***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: PURPOSE We compared the development of new renal damage in small children with dilating vesicoureteral reflux r and omly allocated to antibiotic prophylaxis , endoscopic treatment or surveillance as the control group . MATERIAL S AND METHODS Included in the study were 128 girls and 75 boys 1 to younger than 2 years with grade III-IV reflux . Voiding cystourethrography and dimercapto-succinic acid scintigraphy were done before r and omization and after 2 years . Febrile urinary tract infections were recorded during followup . Data analysis was done by the intent to treat principle . RESULTS New renal damage in a previously unscarred area was seen in 13 girls and 2 boys . Eight of the 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 of 49 or 22 % vs 4 of 152 or 3 % , p < 0.0001 ) . CONCLUSIONS 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 UTIs and new renal damage in girls PURPOSE We evaluated the difference in the febrile urinary tract infection rate in small children with dilating vesicoureteral reflux r and omly allocated to 3 management alternatives , including antibiotic prophylaxis , endoscopic treatment or surveillance only as the control . MATERIAL S AND METHODS At 23 centers a total of 203 children were included in the study , including 128 girls and 75 boys 1 to younger than 2 years . Vesicoureteral reflux grade III in 126 cases and IV in 77 was detected after a febrile urinary tract infection ( 194 ) after prenatal screening ( 9 ) .  Voiding cystourethrography and dimercapto-succinic acid scintigraphy  were done before r and omization and after 2 years . The febrile urinary tract infection rate was analyzed by the intent to treat principle . RESULTS We noted a total of 67  febrile recurrences in 42 girls and a total of 8 in 7 boys ( p = 0.0001 ) . There was a difference in the recurrence rate among treatment groups in girls with febrile infection in 8 of 43 ( 19 % ) on prophylaxis , 10 of 43 ( 23 % ) with endoscopic therapy and 24 of 42 ( 57 % ) on surveillance ( p = 0.0002 ) . In girls the recurrence rate was associated with persistent reflux after 2 years ( p = 0.0095 ) . However , reflux severity ( grade III or IV ) at study entry did not predict recurrence . CONCLUSIONS In this r and omized , controlled trial there was a high rate of recurrent febrile urinary tract infection in girls older than 1 year with dilating vesicoureteral reflux at study entry but not in boys .  Antibiotic prophylaxis and endoscopic treatment decreased the infection rate OBJECTIVES To compare , in a prospect i ve study , the efficacy of a single injection of polydimethylsiloxane ( Macroplastique ) or dextranomer/hyaluronic acid copolymer ( Deflux ) , a new biodegradable substance , and to assess the short-term and 1-year clinical effects concerning reflux resolution and the safety of these two bulking agents . Subureteral injection of bulking agents has recently demonstrated good success rates for endoscopic treatment of vesicoureteral reflux . Macroplastique has been one of the most popular bulking agents during the past years . Nevertheless , considering the synthetic property , new biodegradable substances have become more relevant . METHODS From January 2000 to June 2001 , 16 boys and 56 girls ( total of 114 ureters ) with a mean age of 34.5 months were treated endoscopically for vesicoureteral reflux . A single subureteral Macroplastique or Deflux injection was performed in 34 children ( 58 ureters ) and 38 children ( 56 ureters ) , respectively . Both groups were comparable in terms of baseline parameters . Vesicoureteral reflux was grade II in 52 , grade III in 57 , and grade IV in 5 ureterorenal units . The procedure was performed on an outpatient basis , with the children under general anesthesia . In addition to the routine parameters , the follow-up evaluation consisted of renal ultrasonography and voiding cystourethrography at 3 and 12 months postoperatively . RESULTS Endoscopic treatment was performed without any complications in all cases . At the 3-month follow-up visit , reflux was corrected in 50 ( 86.2 % ) of 58 refluxing ureters in the Macroplastique group and in 40 ( 71.4 % ) of 56 refluxing ureters in the Deflux group . At 1 year of follow-up , reflux correction was maintained in 80.9 % of ureters in the Macroplastique group and in 67.6 % of ureters in the Deflux group . No postoperative complications were observed in either group . CONCLUSIONS A single subureteral injection of either polydimethylsiloxane ( Macroplastique ) or dextranomer/hyaluronic acid copolymer ( Deflux ) is an effective treatment modality for children with vesicoureteral reflux . The procedure was well tolerated , safe , and associated with low morbidity .  Deflux , a new biocompatible , biodegradable substance , seems to be an alternative modality to other bulking agents for treating vesicoureteral reflux in children , with acceptable short-term and 1-year results Approximately 35 % of children with urinary infection have vesico-ureteric reflux ( McGovern , Marshall , and Paquin , 1960 ; Ericsson , 1960 ) . It is not known whether infection causes the reflux by damaging the uretero-vesical valvular mechanism , or whether a congenital abnormality permits reflux which predisposes to infection . Yet whatever the aetiology , it seems logical to assume that when infection occurs in the presence of reflux there will be renal involvement , for it has been shown that there is a close correlation between ureteric reflux and radiological evidence ofkidney scarring ( Hodson and Edwards , 1960 ) . Despite this , it is not clear whether , besides treating the infection by giving prolonged carefully controlled courses of antibiotics , the child will gain additional benefit if a surgical operation is undertaken to eliminate the reflux . The purpose of this paper is to report the results of a controlled trial in which a group of children with surgically treated reflux was compared with an  unoperated group . The trial was a prospect i ve one and the children were allotted at r and om to either the operated or control groups according to whether their birthdays fell on even or odd days . In view of the considerable divergence of opinion about the value of the surgical treatment of reflux ( Spence et al. , 1961 ) and the uncomplicated nature of this type of surgery , it was felt that it was ethically justifiable to conduct a trial in this manner . 58 children were studied , 33 having operations for their reflux and 25 acting as controls . Cases in which reflux was associated either with mechanical obstruction in the urethra , such as posterior urethral valves , or with neurogenic bladder , were excluded from the trial , as it was felt that in these the treatment of the reflux could not be considered in isolation but only as a part of the management of the associated condition OBJECTIVES . The American Academy of Pediatrics recommendation for febrile infants and young children suspected of having a urinary tract infection is early antibiotic treatment , given parenterally if necessary . In support of this recommendation , data suggesting that delay in treatment of acute pyelonephritis increases the risk of kidney damage are cited . Because the risk was not well defined , we investigated renal scarring associated with delayed versus early treatment of acute pyelonephritis in children . METHODS . The research findings are derived from 2 multicenter , prospect i ve , r and omized , controlled studies , Italian Renal Infection Study 1 and 2 , whose primary outcomes dealt with initial antibiotic treatment and subsequent prophylaxis , respectively . From the 2 studies , we selected the 287 children with confirmed pyelonephritis on acute technetium-99m-dimercaptosuccinic acid scans who underwent repeat scanning to detect scarring 12 months later . The children were 1 month to < 7 years of age when they presented with their first recognized episode of acute pyelonephritis in northeast Italy . RESULTS . Progressive delay in antibiotic  treatment of acute pyelonephritis from < 1 to ≥5 days after the onset of fever was not associated with any significant increase in the risk of scarring on technetium-99m-dimercaptosuccinic acid scans obtained 1 year later . The risk of scarring remained relatively constant at 30.7 ± 7 % . Clinical and laboratory indices of inflammation were comparable in all groups , as was the incidence of vesicoureteric reflux . CONCLUSIONS . Early treatment of acute pyelonephritis in infants and young children had no significant effect on the incidence of subsequent renal scarring . Furthermore , there was no significant difference in the rate of scarring after acute pyelonephritis when infants and young children were compared with older children Objective To compare the efficacy of oral antibiotic treatment alone with treatment started parenterally and completed orally in children with a first episode of acute pyelonephritis . Design Multicentre , r and omised controlled , open labelled , parallel group , non-inferiority trial . Setting 28 paediatric units in north east Italy . Participants 502 children aged 1 month to < 7 years with clinical pyelonephritis . Intervention Oral co-amoxiclav ( 50 mg/kg/day in three doses for 10 days ) or parenteral ceftriaxone ( 50 mg/kg/day in a single parenteral dose ) for three days , followed by oral co-amoxiclav ( 50 mg/kg/day in three divided doses for seven days ) . Main outcomes measures Primary outcome was the rate of renal scarring . Secondary measures of efficacy were time to defervescence ( < 37 � C ) , reduction in inflammatory indices , and percentage with sterile urine after 72 hours . An exploratory subgroup analysis was conducted in the children in whom pyelonephritis was confirmed by dimercaptosuccinic acid ( DMSA ) scintigraphy within 10 days after study entry . Results Intention to treat analysis showed no significant differences between oral ( n=244 ) and parenteral ( n=258 ) treatment , both in the primary outcome ( scarring scintigraphy at 12 months 27/197 ( 13.7 % ) v 36/203 ( 17.7 % ) , difference in risk −4 % , 95 % confidence interval −11.1 % to 3.1 % ) and secondary outcomes ( time to defervescence 36.9 hours ( SD 19.7 ) v 34.3 hours ( SD 20 ) , mean difference 2.6 ( −0.9 to 6.0 ) ; white cell count 9.8 � 109/l ( SD 3.5 ) v 9.5 � 109/l ( SD 3.1 ) , mean difference 0.3 ( −0.3 to 0.9 ) ; percentage with sterile urine 185/186 v 203/204 , risk difference −0.05 % ( −1.5 % to 1.4 % ) ) . Similar results were found in the subgroup of 278 children with confirmed acute pyelonephritis on scintigraphy at study entry . Conclusions Treatment with oral antibiotics is as effective as parenteral then oral treatment in the management of the first episode of clinical pyelonephritis in children . Trial registration Clinical Trials NCT00161330 A total of 132 infants and children with grade s III and IV primary vesicoureteral reflux was entered into a prospect i ve trial comparing medical to surgical management .  Inclusion criteria were an age not exceeding 10 years and a glomerular filtration rate of at least 70 ml . per minute per 1.73 m.2 . Children with significant urinary tract malformations and clinical signs/symptoms of dysfunctional voiding were not accepted into the trial .  Medical therapy consisted of continuous low dose antibiotic prophylaxis until vesicoureteral reflux resolved . The type of surgical procedure used for the correction of reflux was left to the discretion of the surgeon . Outcome variables included the appearance or progression of renal lesions , rate of renal growth , recurrence rate of urinary tract infection or pyelonephritis , changes in total kidney glomerular filtration rate , development of hypertension and resolution rate of vesicoureteral reflux . Followup at 6 , 18 , 36 and 54 months after entry included , in addition to history and physical examination , voiding cystourethrography , excretory urography and a urine culture . Of the patients 68 were allocated to the medical group and 64 to the surgical group . They were stratified for age , sex and preexisting renal scarring . Of the patients 10 % were boys , 47 % were between 2 and 6 years old at entry , 93 
    Output:
    
Compared with no treatment , use of long-term , low-dose antibiotics did not significantly reduce the number of repeat symptomatic and febrile UTIs in children with VUR .
The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear .