2022 Recommendations of the AFU Lithiasis Committee: Laser - utilization and settings

Endocorporeal lithotripsy has progressed thanks to the development of lasers. Two laser sources are currently available: Holmium:YAG (Ho:YAG) and more recently Thulium Fiber Laser (TFL). The settings generally used are dusting, fragmentation, and "pop-corning". These are the first recommendations on laser use for stone management and their settings. Settings must be modulated and can be changed during the treatment according to the expected and obtained effects, the location and stone type that is treated. METHODOLOGY: These recommendations have been developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether or not the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU Guidelines on urolithiasis. 2022]) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Percutaneous nephrolithotomy

Percutaneous nephrolithotomy (Labate et al.) is the standard procedure for the treatment of large (≥2cm) kidney stones. The patient can be in prone or modified supine position. The puncture is performed under fluoroscopy and/or ultrasound guidance. The stone-free rate seems to be comparable between miniaturized and standard PCNL. Procedures performed with smaller diameter instruments tend to be associated with significant lower blood loss, but longer procedure times. The limitation of the number of percutaneous tracts results in better preservation of the kidney function and lowers the risk of complications. The use of tranexamic acid during PCNL may be interesting for reducing the bleeding risk, the transfusion rate, and possibly the intervention duration. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Extracorporeal shock wave lithotripsy (ESWL)

Extracorporeal shock wave lithotripsy (ESWL) is a minimally invasive technique for the fragmentation of urinary tract stones using shock waves under fluoroscopic and/or ultrasound guidance. ESWL results depend on the indication (stone size/composition, clinical context) and also on how it is performed. The stone structure, nature and density (Hounsfield units; evaluated by CT without contrast agent) influence the fragmentation achieved by ESWL. The upper size limit of kidney stones has been lowered to 15mm (1.68cm3) due to the increased risk of steinstrasse with larger sizes and the potential need of anesthesia and ureteral stenting. Conversely, the development of endourological technologies allows a finer stone fragmentation and/or better elimination, thus reducing the risk of steinstrasse and decreasing the potential number of sessions or additional interventions. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendations method (CPR) and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.

Standardised practices in the networked management of congenital hyperinsulinism: a UK national collaborative consensus

Congenital hyperinsulinism (CHI) is a condition characterised by severe and recurrent hypoglycaemia in infants and young children caused by inappropriate insulin over-secretion. CHI is of heterogeneous aetiology with a significant genetic component and is often unresponsive to standard medical therapy options. The treatment of CHI can be multifaceted and complex, requiring multidisciplinary input. It is important to manage hypoglycaemia in CHI promptly as the risk of long-term neurodisability arising from neuroglycopaenia is high. The UK CHI consensus on the practice and management of CHI was developed to optimise and harmonise clinical management of patients in centres specialising in CHI as well as in non-specialist centres engaged in collaborative, networked models of care. Using current best practice and a consensus approach, it provides guidance and practical advice in the domains of diagnosis, clinical assessment and treatment to mitigate hypoglycaemia risk and improve long term outcomes for health and well-being.

Congenital hypothyroidism in Northern Ireland: 40 years' experience of national screening programme

OBJECTIVE

The incidence of congenital hypothyroidism (CHT) has progressively increased in several regions around the world but has yet to be evaluated in Northern Ireland (NI). CHT screening programme was introduced in NI in 1980 and has had a relatively unchanged protocol since its inception. The purpose of the study was to evaluate the incidence of CHT in NI from 1981 to 2020 and to explore possible contributing factors to any changes seen over the 40-year period.

DESIGN

This was a retrospective database review of children diagnosed with CHT in NI between 1981 and 2020. Data was collected from the patients' medical (paper and electronic) records, including epidemiological, clinical, laboratory, and radiological features as well as outcomes at 3 years.

RESULTS

Of 800,404 new-borns who were screened for CHT in NI between January 1981 and March 2020, 471 were diagnosed with CHT. There was a steady and significant increase in incidence of CHT over time with an incidence of 26 cases per 100,000 livebirths in 1981 versus 71 cases per 100,000 in 2019 (p < .001). Of these 471, 77 new-borns (16%) were born preterm. The incidence of CHT was observed twice as much in female compared to male new-borns. Diagnostic imaging including radioisotope uptake and thyroid ultrasound scans were performed in 143 cases (30%). Of these, 101 (70%) cases had thyroid dysgenesis and 42 (30%) cases had thyroid dyshormonogenesis. There were 293 (62%) of 471 patients had confirmed permanent CHT, and 90 patients (19%) had transient CHT. Over that period at least 95% of the population were recorded as having United Kingdom/Ireland as country of birth.

CONCLUSION

Our findings demonstrate a nearly tripling of the CHT incidence observed over the last 40 years. This is against a background of a relatively stable population demographics. Future research should focus on the underlying cause(s) of this condition which may include changing environmental exposures in utero.

Quality of life of patients treated for kidney stones 10-20mm in diameter in terms of the type of operation performed: A qualitative study

INTRODUCTION

Urolithiasis is a common chronic disease whose effect on patients' quality of life (QOL) is considerable but depends on the treatment received, differing between types of surgery. Intrarenal stones can be treated with different techniques: extracorporeal shock wave lithotripsy (ESWL), flexible ureteroscopy (fURS), and mini percutaneous nephrolithotomy (mini-PCNL), with proportional success and complication rates. The aim of this study was to qualitatively explore the impact of the different techniques on patients' QOL and understand their experiences of treatment choices.

METHODS

Patients treated for medium-sized kidney stones (10-20mm in diameter) were interviewed in a semi-structured manner. The interview data were transcribed and analyzed by theme according to consolidated criteria for reporting qualitative research (COREQ) guidelines.

RESULTS

Data saturation was achieved after interviewing 15 patients. The mean interview time was 34min (standard deviation (SD), 6.8min). The mean patient age was 54 years (SD, 9.5 years). Eight patients underwent ESWL, 10 were treated with fURS, and 8 underwent mini-PCNL. Twenty-seven subthemes were coded and regrouped into eight major themes, namely: no sense of choice in the decision-making process for eleven patients; extremely negative experiences of double-J stents for fourteen patients; concern about the risk of recurrence or treatment failure for thirteen patients; complicated hygiene and dietary recommendations for nine patients; technique-dependent postoperative outcomes; relatively well-tolerated operations for thirteen patients; a poor experience of sick leave, often because of a double-J stent; different views regarding future operations. In fact, a third of patients would choose the most effective treatment, a third would choose the simplest procedure and the last third would trust their urologist. Patients' experiences of these operations are variable.

CONCLUSION

Urologists must support their patients by presenting the different treatment options with clear, appropriate, and unbiased information. This should ensure patients take part in treatment decisions as part of a personalized treatment plan.

LEVEL OF EVIDENCE: 3

Diagnostic et prise en charge de la fibrose post-COVID

Introduction

La prévalence de la fibrose post-COVID est variable selon les études et sa physiopathologie est encore mal connue. On se propose à travers cette étude de décrire le profil clinique et radiologique des patients ayant développé cette complication suite à une pneumopathie à SARS-CoV-2.

Méthodes

Il s’agit d’une étude prospective, menée auprès des patients hospitalisés pour une pneumopathie à SARS-CoV-2 durant la période allant de septembre 2020 à mars 2021, au CHU Mohamed Taher Maamouri Nabeul et qui ont revus à la consultation de suivi à 1 mois et 3 mois.

Résultats

Deux cent soixante-dix-neuf patients ont été inclus, 161 étaient des hommes avec un sex-ratio à 1,35. L’âge moyen était de 64,9 ans. Les comorbidités les plus fréquentes étaient l’obésité (44,2 %), le diabète (43,5 %) et l’HTA (54,3 %). Les antécédents respiratoires n’étaient retrouvés que chez 46 patients (16,6 %) : asthme dans 3,2 % des cas, BPCO dans 4,3 % et DDB dans 1,8 %. Les symptômes persistants à 3 mois étaient : une dyspnée dans 15,4 % des cas, une toux sèche dans 3,6 % des cas. Les patients encore symptomatiques à 3 mois étaient essentiellement des hommes (38 hommes/19 femmes) de 66 ans d’âge moyen. Parmi eux, 27 avaient un besoin en oxygène initial > 6 L (p = 0,703) ; la majorité avait des lésions étendues (> 25 %) et 12 avaient séjourné en réanimation. La TDM thoracique à 3 mois, faite chez 78 patients (28 %), a objectivé des anomalies persistantes à type de verre dépoli et/ou de condensations parenchymateuses dans 21 cas et des stigmates de fibrose pulmonaire (à type de réticulations, un épaississement des lignes septales, une distorsion bronchique à type de rayon de miel ou de bronchiectasies par traction) chez 18 patients. Un bilan immunologique fait chez les patients avec signes tomodensitométriques de fibrose, revenu positif chez 5 patients. Un bilan fonctionnel respiratoire a été pratiqué 20 les patients encore dyspnéiques à 3 mois et ayant gardé des anomalies scanographiques parenchymateuses. La pléthysmographie a objectivé un syndrome restrictif chez 5 patients et le test de marche 6 min, une désaturation chez 9 patients. Le diagnostic de fibrose post-COVID avec retentissement respiratoire a été retenu chez 10 patients chez lesquels on a entamé une corticothérapie à raison de 0,5 mg/kg/j équivalent prednisone selon le protocole SPLF.

Conclusion

La fibrose post-COVID serait associée aux formes sévères de la pneumopathie COVID-19 avec des lésions parenchymateuses étendues.

Miniaturized percutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of lower pole renal stones

OBJECTIVES

Miniaturization of percutaneous nephrolithotomy techniques have led to their increased consideration for lower pole renal stones that can prove more challenging to reach using retrograde intrarenal surgery. The objectives of the present study were to evaluate and compare the outcomes of miniaturized percutaneous nephrolithotomy (miniPCNL) and retrograde intrarenal surgery (RIRS) for the treatment of lower pole renal stones.

MATERIALS AND METHODS

A retrospective study was performed in two academic urology departments between January 2016 and June 2019. Patients presenting with one or multiple stones of the lower calyx and/or renal pelvis, between 10 and 40mm based on CT-scan treated by miniPCNL or RIRS were included.

RESULTS

In all, 115 miniPCNL and 118 RIRS procedures were included. The rate of patients with no significant residual fragment (stone free rate) after the first procedure was higher in the miniPCNL group (69% vs. 52% P=0.01), especially for stones>20mm (63% vs. 24% respectively, P<0.001) and stones with a density≥1000HU (69% vs. 42% respectively, P=0.009). The higher stone free rate of miniPCNL was confirmed in multivariate analysis, adjusting for stone size and number of stones, OR 4.02 (95% CI 2.08-8.11, P<0.0001). The overall postoperative complication rate was higher in the miniPCNL group than in the RIRS group (23% vs. 11%, P=0.01). A second intervention for the treatment of residual fragments was necessary for 9.6% of patients in the miniPCNL group versus 30.5% of patients in the RIRS group (P<0.001). Pre-stenting rate and duration of ureteral drainage (2 [1-8] vs. 25 days [7-37], P<0.001) were lower in the miniPCNL group.

CONCLUSIONS

The stone free rate was higher after miniPCNL, especially for stones>20mm and with a density>1000 HU, but was associated with a higher risk of postoperative complications and a longer hospital stay. RIRS resulted in fewer complications at the cost of a higher retreatment rate and longer ureteral stenting.

LEVEL OF EVIDENCE

3.

[Recommendations of the Urolithiasis Committee of the French Urology Association for the management and the treatment of the stone formers patients during the COVID-19 pandemic crisis]

Confrontés à une crise d’une ampleur exceptionnelle liée à la pandémie à coronavirus COVID-19 responsable d’une saturation selon les régions des urgences et des places en réanimation, le Comité Lithiase de l’Association Française d’Urologie (CLAFU) a élaboré pour la première fois les recommandations de prise en charge des calculs urinaires durant cette crise sanitaire.

Composition of urinary calculi: Lessons from a French epidemiologic retrospective study

INTRODUCTION

Urolithiasis is a common urological disease whose incidence increases in developed countries. We studied relations between composition of urinary calculi, age and gender.

MATERIAL

An epidemiologic study was conducted in a French population of patients encountered analysis of urinary calculi between 2013 and 2017. This retrospective cohort study was performed from urinary calculi samples analysed in a clinical biochemistry laboratory of University Hospital of Lyon in France. A total of 5782 samples were included. Data, according to stone composition, presence of a papillary umbilication and a Randall's plaque, age and gender, were investigated. Statistical analyses used the Chi² test (R software).

RESULTS

The overall male to female sex ratio was equal to 1.76. The average and the median of age were 52.1 and 53.0 years, respectively. Whewellite was the most frequent main component in our population (44.4%). Carbapatite, weddellite and uric acid represented the main component in 14.0%, 13.4% and 13.0% of samples, respectively. Differences between genders were shown. Whewellite and uric acid were more frequent in men (P<0.001), while carbapatite and struvite were predominant in women (P<0.001).

CONCLUSIONS

Our study provided recent data on the composition of urinary calculi in a French population and the relations between composition of urinary calculi and age and gender.

LEVEL OF EVIDENCE

3.

Prevalence and risk factors of musculoskeletal disorders among Tunisian nurses

BACKGROUND

Musculoskeletal problems depict essentially the most worrying difficulties inside work health today.

AIMS

To evaluate the prevalence of musculoskeltal issues and to search relationships with individual characteristics and work-related risk factors among two public hospitals nurses in Sousse.

METHODS

It is a descriptive-correlational investigation based on a self-administered questionnaire destined for all nurses working in two public hospitals of Sousse. The potential risk of musculoskeletal issues was examined by logistical regression.

RESULTS

The prevalence of musculoskeletal disorders (MSD) over the last twelve months was 48.1%. Musculoskeletal problems developed mainly in low back (68.5%), upper back (36.9%), and knees (34.5%). The Chi-square test indicated that MSD is associated with female gender (p = 0.01), being single (p = 0.013), high BMI (p <0.001), seniority (p =0.001), repetitive work (p = 0.004), prolonged standing position (p = 0.007), intense physical effort (p <0.001), lifting heavy loads (p = 0.002), uncomfortable position (p = 0.008) and low social support (p <0.001). The logistic regression analysis showed that intense physical exertion (OR= 7.72, 95% CI: 2.98 - 19.97) and job-strain (OR= 3.24, 95% CI: 2.98 - 19.97) represent risk factors related to MSD.

CONCLUSION

A high amount of Tunisian nursing staff in this survey complained of musculoskeletal issues considering the low back pain most often affected. Education courses on prevention and coping approaches for musculoskeletal problems are appropriate for nurses as a way to minimize the rate of work risks and even promote performance patient care.

[Evaluation of spinal anesthesia in urological outpatient surgery, comparison between two local anesthetics (Chloroprocaine/Bupivacaine)]

INTRODUCTION

Spinal anesthesia in outpatient urology is controversial (longer hospital stay, risk of urinary retention). The main goal was to evaluate outpatient spinal anesthesia and to compare 2 local anesthetics secondarily.

MATERIAL

Monocentric retrospective study including all patients undergoing surgery in urological ambulatory surgery under spinal anesthesia between December 2011 and May 2015, split into two groups according to the local anesthetic used: bupivacaine (BP) and chloroprocaine (CP). Quantitative variables were compared by Student's t-test, qualitative variables by χ² test.

RESULTS

Seventy-one (95%) out of the 75 patients included have been discharged the same day. Discharge was impossible in these cases: patient alone at home (1), bladder clot (1), JJ intolerance (1), delayed micturition (1). The mean duration of the procedure was 27±19min, the SSPI's was 55±31min, the stay's was 360±91min. A total of 45 patients (60%) received BP and 30 (40%) received CP. The mean residence time in SSPI was significantly reduced in the CP group (47±24min vs. 61±34min, P=0.04). One patient experienced urination delay in the BP group with no significant difference. No significant difference for the other criteria studied despite the mean age, which is higher in the CP group (P=0.02).

CONCLUSION

Spinal anesthesia is adapted to ambulatory urology, and does not increase the risk of urinary retention, especially with CP that would decrease the length of stay in SSPI compared to BP.

LEVEL OF EVIDENCE

4.

A novel IGSF1 mutation in a large Irish kindred highlights the need for familial screening in the IGSF1 deficiency syndrome

OBJECTIVE

Loss-of-function mutations in IGSF1 result in X-linked central congenital hypothyroidism (CeCH), occurring in isolation or associated with additional pituitary hormone deficits. Intrafamilial penetrance is highly variable and a minority of heterozygous females are also affected. We identified and characterized a novel IGSF1 mutation and investigated its associated phenotypes in a large Irish kindred.

DESIGN, PATIENTS AND MEASUREMENTS

A novel hemizygous IGSF1 mutation was identified by direct sequencing in two brothers with CeCH, and its functional consequences were characterized in vitro. Genotype-phenotype correlations were investigated in the wider kindred.

RESULTS

The mutant IGSF1 protein (c.2318T > C, p.L773P) exhibited decreased plasma membrane expression in vitro due to impaired trafficking from the endoplasmic reticulum. Ten hemizygous males and 11 heterozygous females exhibited characteristic endocrine deficits. Ireland operates a TSH-based CH screening programme, which does not detect CeCH; therefore, genetic ascertainment preceded biochemical diagnosis of moderate CH in five of seven boys as well as their 75-year-old grandfather. Clinical features potentially attributable to hypothyroidism were variable; normal free T3 (FT3) and low/low normal reverse T3 (rT3) concentrations suggested that preferential deiodination of FT4 to FT3 may help maintain tissue euthyroidism in some individuals. However, neonatal jaundice, delayed speech or growth, and obesity were observed in seven subjects in whom diagnosis was delayed.

CONCLUSIONS

As observed with other IGSF1 mutations, p.L773P results in variably penetrant IGSF1 deficiency syndrome. Our observations emphasize the need for multi-generation genetic ascertainment in affected families, especially where TSH-based CH screening programmes may fail to detect CeCH at birth.

[Left atrial intimal sarcoma: A rare cause of acute heart failure]

Primitive intimal sarcoma is a rare malignant cardiac tumor. Through the observation of a 41-year-old man who presented with an acute heart failure revealing a left atrial intimal sarcoma, we discuss different diagnostic and therapeutic modalities.

Well-differentiated extraskeletal chondrosarcoma: about a new case

Extraskeletal chondrosarcoma is a rare malignant tumor. The well differentiated histological type, which is found primary in soft tissue, is extremely rare. This report  describes the case of a 58-year-old woman presented with a large palpable mass in the right buttock. Imaging studies revealed a well-defined soft tissue mass, with extensive calcification. A histological examination after surgical resection confirmed the diagnosis of well-differentiated extraosseous chondrosarcoma. The outcome was favorable, without recurrence or metastasis.

Resolution of Consumptive Hypothyroidism Secondary to Infantile Hepatic Hemangiomatosis with a Combination of Propranolol and Levothyroxine

Infantile hepatic hemangiomas (IHH), particularly of the diffuse subtype can, in severe cases, be associated with hepatic and cardiac failure, compartment syndrome and consumptive hypothyroidism. Early recognition and treatment of these pathologies is paramount in order to minimise the risk of long-term sequelae. We report an interesting case of a female infant who presented with systemic compromise, in the absence of large or obvious cutaneous infantile hemangiomas. Imaging identified innumerable hepatic hemangiomas, consistent with diffuse infantile hepatic hemangiomatosis. Subsequent to this, thyroid function tests confirmed an associated but comparatively rare form of hypothyroidism, known as consumptive hypothyroidism. Following joint consultation with dermatology and endocrinology she was promptly treated with oral propranolol and levothyroxine, with subsequent improvement in her clinical parameters. This case reiterates the importance of aggressive investigation and management of consumptive hypothyroidism in any infant diagnosed with IHH, particularly when there is systemic compromise. We advocate propranolol as a single first line treatment for IHH, supported by thyroid replacement when appropriate.

[Adherence to treatment with continuous positive airways pressure]

INTRODUCTION

Continuous positive airways pressure (CPAP) is the standard treatment for obstructive sleep apnea syndrome (OSAS). It produces substantial benefits if used for the appropriate indication and if patients adhere to treatment.

METHODS

We conducted a prospective study of 103 patients treated with CPAP over four years follow-up.

RESULTS

Our population had a mean age of 52 years with a sex ratio of 0.63. Face to face, individual education was provided in all cases. CPAP titration was performed by an unattended domiciliary autoadjusted CPAP device in 83.5% of patients for 15 days to one month. Twenty patients refused CPAP treatment after the period of titration. Eighty two patients (98.8%) were treated by constant CPAP. Seventy five percent of the patients complained of at least one side effect. The more common were nasal (56.6%) and mask related problems (40%). Seventy six percent of patients used CPAP for more than 4hours per day. Eleven patients stopped CPAP therapy because of intolerance (10 cases) and reluctance to instrumental therapy (one case). Adherence to CPAP therapy was associated with the severity of OSAS, the level of daytime sleepiness, higher pressures, repeated education during the course of follow up, clinical efficacy and the presence of fewer side-effects.

CONCLUSIONS

We obtained satisfactory rates of adherence and tolerance of CPAP assisted by regular medical and technical follow-up of patients.

Mortality in type 1 diabetes diagnosed in childhood in Northern Ireland during 1989-2012: A population-based cohort study

OBJECTIVE

To investigate long-term mortality rates and causes of death in individuals diagnosed with type 1 diabetes before the age of 15 years during the period 1989-2012 or known to paediatric diabetes teams in 1989, in Northern Ireland.

METHODS

A cohort of 3129 patients from the Northern Ireland Childhood Diabetes Register was linked to death registrations and underlying causes, coded according to ICD-9 or ICD-10. Standardized mortality ratios (SMRs) were calculated as the ratio of observed to expected deaths by sex, attained age, time since diagnosis, calendar period, and cause of death.

RESULTS

Subjects were followed to December 31, 2012 giving 39 764 person-years of follow-up (median 12.1 years). In total, 59 subjects had died (1.5 per 1000 person-years) compared with 19.9 deaths expected, an SMR of 296 (95% confidence interval (CI) 229-382). Women had a significantly higher excess risk of mortality than men with SMRs of 535 (95% CI 361-764) and 203 (95% CI 136-291), respectively. Over half of the deaths (56%) were judged to be related or possibly related to diabetes with most of these due to acute (n = 24) or late (n = 6) complications.

CONCLUSIONS

Subjects with type 1 diabetes diagnosed less than 15 years of age had 3 times the mortality risk of the general population. Over half of the deaths were related to acute or chronic complications of diabetes.

Hyperglycaemia-related complications at the time of diagnosis can cause permanent neurological disability in children with neonatal diabetes

BACKGROUND

Children with neonatal diabetes often present with diabetic ketoacidosis and hence are at risk of cerebral oedema and subsequent long-term neurological deficits. These complications are difficult to identify because neurological features can also occur as a result of the specific genetic aetiology causing neonatal diabetes.

CASE REPORTS

We report two cases of neonatal diabetes where ketoacidosis-related cerebral oedema was the major cause of their permanent neurological disability. Case 1 (male, 18 years, compound heterozygous ABCC8 mutation) and case 2 (female, 29 years, heterozygous KCNJ11 mutation) presented with severe diabetic ketoacidosis at 6 and 16 weeks of age. Both had reduced consciousness, seizures and required intensive care for cerebral oedema. They subsequently developed spastic tetraplegia. Neurological examination in adulthood confirmed spastic tetraplegia and severe disability. Case 1 is wheelchair-bound and needs assistance for transfers, washing and dressing, whereas case 2 requires institutional care for all activities of daily living. Both cases have first-degree relatives with the same mutation with diabetes, who did not have ketoacidosis at diagnosis and do not have neurological disability.

DISCUSSION

Ketoacidosis-related cerebral oedema at diagnosis in neonatal diabetes can cause long-term severe neurological disability. This will give additional neurological features to those directly caused by the genetic aetiology of the neonatal diabetes. Our cases highlight the need for increased awareness of neonatal diabetes and earlier and better initial treatment of the severe hyperglycaemia and ketoacidosis often seen at diagnosis of these children.

Diagnostic value of exome and whole genome sequencing in craniosynostosis

Background

Craniosynostosis, the premature fusion of one or more cranial sutures, occurs in ∼1 in 2250 births, either in isolation or as part of a syndrome. Mutations in at least 57 genes have been associated with craniosynostosis, but only a minority of these are included in routine laboratory genetic testing.

Methods

We used exome or whole genome sequencing to seek a genetic cause in a cohort of 40 subjects with craniosynostosis, selected by clinical or molecular geneticists as being high-priority cases, and in whom prior clinically driven genetic testing had been negative.

Results

We identified likely associated mutations in 15 patients (37.5%), involving 14 different genes. All genes were mutated in single families, except for IL11RA (two families). We classified the other positive diagnoses as follows: commonly mutated craniosynostosis genes with atypical presentation (EFNB1, TWIST1); other core craniosynostosis genes (CDC45, MSX2, ZIC1); genes for which mutations are only rarely associated with craniosynostosis (FBN1, HUWE1, KRAS, STAT3); and known disease genes for which a causal relationship with craniosynostosis is currently unknown (AHDC1, NTRK2). In two further families, likely novel disease genes are currently undergoing functional validation. In 5 of the 15 positive cases, the (previously unanticipated) molecular diagnosis had immediate, actionable consequences for either genetic or medical management (mutations in EFNB1, FBN1, KRAS, NTRK2, STAT3).

Conclusions

This substantial genetic heterogeneity, and the multiple actionable mutations identified, emphasises the benefits of exome/whole genome sequencing to identify causal mutations in craniosynostosis cases for which routine clinical testing has yielded negative results.

Increased Population Risk of AIP-Related Acromegaly and Gigantism in Ireland

The aryl hydrocarbon receptor interacting protein (AIP) founder mutation R304^* (or p.R304^*; NM_003977.3:c.910C>T, p.Arg304Ter) identified in Northern Ireland (NI) predisposes to acromegaly/gigantism; its population health impact remains unexplored. We measured R304^* carrier frequency in 936 Mid Ulster, 1,000 Greater Belfast (both in NI) and 2,094 Republic of Ireland (ROI) volunteers and in 116 NI or ROI acromegaly/gigantism patients. Carrier frequencies were 0.0064 in Mid Ulster (95%CI = 0.0027–0.013; P = 0.0005 vs. ROI), 0.001 in Greater Belfast (0.00011–0.0047) and zero in ROI (0–0.0014). R304^* prevalence was elevated in acromegaly/gigantism patients in NI (11/87, 12.6%, P < 0.05), but not in ROI (2/29, 6.8%) versus non‐Irish patients (0–2.41%). Haploblock conservation supported a common ancestor for all the 18 identified Irish pedigrees (81 carriers, 30 affected). Time to most recent common ancestor (tMRCA) was 2550 (1,275–5,000) years. tMRCA‐based simulations predicted 432 (90–5,175) current carriers, including 86 affected (18–1,035) for 20% penetrance. In conclusion, R304^* is frequent in Mid Ulster, resulting in numerous acromegaly/gigantism cases. tMRCA is consistent with historical/folklore accounts of Irish giants. Forward simulations predict many undetected carriers; geographically targeted population screening improves asymptomatic carrier identification, complementing clinical testing of patients/relatives. We generated disease awareness locally, necessary for early diagnosis and improved outcomes of AIP‐related disease.

Thermal dysregulation in Prader-Willi syndrome: a potentially fatal complication in adolescence, not just in infancy

A 13-year-old boy with a background of Prader-Willi syndrome (PWS) was admitted to the regional paediatric intensive care unit, with community-acquired pneumonia. Despite a week of intravenous antibiotics, resolution of inflammatory markers and resolving consolidation on radiograph, he remained feverish. Fever of unknown origin investigations were negative and he was diagnosed with central thermal dysregulation secondary to hypothalamic dysfunction in PWS. Following a hyperpyrexia period, secondary rhabdomyolysis and renal failure developed. This was successfully managed with active cooling, ventilation and haemofiltration. After weaning from haemofiltration, the patient was successfully extubated to non-invasive respiratory support.

[The W-shaped ileal neobladder: Long term functional outcomes and health-related quality of life]

PURPOSE

To evaluate functional outcomes and patients' health-related quality of life over ten years after a W-shaped ileal neobladder urinary diversion.

PATIENTS AND METHODS

From 1994 to 2004, 87 patients with bladder cancer underwent a cystoprostatectomy with a W-shaped ileal neobladder. Among them, 31 patients (35.6%) were evaluated. The average follow-up was 158months, average age was 72years. We assessed functional outcomes (use of protections, USP score, uroflowmetry, postvoid residual volume), overall health-related quality of life (SF-36 score), and specific urinary-related quality of life (Ditrovie scale).

RESULTS

Daytime continence was satisfactory in 29 patients (96.8%). Night-time continence was satisfactory in 27 patients (87.1%). Mean daytime continence, hyperactivity and dysuria scores of the USP were respectively 1.5/9, 3.2/21 and 2/9. Mean value of the maximum flow rate was 18mL/s for an average voiding volume of 324mL and an average postvoid residual volume of 70mL. The 8 dimensions of the SF-36 were all comparable with the French population's values. According to the Ditrovie scale whose average value was 1.83, the health-related quality of life was unchanged or little changed by urinary disorders in 28 patients (90.3%).

CONCLUSIONS

Our results suggest that voiding status and health-related quality of life remain satisfactory over ten years after an orthotopic ileal neobladder derivation.

LEVEL OF EVIDENCE

5.

[The syndrome of increased upper airways resistance: What are the clinical features and diagnostic procedures?]

The upper airway resistance syndrome "UARS" is a poorly defined entity, often described as a moderate variant of the obstructive sleep apnea syndrome. It is associated with respiratory effort-related arousal, absence of obstructive sleep apnea, and absence of significant desaturation. It is a relatively common condition that predominantly affects non-obese young adults, with no predominance in either sex. The degree of upper airway collapsibility during sleep of patients with UARS is intermediate between that of normal subjects and that of patients with mild-to-moderate sleep apnea syndrome. Craniofacial and palatal abnormalities are often noted. Patients frequently complain of a functional somatic syndrome, especially daytime sleepiness and chronic fatigue. Polysomnography with esophageal pressure measurements remains the gold standard diagnostic test. The absence of any neurological abnormality gives UARS a good prognosis and it is potentially reversible if treated early. However, some studies suggest that untreated UARS has an increased risk of arterial hypertension. It can also evolve into obstructive sleep apnea.

An unusual tumour of the lung

We report a case of a 51-year-old woman with a solitary mast cell tumour of the lung, a rare neoplasm with only three previously-reported cases reported in the literature. Unlike previous cases, the tumour in the present case was bulky, measuring 14 cm in diameter and budding into the segmental bronchus. Histologically, it showed proliferation of typical metachromatic mast cells intermingled with undifferentiated cells with a ratio of 3:1. The neoplastic mast cells stained strongly with tryptase, CD117, CD68 and CD45, CD14 and CD33; whereas the undifferentiated cells lacked all these markers and expressed EMA and cytokeratin. Histological examination of bone marrow and laboratory data were unremarkable. To our knowledge, this is the fourth case of solitary extracutaneous mastocytoma of the lung. The differentiating features of this neoplasm and a review of literature are presented.

Mixed stromal and smooth muscle tumours of the uterus: a report of two cases

Mixed stromal and smooth muscle uterine tumours, defined as those containing at least 30% of each component as seen by routine light microscopy, are rare. This report describes the morphological features of two such tumours diagnosed in 44-year-old and 50-year-old females complaining from recurrent uterine bleeding that was unresponsive to medical treatment. Morphological and immunohistochemical evaluations were performed, and a final diagnosis of mixed endometrial stromal nodule and smooth muscle tumour of the uterus was rendered in both cases.

Uterine tumour resembling ovarian sex cord tumours presenting as multiple endometrial and cervical uterine polyps: a case report

BACKGROUND

Uterine tumours resembling ovarian sex-cord tumours (UTROSCT) are very rare, benign uterine tumours, composed solely of sex cord elements. These tumours have a polyphenotypic immunophentype that favours a derivation from uterine mesenchymal stem cells.

CASE REPORT

A 43-year-old female presented with recurrent vaginal bleeding. On hysteroscopy, she had multiple endometrial and cervical polyps that were removed endoscopically. Histologically, the specimen contained epithelioid cells arranged in tubules, trabeculae and anastomosing cords, without significant cellular atypia or mitotic activity. Immunohistochemical studies were performed. The tumour was found to be diffusely positive for vimentin, calretinin and desmin, focally positive for cytokeratin, CD99 and inhibin and negative for chromogranin and CD10. A subsequent total hysterectomy was performed and revealed neoplastic infiltration of the myometrium.

CONCLUSION

A polyphenotypic immunophenotype is a characteristic feature of UTROSCT, and may be helpful in diagnosis and in exclusion of other lesions. Familiarity with this tumour by gynaecologists and pathologists is essential to avoid misdiagnosis:correct diagnosis of this neoplasm is important in patient management.

Clinical experience in the screening and management of a large kindred with familial isolated pituitary adenoma due to an aryl hydrocarbon receptor interacting protein (AIP) mutation

CONTEXT

Germline AIP mutations usually cause young-onset acromegaly with low penetrance in a subset of familial isolated pituitary adenoma families. We describe our experience with a large family with R304* AIP mutation and discuss some of the diagnostic dilemmas and management issues.

OBJECTIVE

The aim of the study was to identify and screen mutation carriers in the family.

PATIENTS

Forty-three family members participated in the study.

SETTING

The study was performed in university hospitals.

OUTCOME

We conducted genetic and endocrine screening of family members.

RESULTS

We identified 18 carriers of the R304* mutation, three family members with an AIP-variant A299V, and two family members who harbored both changes. One of the two index cases presented with gigantism and pituitary apoplexy, the other presented with young-onset acromegaly, and both had surgery and radiotherapy. After genetic and clinical screening of the family, two R304* carriers were diagnosed with acromegaly. They underwent transsphenoidal surgery after a short period of somatostatin analog treatment. One of these two patients is in remission; the other achieved successful pregnancy despite suboptimal control of acromegaly. One of the A299V carrier family members was previously diagnosed with a microprolactinoma; we consider this case to be a phenocopy. Height of the unaffected R304* carrier family members is not different compared to noncarrier relatives.

CONCLUSIONS

Families with AIP mutations present particular problems such as the occurrence of large invasive tumors, poor response to medical treatment, difficulties with fertility and management of pregnancy, and the finding of AIP sequence variants of unknown significance. Because disease mostly develops at a younger age and penetrance is low, the timing and duration of the follow-up of carriers without overt disease requires further study. The psychological and financial impact of prolonged clinical screening must be considered. Excellent relationships between the family, endocrinologists, and geneticists are essential, and ideally these families should be managed in centers with specialist expertise.