[Special urological traumatology in children and adolescents]

Isolated injuries of the genitourinary tract are rare, with the kidney being the most frequently affected organ, especially in situations of polytrauma. Overall, the genitourinary tract is involved in approximately 3 % of all children suffering polytrauma accidents. The literature and international guidelines provide clear therapeutic concepts with a consensus on the diagnosis and treatment of renal trauma, both for the treatment of adults and for children and adolescents. However, the most common injuries to the external genitalia in children and adolescents are caused by blunt trauma, abrasion, bruising, and piling. For these forms of injuries there are no general recommendations in literature and guidelines regarding diagnostic or therapeutic procedures, which may be due to the wide variety of origins of the injuries. Consequently, as shown in our sequence of case reports, each type of injury to the external genitourinary system requires an individual evaluation and therapeutic approach.

[Transition of adolescents with the exstrophy-epispadias complex to adult medicine: influence of long-term outcome results on management]

Today, young individuals with rare congenital anomalies as the Exstrophy-Epispadias-Complex (EEC) are mostly monitored interdisciplinary with a high standard of care and enthusiasm during childhood. However, when growing up through adolescence to adulthood adequate care-givers are not available at the moment in adult medicine in Germany and a concrete transition process has yet not been established. Over the past years, we put much effort in systematic evaluation of long-term outcome after reconstruction of the EEC in the newborn period to further improve outcome results. Beside predictive parameters for continence and long-term bladder function, genital function and fertility, as well as postoperative pelvic floor morphology and gynecological outcome, orthopedic results and psychosexual and psychosocial development in EEC were of major interest. As a consequence we currently develop a German-wide follow-up concept in EEC patients regarding age- and gender specific outcome issues. Long-term observations of the EEC outcome however, underline the unrestricted importance of careful long-term follow-up of all EEC patients, as well as the necessity of close cooperation of pediatric urologist, pediatric surgeons, urologists, orthopedic surgeons, gynecologists, andrologists, psychologists and urotherapists from early childhood and the need of knowledge transfer and hopefully a successful transition of the EEC individuals to general medicine.

[Tumour registry and reality: differential diagnosis of testicular tumours in childhood: survey and personal experience]

Painless scrotal swelling must always be considered as a potential malignant testicular tumour until proven otherwise. Prepubertal testicular tumours are seldom entities, for their differential diagnosis testicular sonography is gaining increasing importance. Although, according to national and international tumour registries, most patients tend to have malignant tumours, some clinical series from paediatric centres confirm that prepubertal testicular tumours are mainly benign lesions, especially up to the age of 12 years. Testis-sparing procedures are favoured when AFP is in a normal range and testicular parenchyma is detected sonographically. Oncological principles should be applied to paediatric patients consequently, staging examinations should be requested when a definite histology is proven. Cases should be reported to national tumour registries and, in addition to close surveillance, in some cases adjuvant therapy is necessary. In addition to the clinical guidelines from the tumour registries, differential diagnosis, testis-sparing surgery and the presence of TIN in the paediatric population should be discussed.

Epidemiological survey of 214 families with bladder exstrophy-epispadias complex

PURPOSE

We sought to identify causative nongenetic and genetic risk factors for the bladder exstrophy-epispadias complex.

MATERIALS AND METHODS

A total of 237 families with the bladder exstrophy-epispadias complex were invited to participate in the study, and information was obtained from 214 families, mainly from European countries.

RESULTS

Two families showed familial occurrence. Male predominance was found among all subgroups comprising epispadias, classic bladder exstrophy and cloacal exstrophy, with male-to-female ratios of 1.4:1, 2.8:1 and 2.0:1, respectively (p = 0.001). No association with parental age, maternal reproductive history or periconceptional maternal exposure to alcohol, drugs, chemical noxae, radiation or infections was found. However, periconceptional maternal exposure to smoking was significantly more common in patients with cloacal exstrophy than in the combined group of patients with epispadias/classic bladder exstrophy (p = 0.009). Only 16.8% of mothers followed the current recommendations of periconceptional folic acid supplementation, and 17.6% had started supplementation before 10 weeks of gestation. Interestingly, in the latter group mothers of patients with cloacal exstrophy were more compliant with folic acid supplementation than were mothers of the combined group of patients with epispadias/classic bladder exstrophy (p = 0.037). Furthermore, mothers of children with cloacal exstrophy knew significantly more often prenatally that their child would have a congenital malformation than did mothers of children with epispadias/classic bladder exstrophy (p <0.0001).

CONCLUSIONS

Our study corroborates the hypothesis that epispadias, classic bladder exstrophy and cloacal exstrophy are causally related, representing a spectrum of the same developmental defect, with a small risk of recurrence within families. Embryonic exposure to maternal smoking appears to enforce the severity, whereas periconceptional folic acid supplementation does not seem to alleviate it. There is a disproportional prenatal ultrasound detection rate between severe and mild phenotypes, possibly due to the neglect of imaging of full bladders with a focus on neural tube defects.

[Complete urethral duplication with dorsal epispadiac urethra: case report]

Urethral duplication is a rare congenital anomaly with variable clinical presentation. A number of theories have been proposed to describe the embryology of the condition; the actual mechanism of the disorder is still unclear. We present a 2-year-old boy with complete urethral duplication and two functional sphincters. Functional and surgical results were satisfying with good continence.

Lymphocytoma cutis benigna

Infectious conditions of the infantile genitals are a diagnostic challenge. One of the rare differential diagnoses is lymphocytoma cutis benigna. We report a case of borrelial lymphocytoma of the glans penis in a 9 year old boy. Based on this case, the clinical, diagnostic and therapeutic aspects of this rare form of dermatoborreliosis are discussed.

Apolipoprotein E epsilon 4 is associated with an increased vulnerability to cell death in Alzheimer’s disease

The presumption to suffer from Alzheimer's disease (AD) accelerates with aging. One important risk factor seems to be the isoform epsilon 4 of the apolipoprotein E gene (Apo epsilon 4), which increases the risk to develop AD at an earlier age. Furthermore, convincing evidence is provided that apoptotic cell death mechanisms play an important role in neuronal cell death in AD. In the present study, we investigated whether abnormalities in apoptosis and caspase-3 activity can be found at the level of lymphocytes and a T cell subtype, CD4 T cells, from AD patients compared to aged sex- and ApoE genotype-matched non-demented controls. Under different experimental conditions (at baseline or after in vitro incubation in the presence of proapoptotic stimuli) increased levels of apoptosis and enhanced caspase-3 activity were detected in lymphocytes from AD patients. This difference was most pronounced in the CD4(+) T cell subtype. Notably, we found a significant increase of apoptotic cells and caspase-3 activity in lymphocytes from AD patients bearing one or two alleles of the ApoE4 compared to non-E4 carriers. Again, these effects were strongest in CD4(+) T cells. Circulating amyloid-beta (A beta) levels did not differ between AD patients bearing ApoE4 and non-ApoE4 and age-matched controls. Therefore, it is likely that circulating A beta is not responsible for the observed effects, which might rather reflect an ongoing systemic response in AD, e.g. an increase in CD95 expression.

Comparative evaluation of a new bedside faecal occult blood test in a prospective multicentre study

BACKGROUND

Faecal occult blood testing is an established method of colorectal neoplasia screening. Guaiac-based tests are limited by poor patient compliance, low sensitivity, specificity and positive predictive value. Newer immunochemical-based tests, accurate but tedious, require a well-established laboratory set up. There is need for simpler immunochemical tests that can be performed at the out-patient clinic.

AIM

To compare the performance characteristics of a new bedside immunological test strip device with a sensitive Guaiac-based and established immunochemical test for detection of faecal occult blood in patients undergoing colonoscopy.

METHODS

A total of 389 consecutive patients from four centres who were referred for colonoscopy also provided the stool samples for detection of occult blood without dietary restrictions. Stool tests performed were (i) Guaiac-based, (ii) immunochemical enzyme-linked immunosorbent assay and (iii) bedside immunochemical strip test.

RESULTS

At the optimal threshold level, the sensitivity and specificity of the beside immunochemical strip test for detection of significant colorectal neoplasia (adenomas >1.0 cm and carcinomas) were 60% and 95%, respectively.

CONCLUSIONS

This bedside immunochemical strip test proved to be a simple, convenient, non-cumbersome and accurate tool with similar performance characteristics for detection of any bleeding lesion including colorectal neoplasia when compared with an established immunochemical faecal occult blood test.

Phytotherapy for functional dyspepsia: a review of the clinical evidence for the herbal preparation STW 5

Functional gastrointestinal disorders such as functional (or non-ulcer) dyspepsia are characterized by a broad spectrum of symptoms referred to the upper abdomen without a detectable cause utilizing routine diagnostic measures. It is now believed that disordered gut function (including abnormalities like disturbances of motility such as postprandial fundic relaxation, gastric emptying and disturbed visceral sensory function) play a key role for the manifestation of these disorders. The underlying pathophysiology is not yet fully understood. However, the available data suggest that a number of factors may contribute to the manifestation of symptoms. These factors include environmental factors such as acute infections as trigger event, psychological stressors that may precede acute exacerbations and a genetic predisposition. Considering the large number of mechanisms, a treatment targeting a single mechanism is unlikely to be effective in all patients. Indeed, chemically defined treatments usually gain a 10-15% superiority over placebo. In recent years placebo-controlled studies have demonstrated superiority of a commercial multicomponent herbal preparation, STW 5, with the trade name Iberogast, for the treatment of patients with functional dyspepsia and irritable bowel syndrome. This phytopharmacon is a combination of nine plant extracts each with a number of different active constituents. Pharmacological studies have shown different effects of the single plant extracts on the (molecular) mechanisms which are discussed as underlying the manifestation of symptoms. Various well-controlled clinical trials have independently confirmed clinical efficacy and safety. The clinically efficacy of this multicomponent herbal preparation questions the current trend of highly targeted drug molecules that usually target one single receptor population while it has not been shown that a single receptor group plays a pivotal role for the control of symptoms. Herbal medicines are obtained from various plants and contain complex extracts with a large number of different active substances. While there are only limited head-to-head comparisons with conventional chemically defined medications, the combination of extracts with various gastrointestinal active ingredients appears to be advantageous for a heterogeneous condition such as functional dyspepsia.

Meta-analysis: phytotherapy of functional dyspepsia with the herbal drug preparation STW 5 (Iberogast)

BACKGROUND

Despite a long-standing use of herbal drugs with dyspeptic symptoms, little attention has been paid to their clinical evaluation.

AIM

To assess efficacy and safety of the herbal drug preparation STW 5 (containing, e.g. Iberis, peppermint, chamomile) in the treatment of functional dyspepsia.

METHODS

Research in electronic databases, consultation of experts and of the producer identified STW 5 (Iberogast) as descriptor in six randomized-controlled trials. The raw data of three placebo-controlled studies which met the selection criteria, were reanalysed and pooled for meta-analysis; one reference-controlled study supported the safety analysis (STW 5: n = 199, control: n = 198).

RESULTS

Pooled data showed verum (n = 138) to be more effective than placebo (n = 135) with regard to the severity of the most bothersome gastrointestinal symptom (P-value: 0.001, odds ratio: 0.22, 95% CI: 0.11-0.47). A fourth randomized-controlled trial showed no significant difference between STW 5 and cisapride. As to safety, adverse events were similar with verum and placebo; no serious adverse events occurred.

DISCUSSIONS

From the point of view of efficacy and safety, the herbal medicinal product STW 5 appears to be a valid therapeutic option for patients seeking phytotherapy for their symptoms of functional dyspepsia.

“Very delayed” graft function in a patient after living related kidney transplantation: a case report

We report the case of a patient who experienced anuric renal transplant failure for 44 days after living related kidney transplantation. Immunosuppressive and other therapies were carefully adapted to the findings of frequent renal transplant biopsies, which ultimately led to excellent graft function.

A summary of Food and Drug Administration-reported adverse events and drug interactions occurring during therapy with omeprazole, lansoprazole and pantoprazole

BACKGROUND

Pantoprazole is claimed to have a lower potential for drug interaction than other proton pump inhibitors.

AIM

To estimate the frequency of adverse events and drug interactions reported to the Food and Drug Administration in patients receiving omeprazole, lansoprazole or pantoprazole.

METHODS

The study involved a search of the Food and Drug Administration's database for adverse events and drug interactions with omeprazole, lansoprazole or pantoprazole as primary or secondary suspect drug. An estimate of the amount of drug dispensed during the adverse event collection period (from US drug launch) was obtained from the International Medical Statistics health database.

RESULTS

Of the suspected drug interactions recorded, vitamin K antagonist interactions, although rare, were the most common. The frequency of vitamin K antagonist interactions was 0.09 per million packages for omeprazole and 0.11 per million packages for lansoprazole and pantoprazole. Interactions with benzodiazepines or phenytoin were even rarer, being reported in less than 10 patients on each proton pump inhibitor.

CONCLUSION

The frequency of reported drug interactions was low for omeprazole, lansoprazole and pantoprazole and vitamin K antagonist interactions were by far the most common. These potentially important drug interactions, although rare, were no less frequent on pantoprazole than on omeprazole or lansoprazole, suggesting a class effect.

Primary prevention of diclofenac associated ulcers and dyspepsia by omeprazole or triple therapy in Helicobacter pylori positive patients: a randomised, double blind, placebo controlled, clinical trial

BACKGROUND

There is much controversy as to whether or not treatment of Helicobacter pylori reduces the occurrence of peptic ulcers during therapy with a non-steroidal anti-inflammatory drug (NSAID).

AIM

To assess the efficacy of triple therapy or omeprazole on the occurrence of diclofenac associated ulcers in H pylori positive patients.

METHODS

This was a randomised, double blind, placebo controlled, multicentre trial in H pylori positive patients requiring NSAID therapy who had no past or current peptic ulcer. They received diclofenac 50 mg twice daily for five weeks in combination with one of the four randomly assigned treatments: anti-H pylori treatment for one week (omeprazole 20 mg+clarithromycin 500 mg+amoxicillin 1 g, all twice daily) followed by placebo for four weeks (OAC-P); anti-H pylori treatment for one week followed by antisecretory treatment with omeprazole 20 mg once daily for four weeks (OAC-O); omeprazole 20 mg once daily for five weeks (O-O); or placebo for five weeks (P-P). Patients were endoscoped before and after treatment.

RESULTS

Data from 660 patients were included in an intention to treat analysis. The occurrence of peptic ulcers in the four treatment groups during the study period was: 1.2% for OAC-P, 1.2% for OAC-O, 0% for O-O, and 5.8% for P-P (p<0.05 between placebo and all active treatment groups). Patients who received active treatment developed therapy requiring dyspeptic symptoms less frequently than those who received placebo (p<0.05 between placebo and all active treatment groups).

CONCLUSIONS

In H pylori infected patients, all three active therapies reduced the occurrence of NSAID associated peptic ulcer and dyspeptic symptoms requiring therapy.

A randomised clinical trial comparing the efficacy of a herbal preparation STW 5 with the prokinetic drug cisapride in patients with dysmotility type of functional dyspepsia

AIM

To compare the efficacy of the herbal preparation STW 5 (Iberogast ((R))) and the research preparation STW 5-II with cisapride for treatment of patients with dysmotility type of functional dyspepsia.

PATIENTS AND METHODS

After a diagnostic work-up and 7 days wash-out, 186 patients with dysmotility type of functional dyspepsia were randomly assigned in a double-blind, double-dummy study to one of three treatment arms (STW 5/cisapride-placebo; STW 5-II/cisapride-placebo; cisapride/STW-placebo) for four weeks. Main outcome variable was the improvement of a dyspepsia-specific gastrointestinal symptom score. Symptoms were assessed three times during treatment and after six months follow-up. Hypothesis of non-inferiority was tested. Secondary endpoints were efficacy and tolerability assessments, recurrences and safety parameters.

RESULTS

137 patients were included in the confirmatory analysis. The lower limit of the confidence interval for both herbal preparations was above the pre-defined lower limit of the equivalence border and hypothesis of non-inferiority was proven for STW 5 and STW 5-II. There were no statistical significant differences for the secondary endpoints.

CONCLUSION

In this study STW 5 and the research preparation STW 5-II showed equivalent efficacy to cisapride for the treatment of patients with functional dyspepsia of dysmotility type.

[Long-term drug therapy versus antireflux surgery in chronic reflux]

In endoscopy-negative reflux disease just 25% remain in remission after drug therapy, in reflux oesophagitis only 10%. Long-term management is therefore mandatory in this quality of life-impairing chronic disorder. Following the GENVAL consensus conference proton pump inhibitors (PPI) should be used primarily in a step-down regimen; isomeric PPIs reduce duration of acute therapy by 50%. According to Klinkenberg-Knol et al. 100% of all patients with H2-resistant reflux oesophagitis are asymptomatic and free of recurrency when dosage of PPI is adapted to a higher level. The same result was obtained in the prospective study by Lundell et al. comparing fundoplication and long-term management with omeprazole for 3 years.

Increased endothelin-1 and decreased adrenomedullin gene expression in the stenotic tissue of congenital pelvi-ureteric junction obstruction in children

OBJECTIVES

To test the hypothesis that the gene expression of endothelin-1 and adrenomedullin may be altered in stenotic tissues of patients with congenital hydronephrosis caused by pelvi-ureteric junction (PUJ) obstruction.

MATERIALS AND METHODS

Using real-time reverse transcription-polymerase chain reaction, mRNA of smooth muscle-constricting endothelin-1 and of smooth muscle-relaxing adrenomedullin was quantified in tissue specimens of 20 patients with PUJ obstruction (mean age 5.1 years, SD 7.0) and of 21 controls with normal PUJs (mean age 23.5 years, SD 24.2).

RESULTS

The amount of endothelin-1 mRNA in stenotic specimens was higher than in the controls, indicated by significantly lower threshold cycles (Ct values) in real-time PCR for the target gene in the obstructive tissue, with mean (SD) values of 24.9 (1.6) and 26.0 (2.1) (P < 0.05), respectively. The endothelin-1/CD31 ratio was significantly higher in the patients (P < 0.05) than in controls. In addition, adrenomedullin gene expression in the obstructed junctions was significantly lower than in normal junctions, with higher Ct values for the patient group of 26.7 (1.6) vs 25.2 (1.8) (P < 0.05) and lower adrenomedullin mRNA when standardized to glyceraldehyde-3-phosphate dehydrogenase (GAPDH) (P < 0.05), CD31 (P < 0.01) and smooth muscle alpha-actin mRNA (P < 0.01). The two groups showed no significant differences for GAPDH and CD31 mRNA content, whereas there was about twice as much alpha-actin mRNA in stenotic tissues than in unaffected PUJs, shown by the lower Ct values for the patient group of 16.9 (2.0) vs 17.9 (2.6) (P < 0.05). Furthermore, endothelin-1, adrenomedullin and alpha-actin mRNA amounts were independent of age.

CONCLUSION

Taken together these results provide evidence that the production of autocrine/paracrine acting endothelin-1 and adrenomedullin is altered in tissues of patients with genuine PUJ obstruction, and may be involved in the pathogenesis of congenital hydronephrosis.

[Propofol-remifentanil versus sevoflurane-remifentanil for anesthesia for pediatric procedures in infants, children and adolescents]

INTRODUCTION

The aim of this study was to compare total intravenous anaesthesia (TIVA) using propofol and remifentanil (P/R-group) and balanced anaesthesia (BA) using sevoflurane and remifentanil (S/R-group) for paediatric surgery.

PATIENTS AND METHODS

A total of 120 patients aged 6 months to 16 years scheduled for elective minor lower abdominal surgery were randomly assigned to receive either propofol (5-10 mg/kg/h) and remifentanil (0.125-1.0 microgram/kg/min) or sevoflurane (1.0-1.5 MAC) and remifentanil (0.125-1.0 microgram/kg/min). Perioperative haemodynamics as well as recovery and discharge times, PONV and side-effects were studied. The patients vigilance, comfort and pain intensity were assessed postoperatively using the objective pain discomfort scale, the Steward post-anaesthetic recovery score and a visual analogue scale.

RESULTS

Postoperative recovery (9.0 vs 11.6 min) and extubation times (11.8 vs. 15.0 min) as well as the time taken until a Steward post-anaesthetic recovery score > 3/4 (15.2 vs. 21.4 min) was reached were significantly shorter in the P/R-group. However, the length of time until discharge to the ward, postoperative comfort, pain intensity and analgesic requirements as well as PONV were comparable in both groups.

CONCLUSIONS

With regards to the investigated parameters, TIVA with propofol and remifentanil is equally effective as BA with sevoflurane and remifentanil in paediatric patients. However, considering the selected dosing regimen, recovery times were significantly shorter for children after TIVA.

Alteration of neuronal and endothelial nitric oxide synthase and neuropeptide Y in congenital ureteropelvic junction obstruction

PROBLEM

We investigated whether deranged nitric oxide synthase (NOS) and neuropeptide Y (NPY) expression is detectable in the stenotic segments of patients with congenital ureteropelvic junction obstruction.

METHODS

Using real-time reverse transcription-polymerase chain reaction (RT-PCR), we quantified mRNA amounts of NPY, neuronal (n), endothelial (e) and inducible (i) NOS in the stenotic segments of 20 patients with congenital ureteropelvic junction obstruction (aged 5.1+/-7.0 years) and of 21 unaffected controls (aged 23.5+/-24.2 years). Additionally, mRNAs of glyceraldehyde-3-phosphate dehydrogenase (GAPDH), smooth muscle alpha-actin (Smactin), endothelial cell marker (CD31), and protein gene product 9.5 (PGP 9.5) were evaluated. Immunohistochemistry was made for NPY, nNOS, eNOS, iNOS, PGP 9.5, and CD 31.

RESULTS

The mRNA of nNOS was significantly reduced in the obstructed junctions when related to the mRNAs of Smactin (P < 0.001) or GAPDH (P < 0.05), respectively. A significant reduction was also obtained for eNOS mRNA when standardized to CD31 (P < 0.05), GAPDH or Smactin mRNA (P < 0.05, and P < 0.001, respectively). NPY, PGP 9.5 and iNOS mRNAs were found in comparable quantities in both groups. In the stenotic segments, Smactin mRNA level was about twofold higher than in our control specimens, as shown by the lower CT values for the patients in real-time PCR (16.9+/-2.0 vs 17.9+/-2.6, P < 0.05). Furthermore, Smactin, nNOS, iNOS, eNOS, and NPY mRNA levels in specimens of unaffected ureteropelvic junctions were independent of age. Major differences between control and stenotic tissues were detected by immunohistochemistry: There was a dramatic reduction of innervation density as evidenced by nNOS and NPY labeling.

CONCLUSION

Taken together, we found alterations in NOS gene expression and NPY innervation in tissue specimens of patients with congenital ureteropelvic junction obstruction.

[Bone marrow granulomatosis in Q-fever]

BACKGROUND

Petersdorf and Beeson defined Fever of Unknown Origin (FUO) as an illness characterized by rectal temperature exceeding 38.3 degrees C on at least 3 occasions, evolving during at least 3 weeks, with no diagnosis reached after 1 week of in-patient investigation. A quarter of FUO cases is caused by infectious diseases, most often hidden abscesses, subacute endocarditis and tuberculosis.

CASE REPORT

In a 29-year-old patient with undulating fever of 3 months duration solely the demonstration of bone marrow fibrin ring granulomas led to the diagnosis of protracted Q-fever. The diagnosis later has been proved by elevated Coxiella burnetii antibody titers.

CONCLUSION

The case report underlines the diagnostic value of bone marrow biopsy in the evaluation of fever of unknown origin.

[Ventral urethral diverticulum. Case report of a 10-year-old girl]

In total urethral diverticula in children represent a very rare urological disorder. Primary localisation is the dorsal side of the urethra, ventral located diverticula are extremely rare. We report on a ten year old girl with a ventral, urethral diverticulum presenting with the symptoms of persisting enuresis. The diverticulum was excised through a median laparatomy. Placement of suprapubic catheter facilitated adequate postoperative drainage and postoperative cystourethrography confirmed the absence of extravasation.

Catheter-associated infections in urology: possible use of silver-impregnated catheters and the Erlanger silver catheter

Indwelling urinary catheters play a very important part in urology. However, their use is accompanied by a considerable increase in the risk of nosocomial urinary tract infections. The pathophysiological cause is ascribed to pathogens that adhere to the catheter surface, proliferate and produce a biofilm. In addition to aseptic techniques, modification of the catheter material to confer antimicrobial activity plays an essential part in the prevention of catheter-related urinary tract infections. The antimicrobial efficacy of silver against gram-positive and gram-negative bacteria is well known and amply shown in vitro. The efficacy of silver-impregnated catheters is critically dependent on both the chemical structure of the incorporated silver and the way the silver has been combined with the basic catheter material. Hence, clinical studies on silver-modified catheters have so far given inconsistent results. The new technology of the Erlanger silver catheter offers the opportunity of an effective reduction in catheter-related infections.

[Extravesical correction of the uretero-vesicle junction]

In correction of the ureterovesical junction, the pathology can be corrected using an extravesical or intravesical technique. We performed an extravesical antireflux procedure with the dismembered or non-dismembered technique in 117 ureters between March 1991 and March 1996 at our Department of Pediatric Urology. The success rate was 94.9% (111 renal units). Postoperative morbidity and complications were minimal, hematuria and bladder spasms were not seen. Associated pathology like paraostial diverticula, megaureter with the necessity for modeling and ureter duplex do not compromise the success rate.

[Neurogenic disorders of bladder emptying in childhood]

The treatment of neurogenic bladder dysfunction must be aimed at the protection of the upper urinary tract through complete bladder emptying and normalization of intravesical bladder pressures in rest and during voiding. Nowadays also urinary continence should be restored in childhood. Based on the urodynamic classification modified by Madersbacher the current treatment strategies are presented. Individual pharmacotherapy, especially pharmacological transformation of detrusor hyperreflexia into hyporeflexia and clean intermittent catheterization are the main conservative therapeutic tools. In special cases bladder augmentation, cutaneous vesicostomy and artificial sphincter devices are the method of choice, while bladder substitution should be performed as a last resort.

[Laparoscopic-gastroscopic intragastric stomach surgery]

In three cases, a new technique for intragastric surgery were used. The ports were placed using a step system (blunt trocars) directly into the stomach. In two cases, a benign tumor was resected, and we converted one case of bleeding.

Oral L-ornithine-L-aspartate therapy of chronic hepatic encephalopathy: results of a placebo-controlled double-blind study

BACKGROUND/AIMS

In the current state of knowledge of the pathophysiology of hepatic encephalopathy, a reduction in hyperammonemia is the most important evidence of effective treatment. Therefore, the therapeutic efficacy of oral L-ornithine-L-aspartate, which improves impaired ammonia detoxification, was investigated in patients with cirrhosis, hyperammonemia and stable, overt, chronic hepatic encephalopathy, and in subclinical hepatic encephalopathy in a randomized, double-blind, placebo-controlled clinical trial.

METHODS

Oral L-ornithine-L-aspartate was administered three times daily at fixed times for 14 consecutive days in a total dose of 18 g per day. The design was chosen to prevent an increase in ammonia induced by a protein meal of 0.25 g/kg body weight, given at the start of the daily treatment period. Efficacy variables were: fasting and postprandial ammonia concentration, Number-Connection-Test time, mental state grades, and a Portosystemic Encephalopathy Index. Analyses were based on the total study sample of 32 placebo- and 34 L-ornithine-L-aspartate-treated patients as well as on the subgroup samples in the overt (20 placebo- and 23 L-ornithine-L-aspartate-treated) and subclinical hepatic encephalopathy (12 placebo- and 11 L-ornithine-L-aspartate-treated) patients.

RESULTS

Number Connection Test performance times (p<0.01) as well as fasting (p<0.01) and postprandial (p<0.05) venous blood ammonia concentrations in the L-ornithine-L-aspartate-treated group showed improvement in comparison to placebo. Also, the mental state grade (p<0.05) and the Portosystemic Encephalopathy Index (p<0.01), improved to a much greater degree in the L-ornithine-L-aspartate group than in the placebo group. Adverse events were observed in neither the placebo nor the L-ornithine-L-aspartate-treated patients.

CONCLUSION

Oral L-ornithine-L-aspartate is a safe, well-tolerated treatment with a good compliance rate and a beneficial therapeutic effect in patients with cirrhosis and stable, overt, chronic hepatic encephalopathy.

[Neutropenic enterocolitis]

A 58-year old patient with metastasizing squamous cell carcinoma of the left lung developed fever, diffuse abdominal pain and profuse diarrhea while treated with paclitaxel and radiation therapy. A sigmoidoscopy was performed to exclude pseudomembranous colitis but showed multiple mucosal petechiae. Histologic examination disclosed neutropenic colitis. Conservative treatment was successful.

Gastro-oesophageal reflux disease: medical or surgical treatment? Report of an interactive workshop

Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract. With the introduction of proton pump inhibitors medical treatment of GERD has been significantly improved. However, the development of laparoscopic antireflux surgery resulted in an increasing interest of surgeons in this disease. An interactive meeting was organized in order to develop an agreement between gastoenterologists and surgeons regarding therapeutic decisions and this is the main topic of this paper.

[Tramadol infusion for pain therapy following bladder exstrophy surgery in pediatric wards]

We investigated in 17 children (mean 7.1 years) the continuous administration of tramadol following augmentation cystoplasty or exstrophy reconstruction. Mean duration of the tramadol administration on the pediatric ward was 3.8 +/- 1.1 days (initial dosage 0.25 mg/kg/per hour, dose adjustment by the nursing staff). Mean tramadol consumption was 0.21 mg/kg/h on day 1 and was reduced to 0.08 mg/kg/per hour on day 4. Median pain score (assessed with ten-step scales) was 5 before treatment and between 2.5 (day 1) and 0.5 (day 5) during therapy. Lowest oxygen saturations (mean) ranged from 93.8% to 95.2%. Three patients (17.6%) suffered from nausea/vomiting on 3 of 64 treatment days (4.7%). Pruritus and extreme sedation did not occur. The continuous administration of tramadol is a simple and safe procedure following major urological surgery in children.

Comparison of preoperative innervation pattern and postreconstructive urodynamics in the exstrophy-epispadias complex

A primary neurogenic component is often being postulated to be responsible for unfavourable postoperative results of bladder growth and continence in the exstrophy-epispadias complex. On the other hand, we have seen favourable clinical situations and urodynamic follow-up after primary reconstruction employing the 'Erlangen technique' without evidence of primary dysinnervation. Since there are only few data available on this issue, we decided to apply immunocytochemistry and histochemistry for neuronal markers as a further step to elucidate this problem. Transmural biopsies were obtained during reconstructive surgery from the bladder dome and trigone of 22 children between September 1994 and June 1995. Indirect immunocytochemistry for vasoactive intestinal polypeptide (VIP), neuropeptide Y (NPY), substance P (SP) calcitonin gene-related product (CGRP) and protein gene product (PGP) 9.5, a universal marker for neuronal tissue and histochemistry for nicotinamide adenine dinucleotide phosphate diaphorase (NADPHd), was performed on 14-micron cryostat sections. During the same period of time, control biopsies from 6 healthy bladders of an age-compatible group were subjected to the same examination. In addition, 19 patients were examined urodynamically after reconstruction in order to compare postoperative bladder function with the preexisting innervation pattern. No evidence of dysinnervation was found either morphologically or urodynamically in cases of isolated epispadias and classical exstrophy. Cases of exstrophies after failed reconstruction had muscular innervation deficiencies but increased sub and intraepithelial innervation. This group, according to morphological changes, also demonstrated bladder wall instability, decreased bladder compliance and absent detrusor contractions during micturition. All cloacal exstrophies had an extremely uneven innervation pattern with noticeable calibre differences of nerve fibres and bundles with simultaneously increased innervation density. Functionally these bladders were marked by small capacity and decreased compliance and absent detrusor function. All exstrophies in conjunction with an anal atresia or with a caudal regression syndrome (so-called 'transition forms') had a nearly universal pathological innervation pattern, compatible with cloacal exstrophies and had equally unfavourable functional findings. Cloacal exstrophies and 'transition forms' seemed to have primarily a completely different pattern of innervation when compared to normal bladders. Prognosis of bladder function in these children remains unclear.

Therapeutic efficacy of L-ornithine-L-aspartate infusions in patients with cirrhosis and hepatic encephalopathy: results of a placebo-controlled, double-blind study

One hundred twenty-six patients with cirrhosis, hyperammonemia (>50 micromol/L), and chronic (persistent) hepatic encephalopathy (HE), which developed spontaneously without the existence of known precipitating factors, were enrolled in a randomized, double-blind, placebo-controlled clinical trial of intravenously administered L-ornithine-L-aspartate (OA). Patients with subclinical (grade 0, West-Haven criteria) hepatic encephalopathy (SHE), characterized by a prolonged number connection test A (NCT-A) time, and manifest HE (grades I and II, West-Haven criteria) were included in the investigation. The trial was planned as a confirmatory clinical trial OA administered in a dose of 20 g/d, as well as placebo, were dissolved in 250 mL of 5% fructose and infused intravenously for a period of 4 hours during 7 consecutive days with a superimposed protein load at the end of the daily treatment period. Primary variables were postprandial venous ammonia and NCT-A performance time measured following OA or placebo infusions to evaluate the net effect of the treatment on the prevention of the protein-induced hyperammonemia, and on parameters such as NCT-A influenced by hyperammonemia. Mental state gradation, portal systemic encephalopathy index (PSEI), and fasting ammonia levels were estimated as additional efficacy parameters. The data presented are based on the total study sample (intent-to-treat analysis), which included 63 patients in the placebo group and 63 patients in the OA group. Of the 126 patients, 114 met all the criteria for inclusion and completed the trial and treatment as outlined in the protocol (treated-per-protocol analysis). During baseline, the placebo and treatment groups were homogeneous with regard to mental states, NCT-A performance time, fasting venous blood ammonia levels, and Child-Pugh criteria. Although a slight improvement occurred in the placebo group, NCT-A performance times (P < .001) and postprandial venous ammonia concentrations in the OA-treated group showed improvements in comparison with placebo. In addition, venous fasting blood ammonia concentration (P < .01), mental state gradation (P < .001), and PSEI (P < .01), which includes the mental state gradation, NCT-A time, and postprandial venous ammonia in this trial, improved to a much higher degree in the OA group than in the placebo group. In subgroups retrospectively classified according to their initial mental state gradation, OA showed differential but uniformly significant efficacies in patients with manifest HE with respect to ammonia-lowering, improvement in NCT times, and mental state gradation. In patients with initial SHE, OA revealed differences between the medications in the psychometric test used. Adverse events consisting of mild gastrointestinal disturbances were observed in 3 of the OA-treated patients (5%). OA infusion appears to be a safe, effective treatment of chronic (persistent) manifest HE in cirrhotic patients. Additional investigations are required to assess the efficacy of OA in patients with SHE, as well as in patients with more severe grades of HE.

[Polyps and polyposis--limits of endoscopic therapy. Are we currently overtreating by removing colorectal polyps?]

Today, endoscopic polypectomy is the standard procedure for the diagnosis and treatment of neoplastic polyps of the colon. There is no longer any doubt that the adenoma-(dysplasia)-carcinoma sequence actually holds true. Size, configuration and histology identify the risk for colorectal carcinoma, and endoscopic treatment can be considered a carcinoma-preventive measure. Even in the case of invasive carcinoma developing in a tubular adenoma, endoscopic polypectomy with a margin of 2 to 3 mm is believed to suffice unless the carcinoma involved is undifferentiated and has invaded blood vessels. In the case of polyposis coli, endoscopic polypectomy serves to establish an accurate classification of the polyposis, however, mass polypectomy must be rejected. In adenomatosis coli colectomy with pouch-anal anastomosis is the treatment of choice.

[Fungi in feces, fungi in the intestines--therapeutic consequences?]

Yeast in stool specimen are due to transient or commensal growth in the GI tract. Only in immune deficient subjects candida albicans may grow invasively in squamous epithelium. In dermal or vaginal mycosis systemic therapy does not add benefit to local measures. Candida-induced diarrhea in hospitalized patients following chemotherapy stop after a few days of nystatin treatment. Candida hypersensitivity syndrome does not exist, antifungal diet does not eradicate yeast. Stool examination for candida is of no sense because a positive finding is seen in up to 80% of healthy persons.