Fatal Interaction between Clarithromycin and Colchicine in Patients with Renal Insufficiency: A Retrospective Study

BACKGROUND

Clarithromycin is frequently used to treat community-acquired pneumonia in elderly persons. Like erythromycin, it may interact with other drugs by interfering with metabolism by cytochrome P450 enzymes and with the P-glycoprotein transporter system. Colchicine, used for treatment of acute gout and for prophylaxis, may cause bone marrow toxicity. It is metabolized by CYP3A4 and is transported by P-glycoprotein. Initial case reports suggested potentially fatal interactions between clarithromycin and colchicine.

METHODS

A retrospective study was conducted with 116 patients who were prescribed clarithromycin and colchicine during the same clinical admission. Case-control comparisons were made between patients who received concomitant therapy with the 2 drugs and patients who received sequential therapy. We assessed the clinical presentations and outcomes of the 2 patient groups and analyzed the risk factors associated with fatal outcomes.

RESULTS

Nine (10.2%) of the 88 patients who received the 2 drugs concomitantly died. Only 1 (3.6%) of the 28 patients who received the drugs sequentially died. Multivariate analysis of the 88 patients who received concomitant therapy showed that longer overlapped therapy (relative risk [RR], 2.16; 95% confidence interval [CI], 1.41-3.31; P< or =.01), the presence of baseline renal impairment (RR, 9.1; 95% CI, 1.75-47.06; P<.001), and the development of pancytopenia (RR, 23.4; 95% CI, 4.48-122.7; P<.001) were independently associated with death.

CONCLUSIONS

Clarithromycin increases the risk of fatal colchicine toxicity, especially for patients with renal insufficiency. Since there are other drugs for treatment of pneumonia and gout, these 2 drugs should not be coprescribed, because of the risk of fatality.

Mal-Positioned Umbilical Venous Catheter Causing Liver Abscess in a Preterm Infant

Neonatal liver abscess is uncommon, carries a high mortality and is difficult to diagnose. We report an unusual case of liver abscess in a preterm infant presenting with abdominal distension and suspected gastrointestinal perforation, rather than the more usual features of fever, hepatomegaly, abdominal tenderness, right-sided pleural effusion, and leukocytosis. We discuss current treatments for neonatal liver abscess and argue that in view of the high mortality and difficulty in diagnosis, prevention should be the primary objective. We believe that mal-positioning the umbilical venous catheter in the liver substantially increases the life-threatening risk of this complication, and advocate extreme care in the placement and use of these catheters.

Acupuncture for nocturnal enuresis in children: a systematic review and exploration of rationale

OBJECTIVES

This review identified reports of acupuncture for childhood nocturnal enuresis, with the aim of ascertaining whether acupuncture is efficacious and or better than standard therapy for treating enuresis.

MATERIALS AND METHODS

Studies of children of either gender <18 years of age who received acupuncture treatment for nocturnal enuresis, were considered. The primary outcome measure was change in the mean number of wet episodes following treatment. Electronic searching was supplemented by hand searching of western medicine and traditional Chinese medicine (TCM) journals along with English language alternative medicine journals. Trials were assessed for quality and sources of bias. Meta-analysis was performed and the overall weighted odds ratio (OR) and associated 95% confidence interval (CI) were computed using the fixed effect model; the Forest plot was used to demonstrate results.

RESULTS

Two hundred six abstracts were identified, of which 11 studies were eligible for data extraction. All the trials were of low methodological quality. There was some evidence that acupuncture is useful for nocturnal enuresis when used in conjunction with other treatment that may also include a different form of acupuncture (OR 3.98, CI: 2.2-7.2). When one form of acupuncture is compared with another there was marked heterogeneity, implying that some forms of acupuncture are effective.

CONCLUSION

This review provides tentative evidence for the efficacy of acupuncture for the treatment of childhood nocturnal enuresis. Due to the low methodological quality of studies, evidence to identify, which parameters of acupuncture work best, is lacking. More rigorous trials are clearly warranted.

Endoscopic Cross-Trigonal Ureteral Reimplantation Under Carbon Dioxide Bladder Insufflation: A Novel Technique

PURPOSE

To report on a novel technique of endoscopic intravesical ureteral mobilization and cross-trigonal ureteral reimplantation under carbon dioxide insufflation of the bladder (pneumovesicum) for correcting primary vesicoureteral reflux (VUR) in infants and children.

PATIENTS AND METHODS

Ten boys and six girls with dilating primary VUR (7 bilateral; 23 refluxing ureters) associated with recurrent urinary-tract infections and multiple pyelonephritic renal scars underwent endoscopic Cohen's cross-trigonal ureteral reimplantation with CO(2) pneumovesicum. Their ages ranged from 10 months to 13 years (mean 4.1 years). The endoscopic procedure was preceded by distention of the bladder with saline and insertion of a 5-mm Step port over the bladder dome under cystoscopic guidance. The bladder was then drained and insufflated with CO(2) to 10 to 12 mm Hg pressure with a suction catheter inserted per urethra to occlude the internal urethral meatus. A 5-mm 30 degrees endoscope was used to provide intravesical vision. Two more 3- to 5-mm working ports were inserted on the lateral bladder wall on either side. Endoscopic intravesical mobilization of the ureter, dissection of a submucosal tunnel, and a Cohen's type of crosstrigonal ureteral reimplantation using interrupted 5-0 monofilament sutures was then performed under videoscopic guidance. Bladder drainage by a urethral catheter was maintained for 24 hours postoperatively.

RESULTS

Endoscopic cross-trigonal ureteral reimplantation under CO(2) pneumovesicum was successfully performed in all except one patient, who had displacement of a port into the extravesical space after completion of the ureteral reimplantation necessitating a small vesicotomy for closure of the mucosal defect. The mean operating time was 136 minutes (range 80-230 minutes), being 112 minutes for unilateral cases and 178 minutes for bilateral cases. Two boys developed mild suprapubic and scrotal emphysema postoperatively that subsided spontaneously. All other patients recovered uneventfully and remained well. Follow-up cystograms showed complete resolution of VUR in all except one unit that had persistent grade I reflux, thus giving a success rate of 96%.

CONCLUSIONS

This early experience illustrates that endoscopic intravesical ureteral mobilization and crosstrigonal ureteral reimplantation can be performed safely and effectively with routine laparoscopic surgical techniques and instruments under CO(2) insufflation of the bladder, achieving a high success rate in reflux resolution that is equivalent to that obtained with the open technique but with minimal invasiveness and much faster recovery. The longer-term outcome and potential physiological effects of CO(2) pneumovesicum on the bladder and upper-tract function will need to be evaluated further.

Enhancing the absorption of fortification iron. A SUSTAIN Task Force report

Iron deficiency remains a major global health problem affecting an estimated 2 billion people. The World Health Organization ranked it as the seventh most important preventable risk for disease, disability, and death in 2002. Since an important factor in its causation is the poor bioavailability of iron in the cereal-based diets of many developing countries, SUSTAIN set up a Task Force, consisting of nutritional, medical, industry, and government experts to consider strategies for enhancing the absorption of fortification iron. This paper summarizes the findings of this Task Force. Detailed reviews of each strategy follow this overview. Highly soluble compounds of iron like ferrous sulfate are desirable food fortificants but cannot be used in many food vehicles because of sensory issues. Thus, potentially less well-absorbed forms of iron commonly are used in food fortification. The bioavailability of iron fortificants can, however, be enhanced with innovative ingredient technologies. Ascorbic acid, NaFeEDTA, ferrous bisglycinate, and dephytinization all enhance the absorption of fortification iron, but add to the overall costs of fortification. While all strategies cannot be recommended for all food fortification vehicles, individual strategies can be recommended for specific foods. For example, the addition of ascorbic acid is appropriate for dry blended foods such as infant foods and other dry products made for reconstitution that are packaged, stored, and prepared in a way that maximizes retention of this vitamin. NaFeEDTA can be recommended for fortification of fish sauce and soy sauce, whereas amino acid chelates may be more useful in milk products and beverages. With further development, dephytinization may be possible for low-cost, cereal-based complementary foods in developing countries. Encapsulation of iron salts in lipid coatings, while not an iron absorption-enhancing strategy per se, can prevent soluble forms of iron from interacting undesirably with some food vehicles and hence broaden the application of some fortificants. Research relevant to each of these strategies for enhancing the bioavailability or utility of iron food fortificants is reviewed. Individual strategies are evaluated in terms of enhancing effect and stability, organoleptic qualities, cost, and regulatory issues of interest to the nutrition community, industry, and consumers. Recommendations are made on potential usages and further research needs. Effective fortification depends on the selection of technically feasible and efficacious strategies. Once suitable strategies have been identified, cost becomes very important in selecting the best approach to implement. However it is essential to calculate cost in relation to the amount of bioavailable iron delivered. An approach to the calculation of cost using a conservative estimate of the enhancing effects of the innovative technologies discussed in the supplement is given in the final section.

Urinary tract infection: the urological perspective

Urinary tract infection in babies often presents with non specific symptoms and signs. It must be considered in the differential diagnosis of a febrile sick baby or any baby with failure to thrive. In a significant proportion of babies with recurrent urinary tract infection, urological abnormality is demonstrable. The diagnosis of urinary tract infection is confirmed by the presence of pus cells and growth of microorganism in a fresh urine specimen. The voidoing history and detailed ultrasound examination in the baby including a post void evaluation of the upper and lower urinary tract can lead to the possible diagnosis in the majority. Antibiotic therapy for urinary tract infection should be followed by consideration about the need for urinary drainage at the appropriate level, particularly in cases where resolution is delayed despite antibiotics. There is a role for prophylactic antibiotics after the resolution of acute infection, at least until detailed evaluation several weeks after the acute episode, has excluded any abnormality. Micturating cytourethrogram is usually done under antibiotic cover and better done in centres with facility for fluoroscopic examination. Isotope studies have to be evaluated in the light of inherent limitations. Transient urodynamic abnormality of the urinary bladder in infancy is being increasingly recognized and should be the subject of evaluation in specific circumstances. A multidisciplinary team improves the quality of investigations, subsequent interpretation and long term care of these children. A large majority of urological abnormality in infancy and early childhood can be effectively managed by endocopic procedures. Temporary urinary diversion may be required in a small proportion. Urological reconstruction should be approached with caution, after a detailed analysis of the evolving urological tract in a baby. An aggressive approach to early diagnosis and appropriate treatment of urinary tract infection and any underlying abnormality, has been shown to significantly reduce the incidence of chronic renal failure in long term longitudinal studies in children.

Current indications for laparoscopy and retroperitoneoscopy in pediatric urology

Laparoscopy has raised great interest in the past few years in the field of pediatric urology. It has evolved from a simple diagnostic maneuver to complex operative procedures. The aim of this study was to review urologic laparoscopy literature and provide a critical review of this field to establish current indications for videosurgery in pediatric urology. In general, from an anatomic point of view, retroperitoneoscopy seems to be more suitable than the transperitoneal laparoscopic approach for reaching the upper urinary tract. It also is less invasive and complies with the criteria for open renal surgery. With respect to current indications for videosurgery in pediatric urology, the authors have identified several well-established clinical procedures, although no large series have been published for any of the procedures, except for the treatment of varicocele, nonpalpable testis, and nephrectomy. In conclusion, the data reviewed suggest that videosurgery is a safe and feasible technique in pediatric urology if performed by expert surgeons, and that it certainly will develop further in the next few years.

Primary CD30+ve Cutaneous T-cell Lymphoma Associated with Chronic Burn Injury in a Patient with Longstanding Psoriasis

An increased incidence of lymphoma has been reported in psoriatic patients, but most cases are nodal B-cell lymphoma. We report a unique case of CD30-expressing cutaneous T-cell lymphoma arising from underlying psoriatic plaque after intractable caustic burns and cellulitis in the palm of a patient with generalized chronic plaque psoriasis. Molecular studies confirmed a localized clonal T-cell expansion, and the lesion responded dramatically to multiagent chemotherapy. The case highlighted the possible role of chronic systemic and local T-cell activation in the pathogenesis of primary CD30+ve cutaneous T-cell lymphoma, and the importance of histologic assessment in chronic nonhealing skin lesions.

ULTRASOUND BLADDER MEASUREMENTS IN PATIENTS WITH PRIMARY NOCTURNAL ENURESIS: A URODYNAMIC AND TREATMENT OUTCOME CORRELATION

PURPOSE

Accurate assessment of bladder dysfunction associated with voiding dysfunctions often necessitates invasive urodynamic (UD) studies. We evaluate the use of a special ultrasound (US) protocol for the assessment of bladder dysfunction compared with urodynamic findings, and for prediction of treatment outcome in children with primary nocturnal enuresis (PNE).

MATERIALS AND METHODS

US measurements were performed on 514 children 5 to 18 years old (mean age 11.2) with PNE, and compared with those of 339 normal age matched children. A US protocol was specially designed for the evaluation of bladder parameters using bladder volume and wall thickness index (BVWI %), and expected percentage bladder volume index for kidney volume. Of the enuretic children 218 had severe enuretic symptoms with more than 3 wet nights a week. They underwent urodynamic studies for detailed assessment of any underlying bladder dysfunction. A standard 4-week course of desmopressin was given to these children after the US and UD studies. The US bladder parameters were then correlated with the UD findings and treatment response to desmopressin.

RESULTS

Comparing the BVWI in normal and enuretic children in correlation with functional bladder capacities we were able to delineate bladder wall thickness and capacity as BVWI less than 70-small capacity bladder with thick wall, BVWI 70 to 130-normal bladder capacity with normal wall thickness and BVWI greater than 130-large bladder capacity with thin wall. There were statistically significant correlations between BVWI and treatment response. In addition, there was a high predictive value of normal bladder function with a normal BVWI. Patients with good response to treatment had normal BVWI, whereas poor response to treatment was significantly associated with pathological bladder conditions, that is small bladder capacity with thick bladder wall or large bladder capacity with thin bladder wall (p <0.0001). Of note, abnormalities detected by UD correlated well with bladder abnormalities measured by US.

CONCLUSIONS

PNE comprises a diverse spectrum of conditions resulting in a mismatch of nocturnal urine production in excess of nocturnal functional bladder capacity, and underlying bladder dysfunction has an important role in the pathophysiology especially in refractory cases. This US protocol can provide useful predictive clues, which may be helpful to differentiate treatment subtypes, guide clinical management and minimize the need for invasive urodynamic studies.

URODYNAMIC FINDINGS IN ADULTS WITH PRIMARY NOCTURNAL ENURESIS

PURPOSE

We evaluate bladder function in adults with primary nocturnal enuresis (PNE) since childhood.

MATERIALS AND METHODS

We recruited all patients older than 16 years who presented to our PNE clinic with persistent enuretic symptoms. All patients were assessed by a detailed voiding diary, uroflowmetry and ultrasonography of the urinary tract. Urodynamic studies were performed for those with moderate or severe PNE (more than 3 wet nights a week).

RESULTS

The study included 18 males and 29 females with a mean age of 20 years (range 16 to 43). Of these patients 37 (79%) had moderate or severe symptoms and 17 (38%) also had daytime urinary symptoms. Urodynamic studies were conducted in 30 patients, including 12 males and 16 females (93%) with detrusor overactivity. In addition, 73% of patients had urodynamic evidence of functional bladder outflow obstruction, including dysfunctional voiding and detrusor sphincter or detrusor pelvic discoordination. Two male patients (6.7%) had an obstructive pattern on urodynamics and subsequent cystoscopic examination confirmed the presence of congenital obstructive urethral lesions. Sixteen patients (53%) had significantly reduced bladder capacity of less than 300 ml.

CONCLUSIONS

Unlike in early childhood, the majority (79%) of enuretic adults had significant symptoms, and more than a third also had daytime urinary symptoms. We believe that PNE in adults is not only a psychologically disturbing condition, but also a urological disorder with significant underlying bladder dysfunction that warrants special attention to management.

VARIABILITY IN NORMATIVE URINE FLOW RATES

PURPOSE

Parameters derived from uroflowmetry are frequently used in the evaluation and reassessment of children presenting with lower urinary tract dysfunction. Since current nomograms have been constructed from 1 to 2 voids per child, variability of flow parameters is unknown. We evaluate intraindividual variability of flow parameters in children free of lower urinary tract symptoms.

MATERIALS AND METHODS

Children between 4 and 16 years old (mean age 9.8) who were hospitalized but not suffering from urinary tract infection, pyelonephritis or neurological disturbance, and who had neither structural abnormality of the urinary tract nor acute pain or disorientation voided spontaneously over a flowmeter on 4 to 6 occasions. Post-void urine was estimated by ultrasound within 5 minutes of micturition to confirm complete emptying.

RESULTS

A total of 98 subjects provided a mean of 4.4 traces each. Neither maximum nor average flow rate showed great intraindividual variability (maximum flow rate r >0.8, average flow rate r >0.74). Flow rates significantly correlated with flow duration, volume voided and patient age. Initial flow curves were bell-shaped in 63% of cases, staccato in 30% and intermittent in 6%. These proportions did not change with subsequent voids. There was no significant difference between genders with respect to staccato voiding, although boys demonstrated 70% of intermittent voids and were significantly older than girls.

CONCLUSIONS

In normal children there is minimal variability in flow rates and the phenomenon of staccato voiding is seen approximately 30% of the time, despite no significant levels of post-void residual urine.

A review of non-invasive electro neuromodulation as an intervention for non-neurogenic bladder dysfunction in children

AIMS

The use of electrotherapeutics to improve filling and emptying dysfunction of the adult bladder has been well established, however the practice in children is less well known. The purpose of this review is to summarize the rationale behind the use of electro neuromodulation in children, examine the reported efficacy of the intervention for different presentations of dysfunction, and establish the current limitations to knowledge and practice.

MATERIALS AND METHODS

A modified systematic review was carried out on all Medline studies identified as considering the use of electrotherapy or neuromodulation in children with bladder problems. Literature relating to use of this approach in adults was also searched in order to present current understanding of the treatment rationale and modes of application.

RESULTS

A Medline search and handsearch of relevant conference proceedings revealed six studies of neuromodulation in children with non-neurogenic bladder dysfunction. There were no reports of the intervention in children with isolated pelvic floor dyssynergia, irritative symptoms, structural changes predisposing the pelvic floor to weakness, or monosymptomatic nocturnal enuresis. One report of the favorable effect of neuromodulation on gut dysmotility was identified. Study design and quality generated level 4 evidence. Positive post-intervention changes reported included: increased bladder capacity, decreased severity of urge, improved continence, and decrease frequency of urinary tract infection. Significant improvement in the urodynamic parameters of bladder compliance, number of uninhibited contractions, and bladder volume at first detrusor contraction were also reported.

CONCLUSIONS

There are clear benefits from the use of electroneuromodulation in children with differing forms of voiding dysfunction. The treatment approach is independent of cognitive and pharmacological therapy, is minimally invasive, and free of side effects. To date, there are no clinical variables that reliably predict efficacy of electrotherapy in the various presentations of over and under active detrusor, sphincter dyssynergia, or irritative symptoms.

Characteristics of primary nocturnal enuresis in adults: an epidemiological study

OBJECTIVE

To evaluate the prevalence and characteristics of primary nocturnal enuresis (PNE) in adults in Hong Kong, as there are currently limited epidemiological data in adults.

SUBJECTS AND METHODS

After a telephone survey, 8534 respondents (3996 males and 4538 females) aged 16-40 years were selected for the study and stratified in age groups. The questionnaire used comprised two parts; the first started with questions mainly about the general demographic background to decrease the sensitivity of the study and to establish rapport. The second part was conducted through an automated telephone interview service, with the questions being asked by recorded messages and the respondents then keying in their responses with no need to converse with an interviewer. This part included questions about enuretic symptoms and a subjective assessment of social and psychological effects of bedwetting, and measurements of the individual's self-esteem (Rosenberg Self-esteem Scale) and depression (The Centre for Epidemiological Studies Depression Scale).

RESULTS

Of the 8534 subjects interviewed, 196 had PNE, giving an overall prevalence of 2.3% (2.7% males and 2.0% females); of these 196, 36 (18.4%) also had daytime urinary incontinence. Hence, 1.9% of adults (2.2% males and 1.7% females) had monosymptomatic PNE. Of these, 53% wet >3 nights/week and 26% wet every night. Prevalence rates remained relatively stable among different age groups, with no apparent trend of a reduction with age. Compared with nonenuretic normal controls, significantly fewer enuretics reached tertiary education (33.4% vs 17.8%, P < 0.01). Bedwetters had a significantly higher incidence of depression and lower self-esteem, and a higher incidence of sleep disturbances than the control group. Among bedwetters, 32-40% felt that there was some effect on their choice of job, work performance and social activities, whilst 23% felt the condition affected their family life and in making friends of either sex. However, there was no significant difference in the marital status. Interestingly, only 34.5% of females and half of males used various methods before bedtime to prevent bedwetting.

CONCLUSIONS

Overall, 2.3% of Hong Kong adults aged 16-40 years have persistent PNE. Unlike PNE in early childhood the prevalence remained relatively unchanged with age, suggesting that enuretic symptoms persisting into adulthood are probably less likely to resolve with time. Also, significantly more patients had more severe enuretic symptoms. These findings therefore highlight the possibility that PNE in adults may represent a more pronounced form of the condition, and with a more serious social and psychological effect on affected individuals. Further work is needed to evaluate the pathogenesis and management strategy.

Dynamic gadolinium-enhanced magnetic resonance urography for assessing drainage in dilated pelvicalyceal systems with moderate renal function: preliminary results and comparison with diuresis renography

OBJECTIVE

To evaluate the use of dynamic gadolinium diethylenetriaminepenta-acetic acid (DTPA)-enhanced magnetic resonance urography (Gd-MRU) for assessing kidneys with markedly dilated pelvicalyceal systems and impaired function.

PATIENTS AND METHODS

Eight children (mean age 30 months, sd 25) were assessed, diagnosed as having gross unilateral hydronephrosis with a mean (sd) anteroposterior renal pelvic diameter of 36 (7) mm and reduced (30-40%) renal function. Dynamic Gd-MRU was performed after the patients were pre-loaded with intravenous fluid and diuretics, and comprised a dynamic T1-weighted sequence after Gd-DTPA (0.1 mmol/kg body weight) was administered, with a time-intensity curve of each kidney produced. Drainage was diagnosed by a clearly declining time-intensity curve and direct visualization of contrast medium within the ureter in several frames. High-grade or complete obstruction was diagnosed when drainage of contrast medium could not be detected. Gd-MRU results were compared with diuresis radionuclide (mercapto-acetyltriglycine, MAG3) renography within the same week. Unobstructive units detected by Gd-MRU were treated conservatively with a close follow-up by ultrasonography and radionuclide studies.

RESULTS

Diuresis MAG3 renography showed drainage in three dilated units and poor washout in five; in contrast, Gd-MRU showed drainage in seven dilated systems (three showed poor washout by MAG3), and obstruction in the remaining case. The unobstructed units detected by MRU under conservative treatment thus showed no further deterioration of renal function or progressive hydronephrosis in the subsequent follow-up (mean 18 months, range 15-23).

CONCLUSION

These preliminary results suggest that dynamic Gd-MRU is a useful noninvasive imaging method in distinguishing obstructive from unobstructive dilated systems, particularly in patients with hydronephrosis and reduced renal function.

Selective Approach for Transperitoneal and Extraperitoneal Endoscopic Nephrectomy in Children

PURPOSE

From the experience of a large combined series of transperitoneal (TP) and retroperitoneal (RP) endoscopic complete and partial nephroureterectomies in children, we present a logical selective endoscopic approach to benign renal pathology.

MATERIALS AND METHODS

During a 5-year period 122 complete nephrectomies and nephroureterectomies (bilateral 2, invisible ectopic 8) and 63 partial nephroureterectomies for duplex (52 upper, 8 lower) or singleton polar disease (xanthogranulomatous pyelonephritis 1, cyst 2) were performed. Of the partial nephrectomies, ureterectomy, bladder repair and lower moiety reimplantation were performed in 8. Patient age ranged from 2.7 months to 14 years (mean 2.9 years). Preoperative weight ranged from 2.7 to 98 kg (mean 12.3). The position of the renal remnant, the presence or absence of a refluxing ureter and the need for ureterectomy were the major determining factors affecting choice of endoscopic approach.

RESULTS

A total of 179 (96.7%) procedures were successfully completed endoscopically. The 6 open conversions (3.2%) occurred early in our experience. The operating time reflected the complexity of the excision and lower urinary reconstruction (lateral and posterior RP 25 to 145 minutes [mean 92]) TP with ureterocelectomy and bladder neck repair 105 to 355 minutes [mean 153]. Hospital stay for RP and simple TP was 1.5 days (mean 1 to 4) and for complicated TP 2 to 8 days (mean 3.5).

CONCLUSIONS

We suggest a posterior retroperitoneal approach with isolated renal excision without extended ureterectomy. The lateral retroperitoneal approach allows complete ureterectomy as well as better exposure to horseshoe and pelvic kidneys and, therefore, avoids exposure to intraperitoneal structures. Finally, the transperitoneal approach is recommended when complete moiety excision with lower urinary reconstruction is anticipated.

Prospective study of pulsed dye laser in conjunction with cryogen spray cooling for treatment of port wine stains in Chinese patients

BACKGROUND

Pulsed dye laser (PDL) in conjunction with cryogen spray cooling (CSC) is effective in improving efficacy and safety for treatment of port wine stains (PWSs) in whites. However, for dark-skinned patients such as Chinese, only retrospective studies have been performed.

OBJECTIVES

To compare prospectively clinical efficacy in terms of blanching and acute and long-term adverse effects of PDL alone and PDL-CSC for treatment of PWSs in Chinese patients.

METHODS

Thirty-five Chinese patients (13 males and 22 females) were recruited, and 131 treatments were performed. Half of the test area on the PWS was treated with PDL alone, and the contralateral half was treated with PDL-CSC. The degree of PWS blanching was objectively assessed by spectrophotometer. Skin textural changes were detected by cutometer. All measurements were taken at baseline and before each subsequent laser treatment. Patients were interviewed immediately after treatment and again the following week using a visual analog scale questionnaire to assess the degree of pain and swelling. Occurrence of blisters was noted during each follow-up visit. Patients were evaluated for evidence of long-term adverse effects such as dyspigmentation and scarring after three treatments.

RESULTS

Statistically significant higher fluences were used on the PDL-CSC-treated group. The percentage change in the spectrophotometer a* value was significantly greater using PDL-CSC, indicating that there was more PWS blanching after treatment. There was no significant difference in the incidence of skin textural changes after three treatments with PDL alone or PDL-CSC. The immediate pain scores were significantly higher for PDL alone than with PDL-CSC. Blisters were significantly more common on the area treated using PDL alone than PDL-CSC. The overall incidence of long-term adverse effects was not significantly different between the PDL alone and PDL-CSC treatments. PDL-CSC was also the preferred treatment modality for most patients.

CONCLUSIONS

PDL-CSC was more effective than PDL alone for blanching of PWS in Chinese patients. Moreover, PDL-CSC was better tolerated and resulted in a lower incidence of acute adverse effects such as blistering.

Periurethral injection therapy for urinary incontinence using a laparoscopic port

In a 14-year-old boy with bladder augmentation, Mitrofanoff appendicovesicostomy, Malone antegrade enema stoma, and bladder neck reconstruction, urinary continence was restored by injection of Teflon with a Veress needle and the aid of a 2-mm laparoscopic port. The method has since been used for nine treatments in six children and has been successful in all.

Backside contacted field effect transistor array for extracellular signal recording

A new approach to the design of field-effect transistor (FET) sensors and the use of these FETs in detecting extracellular electrophysiological recordings is reported. Backside contacts were engineered by deep reactive ion etching and a gas phase boron doping process of the holes using planar diffusion sources. The metal contacts were designed to fit on top of the bonding pads of a standard industrial 22-pin DIL (dual inline) chip carrier. To minimise contact resistance, the metal backside contacts of the chips were electroless plated with gold. The chips were mounted on top of the bonding pads using a standard flip-chip process and a fineplacer unit previously described. Rat embryonic myocytes were cultured on these new devices (effective growth area 6 x 6 mm(2)) in order to confirm their validity in electrophysiological recording.

Unusual neurological presentation of neuroblastoma

Acute cerebellar ataxia and opsomyoclonus are presenting signs of occult neuroblastoma for a substantial proportion of paediatric patients. Cerebellar ataxia may be due to antibodies against the neuroblastoma cross-reacting with cerebellar tissue. This report is of a 26-month-old boy who presented with encephalitis-like features of ataxia, seizures, decreased consciousness, and involuntary movements. Magnetic resonance imaging of the brain and spine were normal 2 weeks after presentation. The child did not have the classical signs of opsoclonus or myoclonus at any stage of the disease but was found to have occult neuroblastoma. The late demyelinating changes seen on magnetic resonance imaging of the brain support an immunological basis for the paraneoplastic manifestations of occult neuroblastoma in this child. Occult neuroblastoma should be considered as one of the differential diagnoses for children presenting with persisting encephalitis-like features in the presence of normal neuroimaging findings.

Laparoscopically assisted ureterocystoplasty

OBJECTIVE

To assess the efficacy and safety of laparoscopically assisted ureterocystoplasty (LAU) in children.

PATIENTS AND METHODS

From 1999 to 2001, five patients (mean age 7 years, range 3.5-13) from four centres underwent LAU with laparoscopic mobilization of the small kidney and upper ureter combined with ureterocystoplasty, with exposure of the bladder through a Pfannenstiel incision. The details and outcomes are reviewed.

RESULTS

The LAU was successful in all five patients; there were no complications. A large midline incision was avoided and the LAU carried out through the better tolerated and less painful Pfannenstiel incision.

CONCLUSION

LAU is an appealing technique that is safe with the added benefit of a reduced abdominal incision and acceptable operative duration. This represents the first published report of LAU.

A patient with congenital ichthyosis hystrix (disseminated congenital naevus) and acute lymphoblastic leukaemia

Congenital ichthyosis is an uncommon spectrum of hereditary and sporadic hyperkeratotic epidermolytic disorders that may occur in isolation or in association with other clinical syndromes. The pattern of distribution of the hyperkeratotic lesions and family history form the basis of diagnosis. Ichthyosis may be a marker for immune deficiency and cancer prone conditions. We report a 16-year old Chinese patient with a diagnosis of ichthyosis hystrix hystrix (disseminated congenital naevus) since birth who presented with T cell acute lymphoblastic leukaemia with tetraploid clones. There are four reports of acute leukaemia complicating ichthyosis, all involving paediatric acute lymphoblastic leukaemia. The possible mechanisms involved are discussed.