A UTI in neonates may be non-specific and with no localization.

In small children, a UTI may present with gastrointestinal signs, such as vomiting and diarrhoea. In the first weeks of life, Rarely, septic shock will be the presentation.

Signs of a UTI may be vague in small children, but later on, when they are older than 2 years, frequent voiding, dysuria and suprapubic, abdominal or lumbar pain may appear with or without fever.

From the clinical point of view, severe and simple forms of UTIs should be differentiated because to some extent the severity of symptoms dictates the degree of urgency with which investigation and treatment are to be undertaken Table 3.

Table 3. The child is only slightly or not dehydrated and has a good expected level of compliance. When a low level of compliance is expected, such a child should be managed as one with a severe UTI.

The absence of fever does not exclude the presence of an infective process. Urine must be obtained under bacteriologically reliable conditions when undertaking a urine specimen culture The urine specimen may be difficult to obtain in a child less than 4 years old and different methods are advised since there is a high risk of contamination 17, In order to obtain a urine sample in the best condition in children under 2 years of age girls and uncircumcised boys without sphincteric control , it is better to use suprapubic bladder aspiration or bladder catheterization.

In older children with sphincteric control, midstream urine MSU collection is possible and reliable The presence of pyuria more than 5 leucocytes per field and bacteriuria in a fresh urine sample will reinforce the clinical diagnosis of UTI In these cases, it is better to repeat the culture or to evaluate the presence of other signs, such as pyuria, nitrites or other biochemical markers When an infection is caused by Gram-positive bacteria, the test may be negative 8, A combination of nitrite and leucocyte esterase testing improves sensitivity and specificity, but carries the risk of false-positive results The dipstick test has become useful to exclude rapidly and reliably the presence of a UTI, provided both nitrite and leucocyte esterase tests are negative.

If the tests are positive, it is better to confirm the results in combination with the clinical symptoms and other tests 17, In such cases, it is advisable to repeat the urinalysis after 24 hours to clarify the situation.

Even in febrile children with a positive urine culture, the absence of pyuria may cast doubt on the diagnosis of UTI.

Instead, asymptomatic bacteriuria with a concomitant septic focus responsible for the febrile syndrome has to be considered.

Bacteriuria without pyuria is found in 0. This figure corresponds well with the estimated rate of asymptomatic bacteriuria in childhood 20, 22 LE: 2a.

Chlamydia trachomatis. Thus, either bacteriuria or pyuria may not be considered reliable parameters to diagnose or exclude UTI.

Their assessment can be influenced by other factors, such as the degree of hydration, method of specimen collection, mode of centrifugation, volume in which sediment is resuspended and subjective interpretation of results However, according to Landau et al.

For all of these reasons, in neonates and children under 6 months of age, either pyuria, bacteriuria or the nitrite test, separately, have minimal predictive value for UTI 25,26 LE: 3.

Current techniques do not fulfil all such requirements. It is subjective and therefore operator-dependent, and gives no information on renal function.

However, scars can be identified, although not as well as with technetiumm dimercaptosuccinic acid Tcm DMSA scanning 29,30 LE: 2a.

This technique has been shown to be very sensitive and excretory urography must be reserved only for when images need to be morphologically clarified 31 LE: 2a.

This technique is helpful in determining functional renal mass and ensures an accurate diagnosis of cortical scarring by showing areas of hypoactivity indicating lack of function.

A UTI interferes with the uptake of this radiotracer by the proximal renal tubular cells, and may show areas of focal defect in the renal parenchyma.

A star-shaped defect in the renal parenchyma may indicate an acute episode of pyelonephritis. A focal scarring or a smooth uniform loss of renal substance as demonstrated by Tcm DMSA has generally been regarded as being associated with VUR reflux nephropathy 35, However, Rushton et al.

Minimal parenchymal defects, when characterized by a slight area of hypoactivity, can resolve with antimicrobial therapy 39, However, defects lasting longer than 5 months are considered to be renal scarring 41 LE: 2a.

Tcm DMSA scans are considered more sensitive than excretory urography and ultrasonography in the detection of renal scars It remains questionable whether radionuclide scans could substitute for echography as a first-line diagnostic approach in children with a UTI 46, It is considered mandatory in the evaluation of UTIs in children less than 1 year of age.

Its main drawbacks are the risk of infection, the need for retrogrades filling of the bladder and the possible deleterious effect of radiation on children In recent years, tailored low-dose fluoroscopic VCU has been used for the evaluation of VUR in girls in order to minimize radiological exposure Voiding cystourethrography is mandatory in the assessment of febrile childhood UTI, even in the presence of normal ultrasonography.

It represents an attractive alternative to conventional cystography, especially when following patients with reflux, because of its lower dose of radiation.

Disadvantages are a poor image resolution and difficulty in detecting lower urinary tract abnormalities 51, Further studies are necessary to determine the role of this new imaging modality in UTI.

The major disadvantages in infants are the risks of side effects from exposure to contrast media and radiation However, the role of excretory urography is declining with the increasing technical superiority of CT 54 and MRI.

However, the indications for their use is still limited in UTI. Only a minority of children with a UTI have an underlying urological disorder, but when present such a disorder can cause considerable morbidity.

Thus, after a maximum of two UTI episodes in a girl and one episode in a boy, investigations should be undertaken Figure 3.

Figure 3. Antimicrobial treatment has to be initiated on an empirical basis, but should be adjusted according to culture results as soon as possible.

In patients with an allergy to cephalosporins, aztreonam or gentamicin may be used. When aminoglycosides are necessary, serum levels should be monitored for dose adjustment.

Chloramphenicol, sulphonamides, tetracyclines, rifampicin, amphotericin B and quinolones should be avoided.

The use of ceftriaxone must also be avoided due to its undesired side effect of jaundice. A wide variety of antimicrobials can be used in older children, with the exception of tetracyclines because of teeth staining.

Fluorinated quinolones may produce cartilage toxicity 58 , but if necessary may be used as second-line therapy in the treatment of serious infections, since musculoskeletal adverse events are of moderate intensity and transient 60, For a safety period of hours, parenteral therapy should be administered.

This provides some advantages, such as less psychological impact on the child and more comfort for the whole family.

It is also less expensive, well tolerated and eventually prevents opportunistic infections However, the indication for TMP is declining in areas with increasing resistance.

UPDATE APRIL 39 In children less than 3 years of age, who have difficulty taking oral medications, parenteral treatment for days seems advisable, with similar results to those with oral treatment If there are significant abnormalities in the urinary tract e.

VUR, obstruction , appropriate urological intervention should be considered. If renal scarring is detected, the patient will need careful follow-up by a paediatrician in anticipation of sequelae such as hypertension, renal function impairment and recurrent UTI.

An overview of the treatment of febrile UTIs in children is given in Figure 3. Treatment of febrile UTIs in children.

A single parenteral dose may be used in cases of doubtful compliance and with a normal urinary tract 66 LE: 2a.

If the response is poor or complications develop, the child must be admitted to hospital for parenteral treatment It may also be used after an acute episode of UTI until the diagnostic work-up is completed.

The most effective antimicrobial agents are: nitrofurantoin, TMP, cephalexin and cefaclor Jodal U.

The natural history of bacteriuria in childhood. Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up.

BMJ Sep; Voiding dysfunction in children. Urol Clin North Am Aug;31 3 , ix. Infections of the urinary tract. Pediatr Infect Dis J Feb;11 2 Nosocomial infections in pediatric intensive care units in the United States.

National Nosocomial Infections Surveillance System. Pediatrics Apr; 4 :e Staphylococcus saprophyticus urinary tract infections in children.

Eur J Pediatr Jan; 1 Urinary tract infection in children: etiology and epidemiology. Urol Clin North Am Aug;31 3 , ix-x.

Effect of circumcision on incidence of urinary tract infection in preschool boys. J Pediatr Jan; 1 Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection.

Lancet Dec; Adherence of bacteria to human foreskins. J Urol Nov; 5 Toilet habits of children evaluated for urinary tract infection.

J Urol Aug; 2 Pt 2 The characteristics of primary vesico-ureteric reflux in male and female infants with pre-natal hydronephrosis.

Br J Urol Aug;80 2 Urinary tract infection in febrile infants younger than eight weeks of Age. Pediatrics Feb; 2 :E Diagnosis and management of pediatric urinary tract infections.

Clin Microbiol Rev Apr 2 Pediatric urinary tract infection. Urinary tract infection in children: pathophysiology, risk factors and management.

Infect Med ; Hoberman A, Wald ER. Urinary tract infections in young febrile children. Pediatr Infect Dis J Jan;16 1 The urine dipstick test useful to rule out infections.

A meta-analysis of the accuracy. BMC Urol Jun; Spontaneous clearance of asymptomatic bacteriuria in infants.

Acta Paediatr Scand Mar;79 3 Measurement of pyuria and its relation to bacteriuria. Am J Med Jul;75 1B The value of urinalysis in differentiating acute pyelonephritis from lower urinary tract infection in febrile infants.

Pediatr Infect Dis J Sep;13 9 Prevalence of urinary tract infection in febrile infants. J Pediatr Jul; 1 Diagnosis and management of urinary tract infections.

Curr Opin Urol Feb; Urinary N-acetylbetaglucosaminidase and betamicroglobulin in the diagnosis of urinary tract infection in febrile infants.

Pediatr Infect Dis J Apr;13 4 Interleukin 6 response to urinary tract infection in childhood.

Pediatr Infect Dis J Jul;13 7 The sensitivity of renal scintigraphy and sonography in detecting nonobstructive acute pyelonephritis.

Sonographic measurement of renal enlargement in children with acute pyelonephritis and time needed for resolution: implications for renal growth assessment.

Urinary tract infection in infants and children evaluated by ultrasound. Radiology Feb; 2 Imaging in acute pyelonephritis.

Curr Opin Urol Jan; Vesico-ureteric reflux in the damaged non-scarred kidney. Pediatr Nephrol Jan;6 1 Renal radionuclide studies.

Textbook of genitourinary surgery. Oxford: Blackwell Science, ; pp. Evaluation of acute urinary tract infection in children by dimercaptosuccinic acid scintigraphy: a prospective study.

J Urol Nov; 5 Pt 2 Diagnostic significance of 99mTc-dimercaptosuccinic acid DMSA scintigraphy in urinary tract infection. Arch Dis Child Nov;67 11 Renal scarring following reflux and nonreflux pyelonephritis in children: evaluation with 99mtechnetium-dimercaptosuccinic acid scintigraphy.

J Urol May; 5 Renal papillary morphology in infants and young children. Urol Res Oct;3 3 The small scarred kidney of childhood.

A congenital or an acquired lesion. Pediatr Nephrol Oct;1 4 Renal pathology and the 99mTcDMSA image during the evolution of the early pyelonephritic scar: an experimental study.

Transient pyelonephritic changes on 99mTechnetium-dimercaptosuccinic acid scan for at least five months after infection.

Acta Paediatr Aug;86 8 Evaluation of 99mtechnetium-dimercapto-succinic acid renal scans in experimental acute pyelonephritis in piglets. Radiologic evaluation of urinary tract infection.

Int Urol Nephrol ;27 1 Comparison of DMSA scintigraphy with intravenous urography for the detection of renal scarring and its correlation with vesicoureteric reflux.

Br J Urol Mar;69 3 The value of ultrasound in the child with an acute urinary tract infection. Br J Urol Aug;74 2 Does routine ultrasound have a role in the investigation of children with urinary tract infection?

Clin Radiol May;49 5 Further investigation of confirmed urinary tract infection UTI in children under five years: a systematic review.

BMC Pediatr Mar;5 1 A practical approach to evaluating urinary tract infection in children. Pediatr Nephrol Jul;5 4 Tailored low-dose fluoroscopic voiding cystourethrography for the reevaluation of vesicoureteral reflux in girls.

Paediatric urinary tract infection and the necessity of complete urological imaging. BJU Int Jul;86 1 How good is technetiumm mercaptoacetyltriglycine indirect cystography?

Eur J Nucl Med Mar;21 3 : Cystosonography and voiding cystourethrography in the diagnosis of vesicoureteral reflux.

Pediatr Nephrol Jan;18 1 Barcelona: Ed Prous, ; pp. Acute bacterial nephritis: a clinicoradiologic correlation based on computer tomography.

Am J Med Sep;93 3 Relationship among vesicoureteral reflux, Pfimbriated Escherichia coli, and acute pyelonephritis in children with febrile urinary tract infection.

J Pediatr Oct; 4 Involvement of the renal parenchyma in acute urinary tract infection: the contribution of 99mTc dimercaptosuccinic acid scan.

Eur J Pediatr Jul; 7 Pitfalls in the investigation of children with urinary tract infection. Arch Dis Child Mar;72 3 Urinary tract infection: a comparison of four methods of investigation.

Infeccion urinaria. Madrid: Ed Aula Medica, ; pp. Safety profile of quinolone antibiotics in the pediatric population.

Pediatr Infect Dis J Mar;22 12 Prescrire Int Oct;13 73 Antibiotics for acute pyelonephritis in children. DGPI ed. Futuramed: Munich, , pp.

Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Short-course versus conventional length antimicrobial therapy for uncomplicated lower urinary tract infections in children: a meta-analysis of patients.

Efficacy of single-dose therapy of urinary tract infection in infants and children: a review. J Nalt Med Assoc Sep;86 9 Old and new concepts.

Pediatr Clin North Am Dec;42 6 : Prophylactic co-trimoxazole and trimethoprim in the management of urinary tract infection in children.

Pediatr Nephrol Jan;2 1 Vesicoureteral reflux and evidence-based management. J Pediatr Nov; 5 However, if in the adult, the kidney is normal beforehand, chronic renal damage is most unlikely.

There is no evidence that more prolonged or intensive antibiotic treatment of acute pyelonephritis will shorten the episode or prevent complications.

In diabetes mellitus, overwhelming infection can predispose to pyogenic infection with intrarenal perinephric abscess formation, emphysematous pyelonephritis, and, very rarely, a specific form of infective interstitial nephropathy.

Papillary necrosis is a common consequence of pyelonephritis in diabetics. Females are more prone to asymptomatic bacteriuria than diabetic men but in both sexes progression to clinical pyelonephritis is more likely than in normal individuals.

The risk factors for developing asymptomatic bacteriuria differ between type I and type II diabetes.

It is arguable that diabetic patients are susceptible to rapid progression of parenchymal infection. However, the clearance of asymptomatic bacteriuria should not be attempted if the intention is to prevent complications, notably acute pyelonephritis GR: A.

Typically, adult polycystic kidney disease APCKD , gross vesicoureteric reflux VUR and endstage obstructive uropathy will harbour infective foci or promote ascending infection, but not invariably so.

Clearly, severe urinary tract infection UTI with accompanying bacteraemia can hasten progression of renal failure, but there is little evidence that vigorous treatment of lesser degrees of infection or prophylaxis will slow renal functional impairment once it is established C.

Bilateral nephrectomy should be utilized as a last resort GR: B. Nephrectomy should be performed as a last resort, but even residual renal function may be of vital importance GR: B.

Obstruction may be covert and require specific diagnostic tests, e. Even so, the results of nephrectomy for a scarred or hydronephrotic kidney may be disappointing.

Immunosuppression is of secondary importance, although if this is extreme, immunosuppression will promote, at least, persistent bacteriuria, which may become symptomatic.

HIV infection is associated with acute and chronic renal disease, possibly through the mechanisms of thrombotic microangiopathy and immune mediated glomerulonephritis.

Steroids, angiotensin-converting enzyme ACE inhibitors and highly active retroviral therapy appear to have reduced progression to endstage renal disease.

There are also important scientific issues to be considered concerning the cause, special susceptibilities, effects and complications of renal parenchymal infection, particularly in the immunosuppressed patient.

This part of the guidelines can be subdivided into four sections. What are the acute effects of UTI on the kidney and do the lesions become chronic?

Does chronic renal disease progress more quickly as a result of infection and do particular renal diseases predispose to UTI?

Are immunosuppressed patients prone to UTI particularly in the context of renal transplantation? Is UTI a significant cause of graft failure?

Which problems arise in antibiotic therapy in patients with renal insufficiency and after renal transplantation? Pathologically, a similar process may occur in such fundamentally different situations as obstructive and reflux nephropathies, although the distribution and extent of the lesions may be different LE: 2a.

Renal scarring can certainly be acquired as a result of these three factors, although, in almost all cases, this usually occurs very early in life.

In this narrow age range, developmental renal dysplasia must be a major consideration in the pathogenesis of chronic pyelonephritis.

Although acute infection is important in the early stages of this disease, the status of either recurrent acute urinary infection or asymptomatic bacteriuria specifically in the progression of scar formation is tenuous.

Prophylactic antibiotics will therefore offer little benefit in preserving renal tissue in reflux nephropathy in the older child and adult, even if the reflux has not already been successfully treated 6 GR: A.

However, further discussion of reflux nephropathy is beyond the scope of these guidelines. In extreme cases, pyonephrosis, perinephric abscess and widespread systemic sepsis will develop.

Obstruction has to be cleared if infection is to be eradicated 7 GR: A. A detailed discussion of obstructive nephropathy is not appropriate here, but the kidney which is permanently damaged from any cause will have less reserve to withstand the effects of reflux, obstruction and infection.

In any circumstances, the combination of obstruction and infection is a surgical emergency and both must be relieved without delay.

It is sometimes difficult to exclude an element of obstruction when discussing the pathogenesis of putative infective renal damage in the alleged normal kidney.

Urinary calculi and pregnancy can cause urinary stasis and an intermittent increase in pressure in the upper tracts, which can cause subtle and persistent damage.

The presence of renal calculi and diabetes mellitus will further reduce host defences 8. They are worth reviewing as they may provide a lead in deciding how chronic changes can occur and therefore a basis for the development of guidelines on the prevention of renal damage.

Escherichia coli is the commonest of the Gram-negative organisms isolated in the majority of patients with acute pyelonephritis.

The proportion of infections caused by E. Virulent organisms cause direct cellular injury, usually after colonizing the renal pelvis.

Damage can also occur indirectly from the effects of inflammatory mediators. Metastatic infection will rarely cause renal infection, presenting as cortical abscesses and usually only in susceptible individuals see the sections below on Diabetes mellitus and Immunosuppression Bacterial infection in the urinary tract can induce fever and elevate acute phase reactants, such as C-reactive protein and erythrocyte sedimentation rate ESR.

Bacterial infection also elicits immunoglobulin A and cytokine responses 11 LE: 2b. In functional terms, there may be a loss of concentrating power which can persist long term 14,15 LE: 2b.

The fact that there is a serological immune response and bacteria become coated with antibodies to various antigenic components of the micro-organism is regarded as evidence of an immune response and therefore of exposure to micro-organisms which are potentially damaging to the renal parenchyma 16 LE: 2b.

There are many identifiable factors relating to virulence of the bacterial cell and to its ability to adhere to the mucosa as a preliminary to invasion For example, type 1 pili or fimbriae will combine with mannose receptors on the uromucoid, which is part of the protective mucopolysaccharide layer found on uroepithelial cells lining the urinary tract.

Type 2 or P fimbriae bind to glycolipids of the blood group substances which are secreted by the host urothelium.

In practical terms, E. Bacterial adhesion may be of variable benefit to the micro-organism, as its attachment may mean that it is easier for host defence mechanisms to localize and abolish it The cellular and humeral inflammatory host response is also a critical part of host defence.

Various cytokines e. IL-6, IL-8 are responsible for inducing leucocyte migration and may be intrinsically deficient in converting asymptomatic bacterial colonization to clinical infection.

Paradoxically, reduced adhesiveness can facilitate silent penetration into the renal parenchyma. In the majority of these patients, the infiltrating bacteria had reduced adhesive characteristics, perhaps facilitating their penetration into the renal parenchyma and promoting more permanent structural and functional damage 15 LE: 2b.

An earlier study by Alwall 21 described 29 women followed for years with evidence of increasing renal damage and chronic pyelonephritis upon biopsy LE: 3.

As this study would have used cruder diagnostic techniques, which might not have identified pre-existing disease, patients may have had renal damage initially.

Over such a long period, it was impossible to exclude other causes of renal impairment and interstitial nephropathy, e.

This important issue is clarified by a recent more critical study of DMSA scanning during the acute phase of acute pyelonephritis.

In the study, 37 of 81 patients had one or more perfusion defects, of which the majority resolved within 3 months. In lesions that persisted, further imaging invariably showed evidence of reflux or obstructive nephropathy that must have predated the acute infective episode 22 LE: 2a.

In summary, small parenchymal scars demonstrated by modern imaging may develop as a result of acute non-obstructive pyelonephritis.

However, such patients do not develop chronic renal failure and the scar is a very different lesion from the typical scar of reflux nephropathy.

This is reflected in clinical experience. Thus, in acute pyelonephritis, IVU or DMSA scanning during an acute urinary infection can have very alarming and dramatic results, but in practical terms the observed changes will mostly resolve.

The poor correlation between the severity of the symptoms in an episode of acute pyelonephritis and the risk of permanent damage, which is very small, should discourage the clinician from prescribing excessive antibiotic treatment beyond that needed to suppress the acute inflammatory reaction GR: A.

In the future, the rare occurrence of renal damage apparently arising from acute or recurrent uncomplicated UTI may be prevented by targeting long-term treatment at selected patients.

These patients will have been identified as having an intrinsic genetic defect in the host response of cytokine release to infection.

Such a genetic defect would be even more important if a patient also had structural abnormalities causing complicated UTI. Women with type I diabetes were particularly at risk if they had had diabetes for a long time or complications had developed, particularly peripheral neuropathy and proteinuria.

Risk factors in patients with type II diabetes were old age, proteinuria, a low body mass index and a past history of recurrent UTIs 23 LE: 2a.

Diabetes mellitus increases the risk of acute pyelonephritis from infection by Enterobacteriaceae originating in the lower urogenital tract.

Asymptomatic bacteriuria is common in female diabetics though not in males. If left untreated, it may lead to renal functional impairment The mechanism is ill-understood and, as in uncomplicated acute pyelonephritis, a direct causal link is dubious.

Other subtle factors may be present, such as an underlying diabetic nephropathy 25 and autonomic neuropathy causing voiding dysfunction.

Impaired host resistance is thought to predispose to the persistence of nephropathogenic organisms, but specific evidence is lacking for the development of renal complications.

Glycosuria inhibits phagocytosis and perhaps cellular immunity and encourages bacterial adherence. However, diabetic women with asymptomatic bacteriuria can have good glycaemic control, but still show reduced urinary cytokine and leucocyte concentration although polymorph function is normal.

Interestingly, poor glycaemic control has not been shown to increase the risk of bacteriuria It has always been recognized that diabetic patients are particularly susceptible to rapid progression of renal parenchymal infection and ensuing complications.

Until recently, there was no consensus on the questions of pre-emptive screening, treatment and prophylaxis of asymptomatic bacteriuria.

However, these issues have been addressed in a placebo-controlled double-blind randomized trial 27 LE: 1b , which concluded that treatment did not reduce complications and diabetes should not therefore be regarded as an indication for screening or treatment of asymptomatic bacteriuria.

The findings from this trial were subsequently recognized in the guidelines published by the Infectious Diseases Society of America IDSA on the diagnosis and treatment of asymptomatic bacteriuria in general Diabetic patients are also prone to an under-reported and probably unusual form of infective interstitial nephritis, which is sometimes infected by gas-forming organisms, with a high mortality emphysematous pyelonephritis This is characterized histologically by acute pyogenic infiltrate with microabscesses and the development of acute renal failure.

The origin of the organisms may be haematogenous. Even in the 48 UPDATE APRIL absence of obstruction, acute parenchymal infection may progress insidiously to form an intrarenal abscess which ruptures leading to a perinephric collection and a psoas abscess.

This tutorial will instruct material science and technology of silicon crystals, which will cover crystal growth, wafer characterization, and fundamental science of crystal defects.

As the crystal growth topics, new concept growth methods, i. Secondly, principle and feature, in particular detection error and limit, will be discussed for various characterization techniques, such as microPCD, PL imaging, FTIR, and etch pit observation, for silicon wafers and bulk ingots.

Furthermore, lecture of fundamental science of crystal defects will be presented. This lecture will cover generation and propagation mechanism of dislocations and incorporation mechanism of impurities during the crystal growth process that will be a help to develop the growth technologies of silicon ingots.

Topic B ; Thin Film Silicon Solar Cells In this tutorial, there will be three main topics on Si thin film PV, that is, preparations of amorphous and microcrystalline Si, fundamental physics of thin film silicon solar cells including transparent conducting oxides TCO and future outlook of the type of cells.

Furthermore, fundamental physics and preparation techniques of quantum dot and nanowire solar cells will be described.

This suggests that the performance of solar cells could be improved times if fundamentally different new concepts were used in their design.

In addition, there would be an enormous impact on economics if the new concepts could be implemented in thin-film form, making photovoltaics one of the cheapest energy resource.

Nanostructured photovoltaics, such as quantum dot solar cells, are proposed as a potential candidate to demonstrate high performance, low-cost photovoltaics.

To date, while some characteristic operations, such as an enhanced photocurrent generation due to quantum dots, have been confirmed, the conversion efficiency of quantum dot solar cells has remained less than those of conventional single junction solar cells without quantum dots.

In this tutorial, new physical mechanisms for high conversion efficiency will be presented, including multi-exciton generation impact ionization , intermediate-bands, and hot carrier solar cells.

The tutorial will provide fundamental physics and preparation techniques of quantum dots. The principle in quantum dot solar cell operations will be discussed, along with a survey of quantum dot solar cell technologies.

In addition, current status and prospects of quantum dot solar cells for meeting future global energy demands will be presented.

Makoto Tanaka Core Technologies Development Center Eco Solutions Company Panasonic Corporation, Japan 30 Synopsis ; Improvement of energy conversion efficiency of solar cells is an important issue for resolving energysupply problems in the world.

One of the promising materials for realizing solar cells with higher efficiency and lower cost seems to be Si thin film.

The session C-1 will describe both fundamental properties and the recent progress in the characterization methods of the chalcogenide materials for solar cell application, and discuss the material properties to be improved to enhance device performance further.

The session C-2 will present an overview of the recent progress in the development of the device fabrication technique of compound solar cells, placing special emphasis on the chalcogenide solar cells such as CIGS, CZTS, etc.

Also, non-vacuum process will be presented for future low cost cells. Chalcopyrite solar cell absorber growth techniques and their development will be briefly introduced.

The fundamentals of the growth mechanisms of chalcopyrites will be reviewed and compared to other thin film absorbers including kesterite and perovskite absorbers.

Different characterization methods and fundamental material properties to be monitored will be discussed, e.

A focus will be the structural characterization of thin film growth by X-ray diffraction XRD. The in-site detection of crystal phases during the deposition opens valuable optimization pathways, as the formation, transitions and evolutions of different phases can be monitored in real-time.

Different technological approaches concerning the implementation of in-site XRD and an overview of results obtained by this powerful 31 Tutorials technique will be presented and discussed.

In this lecture, basic material properties of CIGS and fabrication methods of component layers Mo back contact, CIGS absorber layer, buffer layer and window layers will be reviewed.

Also, operation mechanism of CIGS solar cells will be explained and physics parameters to improve short-circuit current and open-circuit voltage will be revealed.

In addition, recent progresses of CIGS solar cells will be summarized. Finally, potential of other chalcogenide materials without rare metals will be discussed with some experimental data.

Topic D ; Organic, Dye Sensitized and Perovskite Solar Cells Organic solar cells are a promising candidate for the next generation solar cells, which develop novel indoor and outdoor applications.

The tutorial presents the recent progress and future perspectives of dye-sensitized solar cells, and overviewing of the organic-inorganic hybrid solar cells, particularly focusing on one of the fastest growing organic photovoltaic technology based on organometal halide compounds with the perovskite structure.

The market introduction is accompanied by a strong increase in patent applications in the field during the last 4 years which is a good indication that further commercialization activities are undertaken.

Materials and cell concepts have been developed to such extend that an uptake by industrial manufacturers is possible. The critical phase for a broad market acceptance is therefore reached which implies to focus on standardization related research topics like electrolumi- Tutorials nescence mapping and accelerated testing.

In parallel the amount of scientific publications on DSC is growing further larger since and the range of new or renewed more fundamental topics, like solid-state p-conductors and cobalt or organic radical based redox electrolytes, is broadening, as will be explained in the tutorial.

In this sense a growing divergence between market introduction and research could be the consequence. In this tutorial an effort is undertaken to show, that such an unwanted divergence can be prevented by developing suitable reference type cell and module concepts as well as manufacturing routes which can be applied to mesoscopic based solar cells in a broader sense.

As a guideline for developing future mesoscopic cell and module concepts, perovskite solar cells being a prominent example here, our recent work on up-scaling large area glass frit sealed DSC modules [2] for efficiency studies 6.

Another important point addressed in the tutorial is the issue of sustainability both affecting market introduction as well as the direction of fundamental research.

Mathew, A. Yella, P. Gao, R. Humphry-Baker, B. Curchod, N. Ashari-Astani, I. Tavernelli, U. Rothlisberger, Md. Nazeeruddin and M.

Hinsch, W. Veurman, B. Brandt, K. FlarupJensen, S. Seigo Ito Department of Electrical Engineering and Computer Sciences, Graduate School of Engineering, University of Hyogo, Japan Synopsis ; V ery recently, organic-inorganic leads halide based perovskites have emerged as a new class of light absorbers, achieving exceptional progress in solar cell performance.

The structure of perovskite solar cells has been close to that of dye-sensitized solar cells. These types of perovskites have favourable bandgap for photovoltaic applications and large extinction coefficients.

Discovery of its solution processability and stability combined with the earth abundance of the constituent materials has made the lead halide perovskites among the most promising solar cell materials.

The third mehod relies on vacuum evaporation deposition using dual source pods with PbX2 and CH3NH3X, which can produce very thin smooth layers on flat substrates.

These perovskite solar cells have typically employed a wide variety of organic hole conductors. In fact, the current commercial price of high purity spiro-OMeTAD is over ten times that of gold and platinum.

While increased demand lowers this cost in some extent, it is still likely to remain expensive due to its high purity needed for photovoltaic applications.

On the other hand, inorganic copperbased p-type semiconductors, such as CuSCN and CuI, are highly promising as hole conductors, because of their solution processablilty, wide band gap with high conductivity, and lower cost.

In this tutorial, the history, the devise principal, the variation of devise structure and the fabrication methods will be presented for the beginners of prerovskite solar cells.

Topic E ; Photovoltaic Systems Terrestrial Photovoltaic PV power generation is one of the widespread countermeasures to solve environmental and energy problems and is recently becoming the mainstream of energy economy.

Many countries maintain high rates of installed PV 34 Tutorials capacity, which seems to be the trend for the foreseeable future. With this background, the technologies of efficient PV evaluation grow rapidly in importance.

Furthermore, the decline in gird power quality caused by mass PV introduction is a growing issue in our society.

In this tutorial, we focus on the above topics and explain their current status and future perspective.

Joshua S. Stein, Sandia National Laboratories, Albuquerque, NM USA Synopsis ; Photovoltaic systems are intermittent generation resources and their performance depends on the PV technology and local irradiance, weather, and environmental conditions.

This tutorial will provide a technical overview of how PV technologies are characterized and how energy produced from PV systems is predicted.

This will be done by covering a series of PV performance modeling steps including: irradiance translation, shading, surface reflection, spectral mismatch, IV curve models, array mismatch, inverter performance, and other performance factors.

Participants will be introduced to open source tools that will allow them create detailed, physically-based PV performance models. If time allows, we will also examine power output characteristics from operating PV systems including: variability, ramp rates, and power quality and discuss how these features influence the integration of PV systems into the electrical grid.

Whatever the device we think to use, it has 35 Tutorials 36 a certain form, that will influence the way we will design it, or, at the end of the process, the shape of our living environment.

Thanks to their features, photovoltaic system offer the designer the possibility of envisioning the use of photovoltaic at the architectural scale building integrated photovoltaic , as well as at the landscape scale.

Different technological and design issues are related to these uses of photovoltaic. In the first case, photovoltaic components are used as parts of the building envelopes, and this implies a relevant importance in developing special BIPV technological elements, which could ensure the desired building performances; or in finding appropriate solutions in order to use standard components on the envelope, in an innovative way.

This topic has been largely investigated in the past years, and the tutorial will give an overview on the general topic of the building integration of photovoltaic, and on the design fundamentals.

In the second case, photovoltaic modules are arranged in the form of solar arrays, without exploiting any other function than generating energy.

They can be understood as a tangible image of an increasing need of energy from renewables to significantly reduce the pollution caused by traditional energy generation systems, but anyway they generate a diffuse concern about the land use and transformation that they cause.

PV and crops are kinds of opposing needs that should share the same limited resource: the land. Because of this reason in many countries local authorities prohibited the installation of PV in agricultural areas; and due to this barrier, in recent years companies working in the PV development have been experimenting with solutions for producing energy and food in the same land area.

Such experiences will be presented and the issue of PV power generation will be addressed from the landscape design point of view PV landscapes.

JR Haruka Airport Express 75min. Limousine bus approx. Subway Karasuma Line Kitaoji St. Imadegawa St. Horikawa St. Senbon St. Nijo Nijo-jo Castle Nijo Sta.

Oike St. Nijojomae Sta. Hankyu Line 27 18 9 30 15 Omiya Sta. Shijo Sta. Kujo St. Kyoto Sta. Tanbaguchi Sta. Omiya St.

Gojo St. Kokusai Kaikan Sta. Kitayama Sta. Kyoto International Matsugasaki Sta. Kuramaguchi Sta. Demachiyanagi Sta. Imadegawa Sta.

Shirakawa St. Higashioji St. City Hall Karasuma Sta. Nanzenji Temple Kyoto Shiyakusho-mae Sta. Keage Sta. Sanjo Keihan Sta.

Keihan Line Shijo Sta. Heian Jingu 19 9 Kawabata St. Kawaramachi St. Marutamachi Sta. Gion shijo Sta.

Kodaiji Temple Gojo Sta. Honganji Kiyomizu Gojo Sta. Sanyo Electric Co. Toppan Printing Co. Jinko Solar Co. Toray Engineering Co.

Toray Industries, Inc. UL Japan, Inc. Stanbery Heliovolt Vice-Chair: A. Terakawa Panasonic R. Raffaelle Rochester Inst. Wada Ryukoku Univ.

Vice-Chair: T. Okamoto Univ. Usami Tohoku Univ. Ueda Tokyo Univ. Takakura Ritsumeikan Univ. Vice-Chair: M. Nonomura Gifu Univ.

Vice-Chairs: S. Wakao Waseda Univ. Tanaka Panasonic Vice-Chair: Y. Ohshita Toyota Tech Inst. Yamaguchi Toyota Tech Inst. Raffaelle Rochester Institute of Technology J.

Okada Univ. Tokyo Area Co-chair: K. Terakawa Panasonic Area Co-chair: T. Smets Univ. Delft Area Co-chair: C.

Dimmler Manz Co. Ogura Meiji Univ. Takamoto Sharp Area Co-chair: M. Benner Stanford Univ. Area Co-chair: S. Baumgartner Zurich Univ.

Konagai Tokyo Tech Secretary: M. Green, D. Kim, M. Kondo, K. Kurokawa, C-W. Lan, J. Song, M. Tanaka, Y. Benner, D. Flood, L.

Kazmerski, R. King, R. Raffaelle, B. Stanbery, R. Swanson, R. Walters, D. Wilt, C. Helm, A. Mine, S.

Nowak, W. Palz, J. Poortmans, G. De Santi, W. Sinke, A. Jager-Waldau, E. Konagai Vice-Chair: Y. Kuwano Vice-Chair: M.

Hashimoto Special advisor: O. Ikki Secretary: A. Yamada Advisor: Y. Hamakawa Advisor: M. Umeno Advisor: T. Saito Advisor: K. Takahashi Advisor: H.

Matsunami Members: K. Arafune H. Arakawa K. Araki K. Funakawa K. Kurokawa K. Kushiya H. Enomoto S.

Maeshima K. Ogimoto Y. Ohshita Y. Okada H. Okamoto Y. Tawada O. Tsuji Y. Ueda N. Usami 45 Committees T. Fuyuki L. Han S. Hayase M.

Hiramoto Y. Hishikawa T. Hokiyama M. Imaizumi M. Isomura T. Ito K. Kakimoto H. Katagiri M. Kondo A. Masuda H.

Matsumura T. Minemoto T. Motohiro T. Nakada K. Nakajima Y. Nakano T. Negami S. Niki Y. Nishikitani K. Nishioka S. Nonomura T. Oozeki Y. Sakai H.

Segawa M. Tajima H. Takakura T. Takamoto A. Takano H. Takatsuka Y. Takeuchi M. Tanaka R. Tanaka N. Taneda M.

Ushijima T. Wada S. Wakao M. Yamaguchi K. Yamamoto M. Yamatani T. Yanagisawa S. Yoshikawa K. Konagai Vice-Chair: A.

Yamada Secretary: Y. Ueda Secretary: S. Miyajima Members: A. Asano Y. Ohshita T. Wada A. Masuda T. Takamoto M. Yamatani S. Nonomura N.

Usami M. Kondo H. Takakura K. Yamamoto Y. Nishikawa A. Terakawa T. Tajima M. Yamaguchi S. Niki M. Tanaka T. Fuyuki H. Okamoto S.

Wakao T. Minemoto H. Tamai T. Arafune Hyogo Pref. Araki Daido D. Funakwa Honda Soltec L. Hara Hokkaido Univ. Hiramoto Inst.

Kambe AGC T. Katagiri Nagaoka-ct 46 H. Nakaniwa Dupont Japan Y. Nasuno Sharp T. Negami Panasonic S. Nishioka Miyazaki Univ.

Ogimoto Univ. Ohkita Kyoto Univ. Osaka Riken T. Saitoh Fukushims Univ. Segawa Univ. Kojima TTI K. Komoto Mizuho A. Matsubara Kyocera T.

Minemoto Ritsumeikan Univ. Miyajima Tokyo Tech T. Miyasaka Toin Yokohama Univ. Sugiyama Univ. Tanabe Meidensha T.

Usami Nagoya Univ. Lan National Taiwan Univ. Yagi Saitama Univ. Yamada Tokyo Tech K. Yamamoto Kaneka D. Yang Zhejiang Univ.

Committees D. Kim Korea Univ. Kobayashi Gifu Univ. Yi Sungkyunkwan Univ. Zhao Nankai Univ. Konagai Honorary Chairperson: Y.

Hamakawa Honorary Chairperson: C. Chung Honorary Chairperson: S. Panyakeow Members: A. Aberle P.

Sichanugrist C. Tsai Y. Matsumoto B. McNelis M. Murthy H. Ossenbrink W. Palz Y. Peinuo J. Poortmans S.

Ray A. Rohatgi T. Saito A. Sayigh H. Schock W. Shafarman W. Shen Ir. Ahmad Hadri Haris B. Ahn C. Signorini J. Oracle includes geospatial capabilities integrated across its entire technology stack.

Oracle Locator provides location data type support and spatial queries in every edition of Oracle Database. Oracle Spatial and Graph provides advanced features such as linear referencing, geocoding, routing, a network data model, topology support, georaster management, and support for 3D data structures such as TINs and point clouds.

For geospatial analysis of streaming data, such as sensor data transmitted from GPS devices, Oracle Event Processing provides a complete real-time end-to-end EDA solution.

Th is Java-based event processing engine can detect patterns in streams by correlating and aggregating data across event sources using CQL Continuous Query Language , and has integrated spatial analytics for purposes such as geofencing.

Oracle Fusion Middleware MapViewer is a Java-based visualisation and mash-up component that renders HTML5based interactive maps with spatial data from a variety of sources.

All rights reserved. Other names may be trademarks of their respective owners. Pacific Crest provides a total customer solution that reduces the size, cost, and complexity of critical data communications and positioning systems.

Pacific Crest serves a broad crosssection of the precise positioning and remote sensing markets with its rugged and reliable radio and positioning solutions.

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The private data communication network based on radio modems provides a secure and cost-effective way for computers, remote instruments and other devices to communicate in real time.

The network can be used to automate processes, reduce costs and help to predict system failures even before they happen. Radio modems can be utilised e.

Short delivery times and consistent quality guarantees that the systems using SATEL radio modems can be depended on even in the most challenging circumstances.

SATEL radio modems are widely used all over the world; its products are type approved worldwide and can easily be integrated into different systems.

The company is happy to notice that its market share and customer base keep growing every year. It is well on the way to becoming the most popular radio modem supplier in the world.

The smallest. This is the actual size of the module! Packaged in a modern, sleek, and streamlined design, it is easy-to-use, affordable, and tough.

All other trademarks are the property of their respective owners. Spectra Precision products are characterised by high performance under difficult GNSS conditions and superb value for money.

Spectra Precision leverages patented technologies such as Z-Blade processing to make optimal use of all available GNSS satellite signals, even in difficult conditions.

Spectra Precision also acts as the exclusive international distributor of Nikon-branded mechanical total stations.

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