Colloidal-electrochemical fabrication strategies for functional composites of linear polyethylenimine

Colloidal-electrochemical fabrication strategies have been developed for the deposition of linear polyethylenimine (LPEI) composite materials. Electrophoretic deposition (EPD) allowed for the fabrication of composite films containing Mn₃O₄ and ZnO nanoparticles, as well as advanced flame retardant materials, such as halloysite nanotubes and memory-type Al-Mg-Zr complex hydroxide (AMZ) in the matrix of the water-insoluble LPEI. A liquid-liquid extraction method has been designed for the agglomerate-free processing of AMZ particles. Efficient extraction was achieved using decylphosphonic acid as an extractor. A conceptually new polymer complex (PC)-EPD method has been developed, which is based on the use of LPEI-metal ion complexes. Proof-of-concept studies involved the fabrication of LPEI-Ni(OH)₂ and LPEI-MnOx nanocomposites. The composites showed valuable flame retardant and charge-storage properties. The analysis of basic EPD and PC-EPD mechanisms as well as complexing properties of LPEI has driven the development of new strategies for the fabrication of organic composites. Hemoglobin was used as a model protein for the fabrication of composite films. Another important finding was the fabrication of composites, containing cyclodextrin, which is a unique carrier of various functional organic molecules. EPD and PC-EPD are versatile methods, which allow for the deposition of novel LPEI based composites containing various functional materials.

Bioactive lipids serve as biomarkers of host immune response during severe influenza infection in pediatric patients

Influenza virus infects 5–20% of the population annually, leading to considerable morbidity and mortality especially in children. Robust biomarkers, reflecting the host immune response, are needed to identify patients at risk of prolonged illness or death. Eicosanoids, a family of bioactive arachidonic acid metabolites produced by the host in response to influenza infection, have pro- and anti-inflammatory properties. This study aimed to assess the relationship between the host lipid response at ICU admission with clinical outcomes in a multicenter cohort of 105 children with influenza-related illness (PICFLU study). We developed a mass spectrometry-based method to quantify >100 lipid metabolites from nasopharyngeal swabs and endotracheal aspirates. The bioactive lipid profile in influenza infected children was impacted by multiple factors including patient age and bacterial coinfection. Patients coinfected with methicillin-resistant Staphylococcus aureus and influenza had significantly elevated levels of pro-inflammatory lipids and concomitantly lower levels of anti-inflammatory 15-lipoxygenase metabolites. Interestingly, children that presented with high levels of lipids including prostaglandin E2 and 12-hydroxyeicosatetraenoic acid were more likely to have fatal outcomes despite reports indicating these lipids have opposing immunomodulatory activity. These results suggest children at risk of mortality have an amplified bioactive lipid immune response that may negatively impact disease resolution. Our study provides evidence that bioactive lipids are potential prognostic biomarkers of patient immune response phenotype, and may help to identify children at risk of influenza-related death.

Rates and types of hospitalisations for children who have subsequent contact with the child protection system: a population based case-control study

OBJECTIVES

To determine whether children who have child maltreatment allegation or substantiation have a higher rate of general hospital admissions and injury related admissions when compared to other children and to investigate other types of admissions, such as mental health, infections and admissions due to external causes.

STUDY DESIGN

A prospective matched case-control study of children born in Western Australia between 1990 and 2005 using de-identified record linked Child Protection and Hospital Morbidity data. Rates of prior hospital admissions for cases versus controls were calculated, and conditional logistic regression was used to estimate the effect of hospital admission rate on the risk of child maltreatment allegation and substantiated allegation.

RESULTS

Children with child maltreatment allegations and substantiations had higher mean prior admission rates compared to controls. Higher rates of general admissions and admissions for injuries, infections, mental and behavioural disorders, and external causes of morbidity, were associated with a markedly increased risk of child maltreatment allegations and substantiation.

CONCLUSIONS

The hospital system plays not only an important role both in the surveillance of maltreatment-related injuries and conditions but also in the role of prevention in the referral of families who may need support and assistance in ensuring the health and safety of their children. This research highlights the importance of moving to electronic patient records in identifying children who have high rates of admissions and the types of conditions they have previously presented with, particularly for injuries, mental and behavioural disorders and external causes of admissions.

Extrarenal retroperitoneal angiomyolipoma: management of a rare benign tumour

BACKGROUND

Extrarenal retroperitoneal angiomyolipomas are benign tumours of mesenchymal tissue origin. The diagnosis of these tumours is usually based on the perioperative findings and confirmed by the resultant specimen's histology. The main differential diagnosis is liposarcoma, and accurate preoperative imaging combined with fine-needle aspiration cytology may permit a non-operative approach to these tumours.

CASE PRESENTATION

We describe a single case of extrarenal retroperitoneal pelvic angiomyolipoma and provide the first case of magnetic resonance imaging of these extremely rare tumours.

CONCLUSION

This article discusses the presentation, management, and outcome associated with these tumours.

Hugh Hampton Young: a pioneer in pediatric urology

PURPOSE

Hugh Hampton Young (1870-1945) is regarded as a major force in urology during the first half of the 20th century. While he is acknowledged for many advances in open and transurethral prostatic surgery, his contributions to pediatric urology have been less well recognized.

MATERIALS AND METHODS

The manuscripts and autobiography of Hugh Hampton Young were reviewed and major contributions to pediatric urology were identified. Patient records corresponding to these areas were then obtained from the Alan Mason Chesney Medical Archives and reviewed.

RESULTS

Hugh Hampton Young was the first clinically to recognize and surgically treat posterior urethral valves, the first to develop a procedure to correct incontinence in patients with the epispadias-exstrophy complex and the first to describe bilateral subtotal adrenalectomy for virilization secondary to congenital adrenal hyperplasia. He was successful in his endeavors and his techniques are still in use today or have become the building blocks of future modifications.

CONCLUSIONS

The contributions of Hugh Hampton Young to pediatric urology were numerous. In addition to his accomplishments in academic and adult urology, Young should be recognized as a true pioneer in pediatric urology.

Irradiation of diets fed to captive exotic felids: microbial destruction, consumption, and fecal consistency

Two frozen, raw horse meat-based diets fed to captive exotic felids at Brookfield Zoo were irradiated to determine the extent of microbial destruction and whether radiation treatment would affect consumption and/or fecal consistency in exotic cats. Fifteen cats, two African lions (Panthera leo), two Amur tigers (Panthera tigris altaica), one Amur leopard (Panthera pardus orientalis), two clouded leopards (Neofelis nebulosa), two caracals (Felis caracal), one bobcat (Felis rufus), and five fishing cats (Felis viverrinus), housed at Brookfield Zoo were fed nonirradiated and irradiated raw diets containing horse meat with cereal products and fortified with nutrients: Nebraska Brand Feline and/or Canine Diet (Animal Spectrum, North Platte, Nebraska 69103, USA). Baseline data were obtained during a 2-wk control period (nonirradiated diets), which was followed by a 4-wk period of feeding comparable irradiated diets. Feed intake and fecal consistency data were collected. An estimated radiation dose range of 0.5-3.9 kilograys reduced most microbial populations, depending on specific diet and microbe type. Irradiation had no overall effect on either feed consumption or fecal consistency in captive exotic cats, regardless of species, age, sex, or body mass. Data indicate that irradiation of frozen horse meat-based diets (packaged in 2.2-kg portions) result in microbial destruction in these products but that product storage time between irradiation and sampling may also affect microbial reduction. However, irradiation would be an appropriate method for reducing potentially pathologic bacteria in raw meat fed to exotic cats.

Health status and health care use of Massachusetts women reporting partner abuse

BACKGROUND

Studies indicate that women abused by their intimate partners are at increased risk for a number of health problems and have increased rates of health care utilization. However, these findings are based mainly on studies using clinic or health plan populations. In this study, we examined the association between intimate partner abuse (IPA) and health concerns and health care utilization in a population-based sample of adult women.

METHODS

We analyzed data on 2043 women aged 18 to 59 who participated in the 1998 Massachusetts Behavioral Risk Factor Surveillance System (BRFSS), a population-based health survey that included questions on IPA. IPA was defined as experiencing physical violence by, fear of, or control by an intimate partner. Consequences of IPA and self-rated health status and health care utilization of women experiencing IPA were examined.

RESULTS

A total of 6.3% of Massachusetts women aged 18 to 59 reported IPA during the past year. Women experiencing IPA were more likely than other women to report depression, anxiety, sleep problems, suicidal ideation, disabilities, smoking, unwanted pregnancy, HIV testing, and condom use. Women experiencing IPA were less likely to have health insurance, but received routine health care at similar rates as other women.

CONCLUSIONS

These results indicate that women in the general population experiencing IPA are at increased risk for several serious emotional and physical health concerns. Most of these women are in routine contact with health care providers. These findings also suggest that the BRFSS may provide a valuable mechanism for tracking state-based IPA prevalence rates over time.

Orchiopexy using 2 mm. laparoscopic instruments: 2 techniques for delivering the testis into the scrotum

PURPOSE

We describe modified techniques of laparoscopic orchiopexy using 2 mm. instruments that enable straightforward delivery of the testis into the scrotum.

MATERIALS AND METHODS

The preferred technique involves a radially dilating trocar advanced over the 2 mm. grasper placed antegrade through the new internal ring. The other method is similar but Amplatz dilators are used when a radially dilating trocar system is not available.

RESULTS

We used these techniques with complete success to deliver 18 testes into the scrotum.

CONCLUSIONS

The testis may be safely and effectively delivered to the scrotum using 2 mm. instruments and disposable fascial dilators or a radially dilating trocar system.

Penile reconstruction combined with bladder closure in the management of classic bladder exstrophy: illustration of technique

OBJECTIVES

Interest has increased in combining procedures during reconstruction of bladder exstrophy in an effort to reduce the number of procedures required for reconstruction and to improve results. This study illustrates our technique of reconstruction and summarizes our current experience with the combination of epispadias repair and bladder closure during initial reconstruction or following prior failed bladder closure.

METHODS

Twenty-four boys with classic bladder exstrophy underwent combined bladder closure and epispadias repair. The mean patient age was 20 months, and 18 boys had a prior failed closure. Osteotomies were performed in all patients.

RESULTS

No instances of bladder prolapse or dehiscence were noted on follow-up. Urethrocutaneous fistula developed in 7 patients. Eventual bladder neck reconstruction has been performed in 11 boys (6 boys are dry day and night, 3 are dry during the day with occasional wet episodes at night, 2 have required follow-up bladder augmentation and continent diversion for persistent incontinence), and 1 boy had augmentation at the same time as bladder neck reconstruction. Twelve boys are awaiting adequate capacity for bladder neck reconstruction, and 1 is awaiting bladder augmentation and continent stoma construction.

CONCLUSIONS

Epispadias closure can be safely combined with bladder closure in select patients with classic bladder exstrophy. Complication rates and cosmesis approximate that achieved with staging the two procedures. This achievement represents strict patient selection and attentive follow-up.

Bladder neck reconstruction in classic bladder exstrophy: the role of osteotomy in the development of continence

OBJECTIVE

To assess the role of osteotomy at the time of bladder neck reconstruction (BNR) for continence in classic bladder exstrophy, in which closure of the pelvic ring and reconstitution of the pelvic diaphragm may affect eventual continence.

PATIENTS AND METHODS

The results of using osteotomy at the time of BNR in 29 children were reviewed. The mean bladder capacity before BNR was 76 mL. The indications for osteotomy were a wide pubic diastasis and a soft intersymphyseal bar. After osteotomy, all children were maintained in external fixation and lower-extremity traction for 6-8 weeks.

RESULTS

Complications of osteotomy were limited to a partial femoral nerve palsy (one patient) and delayed union of fragments (one patient). Complications of BNR included urethral stricture (five patients) and bladder calculi (six patients). Continence results were modest, with 11 of 29 children (38%) dry during the day (dry interval >3 h) and eight of 29 (28%) dry at night. Eight children had daytime dry intervals of approximately 3 h. The mean preoperative bladder capacity in children who were dry both day and night was 101 mL.

CONCLUSIONS

The preoperative bladder capacity remains a key determinant for the attainment of continence after BNR in the reconstruction of classic bladder exstrophy. Osteotomy allows pelvic closure and thus improves cosmesis of the mons and stabilizes the BNR in patients with a soft intersymphyseal bar, but seems to have no effect on continence when performed at the time of bladder neck plasty.

Cost analysis of the treatment of vesicoureteral reflux: a computer model

PURPOSE

Surgical intervention for vesicoureteral reflux is generally limited to children who have recurrent infection despite adequate antimicrobial prophylaxis or in whom compliance with followup cannot be ensured. In addition, surgical therapy is considered in children with persistent reflux after a reasonable period of surveillance. We used a model based on the management of a theoretical population of girls with various grades of reflux and followed the costs incurred during a 5-year management period.

MATERIALS AND METHODS

The literature on vesicoureteral reflux was used to create a set of assumptions regarding epidemiology, likelihood of resolution, need for operative intervention, risk of infection and appropriate regimen for nonoperative surveillance. These parameters were evaluated in infants and children as noted in the literature. A 5-year management period was considered. Patients in whom reflux did not resolve with medical management at the end of 5 years were assumed to have undergone surgical correction. Costs were calculated based on the amounts billed, managed care reimbursement and Medicaid reimbursement in Maryland. The costs of up front surgical management were calculated and compared to those of 5 years of standard management. All costs were discounted at a rate of 10%.

RESULTS

Calculated costs of standard management were lower for lower grades than those for higher grades of reflux. The costs of surgical management were lower than those of standard management for higher reflux grades using nondiscounted costs. However, when costs were discounted to present value, the costs of standard management were significantly lower than those of up-front surgery for all scenarios studied.

CONCLUSIONS

The cost of vesicoureteral reflux is considerable when whole patient groups are considered. Using cost as the only parameter the standard management of reflux is less costly than up-front surgery. In the individual surgical intervention usually is predicated by patient and family factors which were not considered in this model. This computer based construct allows data from different institutions to be analyzed to project costs of the management of reflux.

Neural innervation of the newborn exstrophic bladder: an immunohistochemical study

PURPOSE

Continence in bladder exstrophy is not always easy to attain. Some patients have a small noncontractile bladder while in others an adequate capacity bladder may not contract normally. Innervation of the detrusor determines its ability to contract. The exstrophic bladder during organogenesis does not store urine. Therefore, its requirements for contraction are limited and its innervation would potentially reflect this difference in function. The availability of specific immunostains allows better differentiation of the neural elements in tissue specimens. Our study focuses on myelinated nerves innervating the newborn exstrophic detrusor.

MATERIALS AND METHODS

Biopsies were obtained from the anterior wall of 10 newborn exstrophic bladders at the time of initial closure and compared to 10 newborn controls. Patient age at bladder closure ranged from 1 to 90 days (mean 22). Specimens were formalin fixed and paraffin embedded. Then 4 micro. thick sections were stained with S100, an immunostain that stains neural crest elements including Schwann's elements (myelinated nerve fibers). The entire tissue section was examined. Microscopic fields were sequentially examined with a morphometric system comprising a microscope, video camera and personal computer with a video frame grabber. The output image was displayed on a second monitor and the nerves in each field and numbers of fields in each section were counted. To be considered, fields had to have greater than 75% tissue coverage. The average number of nerves per field was compared between the exstrophic bladders and normal controls.

RESULTS

The average number of myelinated nerves per field in the newborn exstrophic bladders (0.13 per field) was significantly reduced compared to normal controls (1.25 per field) and statistically significant (p<0.001). This reduction in nerve fibers appeared to be due to lack of smaller fibers with preservation of larger fibers. There was no difference in innervation in cases closed at birth compared to those closed after month 1 of life.

CONCLUSIONS

The newborn exstrophic bladder has fewer myelinated nerve fibers than normal controls primarily due to reduction in the smaller fibers which may represent a maturational delay in the development of the exstrophic bladder. Another possible explanation may be degeneration of the fibers due to lack of bladder contraction but no indication of nerve degeneration was evident in our study. Followup studies of patients at various stages of reconstruction will determine the evolution of neural innervation in the exstrophic bladder.

Anomalies of the inferior vena cava and renal veins: embryologic and surgical considerations

Anomalies of the inferior vena cava and renal veins occur infrequently but if unidentified can lead to significant morbidity during surgical exploration. An understanding of the embryologic development of the vena cava and its tributaries is necessary to understand the genesis of these sometimes complex anomalies and their accompanying anatomic variants. Newer radiologic modalities in the form of spiral computed tomography (CT) and three-dimensional reconstruction of spiral CT allow clear definition of the anatomy of these anomalies. Variations in the embryologic evolution of the vena cava dictate the different venous anomalies that may be encountered in the retroperitoneum. Additionally, the utility of newer radiologic modalities in the identification of these anomalies is discussed.

Single system ureteral ectopia in boys associated with bladder outlet obstruction

PURPOSE

Ureteral ectopia is frequently associated with dysplasia of the associated renal segment in girls with ureteral duplication. However, single system ureteral ectopia is an uncommon anomaly more frequently noted in boys. We report on 6 boys with single system ureteral ectopia into the prostatic urethra above the verumontanum, who presented with radiological and clinical findings of bladder outlet obstruction.

MATERIALS AND METHODS

Antenatal ultrasound in 3 boys demonstrated renal abnormalities and postnatal studies suggested the diagnosis of posterior urethral valve obstruction. Older boys presented with symptoms suggestive of bladder outlet obstruction.

RESULTS

An ectopic ureter inserting into the prostatic urethra was noted in all 6 boys. The distal ureter was dilated elevating the bladder neck causing outlet obstruction. Surgical management consisted of nephrectomy and transurethral endoscopic incision of the distal ureter or nephroureterectomy with reconstruction of the prostatic urethra. In 2 younger boys voiding dysfunction with inability to empty developed.

CONCLUSIONS

Single system ectopic ureters in boys may present with symptomatic and radiological findings resembling posterior urethral valves. Surgical treatment should include nephroureterectomy with reconstruction of the hypoplastic prostate. Some patients may have later voiding dysfunction.

Hyperbaric oxygen therapy for radiation induced hemorrhagic cystitis

PURPOSE

Radiation therapy has been used successfully to treat pelvic malignancy but morbidity from hemorrhagic cystitis remains a major long-term sequela in 1 to 2% of patients. Obliterative endarteritis secondary to ionizing radiation leads to tissue hypoxia and poor healing. Hyperbaric oxygen therapy has been demonstrated to improve angiogenesis and promote healing in radiation injured tissue, including the bladder. We describe the treatment and long-term followup of a cohort of patients treated with hyperbaric oxygen for hemorrhagic cystitis.

MATERIALS AND METHODS

A total of 17 patients (mean age 62 years) with hemorrhagic cystitis received hyperbaric oxygen following failure of standard treatment modalities. Hyperbaric oxygen was administered on a once daily schedule (mean number of treatments 14) until hematuria resolved. Followup ranged from 9 to 60 months (mean 21).

RESULTS

Hematuria resolved completely in 11 of 17 patients (64%), 2 had only residual microscopic hematuria, 2 had improvement but died of complications relating to cancer shortly after completion of treatment and 2 had recurrence of gross hematuria. Early application of hyperbaric oxygen was associated with earlier resolution of hemorrhagic cystitis.

CONCLUSIONS

Radiation induced hemorrhagic cystitis that does not respond to standard regimens can be successfully treated with hyperbaric oxygen. This modality is well tolerated even in patients debilitated by advanced cancer and blood loss. Long-term remission can be achieved in the majority of patients.

Cloacal exstrophy--improving the quality of life: the Johns Hopkins experience

PURPOSE

Exstrophy of the cloaca is a multisystem anomaly involving the gastrointestinal, nervous, musculoskeletal and genitourinary tracts which should be managed with a multidisciplinary approach. Improvement in management has led to survival for the majority of infants, and the focus has shifted to improvement in quality of life. The experience with management of cloacal exstrophy at a large center is evaluated.

MATERIALS AND METHODS

Demographic data as well as functional results of management of the multiple anomalies in 37 patients with cloacal exstrophy were evaluated. Surgical reconstruction was aimed at providing the best functional and cosmetic results.

RESULTS

Average patient age at review was 13.6 years. Most patients (32 of 37) had undergone an initial attempt at bladder closure from birth to greater than 24 months of age. Colostomy was performed when possible and if initial ileostomy was performed, the bowel was augmented later with the hindgut segment. When the hindgut segment was not used for bowel reconstruction, it was preserved for bladder augmentation or genital reconstruction. While urinary continence was achievable in many children, it was usually after augmentation and/or continent diversion.

CONCLUSIONS

Improvements in perinatal management have increased survival in cloacal exstrophy. Therefore, the focus of reconstruction has shifted to reduction in the numbers of incontinent stomas, assistance with ambulation and improved cosmesis. All of these goals are achievable using a multidisciplinary approach to the management of this complex anomaly.

Combined bladder closure and epispadias repair in the reconstruction of bladder exstrophy

PURPOSE

Children with bladder exstrophy in whom initial closure fails are less likely to achieve adequate bladder capacity for later bladder neck reconstruction and continence. Repeat bladder closure may be combined with epispadias repair as initial management, decreasing the need for repeat anesthesia as well as providing increased outlet resistance to permit bladder growth in preparation for later bladder neck reconstruction. We compared results in boys who underwent combined bladder closure and epispadias repair or staged reconstruction.

MATERIALS AND METHODS

A total of 16 boys with a mean age of 22 months with bladder exstrophy were referred for bladder closure after previous closure had failed in 15 and for delayed primary closure in 1. Osteotomies were performed in all patients, with bladder closure and epispadias repair as initial treatment. Results were compared to those in 21 boys with a mean age of 26 months in whom exstrophy closure had failed, and who underwent standard staged reconstruction by repeat closure followed by epispadias repair and subsequent bladder neck reconstruction in those who achieved adequate bladder capacity.

RESULTS

At a mean followup of 87 months fistula rates were similar in the 2 groups. Eventual bladder neck reconstruction was possible in 69% of the patients in each group. In addition, 2 boys in the combined repair group achieved continence before bladder neck reconstruction was performed.

CONCLUSIONS

We recommend epispadias repair combined with bladder exstrophy closure for treating failed exstrophy closure or late initial closure. Operative complications and results are comparable to those in patients in whom previous exstrophy closure failed and who undergo standard staged repair.

Hernia development in CAPD patients and the effect of 2.5 l dialysate volume in selected patients

The aim of this study was to estimate the prevalence of hernia formation in CAPD patients and to study the effect of increased dialysate volume (2.5 l) in selected population of patients who could tolerate it. We reviewed the charts of 454 individuals treated with CAPD in our center during a five-year period (September 1991-September 1996). Out of 404 patients who used 2.0 l dialysate exchange volume forty-nine (11%) developed hernia (umbilical 53%, inguinal 33%, incisional 14%) after having been on CAPD for an average of 10 +/- 11 months, while only one of the 50 patients who would tolerate 2.5 l developed a hernia (inguinal 2%), after having been on CAPD for 12 months. All hernias were repaired surgically and most of the patients returned to CAPD after temporary intermittent peritoneal dialysis. Age, sex, nutritional status, polycystic kidneys, and diabetes do not seem to be predisposing factors for hernia formation, while previous operation for aortic abdominal aneurysm repair, or low body weight (< 60 kg) were risk factors. The use of increased dialysate volume (2.5 l) in patients who could tolerate it, did not result in a higher frequency of hernia development. Surprisingly, patients with hernias seem to have a higher mortality than those without.

Breakfast and cognition: an integrative summary

In this supplement, the papers presented at the International Symposium on Breakfast and Performance in Napa, CA in 1995 are summarized and integrated with data published since that time. In particular, the focus is on issues of research design, measurements, mechanisms, potential effect modifiers (eg, age), and relevance for public policy. No definitive conclusions can be drawn from the existing data on either the long- and short-term benefits of breakfast on cognition and school learning or the mechanisms that mediate this relation. The pooled data suggest that omitting breakfast interferes with cognition and learning, an effect that is more pronounced in nutritionally at-risk children than in well-nourished children. At the very least, breakfast consumption improves school attendance and enhances the quality of the students' diets.

The structure and autonomic innervation of the vesico-ureteric junction in cases of primary ureteric reflux

OBJECTIVE

To determine the histological structure and autonomic innervation of the vesico-ureteric junction (VUJ) in cases of primary ureteric reflux, to compare the results with those reported previously for non-refluxing VUJs and thus determine possible structural anomalies which could be responsible for vesico-ureteric reflux (VUR).

MATERIALS AND METHODS

Nineteen specimens of VUJs with reflux were obtained from four males and 10 females undergoing ureteric reimplantation. Serial frozen sections were cut and stained either with Masson's trichrome or immunostained for protein gene product (PGP 9.5), a general nerve marker, dopamine beta hydroxylase (D beta H), a marker for noradrenergic nerves, or neuropeptide Y (NPY).

RESULTS

Longitudinally orientated muscle bundles of narrow diameter accompanied the ureter to its termination at the ureteric orifice. Where they merged with those of the superficial trigone. In some specimens, an additional muscle component was identified, situated on the outer aspect of the ureteric muscle coat, consisting of an incomplete layer of distinctive muscle whose constituent cells formed an interlacing mesh-work. Occasionally, specimens included detrusor muscle which consisted of relatively large diameter compact bundles separated from the ureter by a connective tissue sheath. D beta H- and NPY-immunoreactive (-IR) nerves were numerous among the ureteric muscle bundles. Many NPY-IR nerves occurred within the detrusor muscle while D beta H-IR nerves were mainly perivascular. When present, the outer muscle component was richly innervated by both D beta H- and NPY-IR nerves. PGP immunoreactivity varied among regions in the same section, PGP-IR nerves frequently being less numerous than those containing D beta H or NPY.

CONCLUSION

These results indicate that the morphology of the VUJ in cases of VUR is indistinguishable from the normal VUJ described previously. Furthermore, the density and distribution of D beta H- and NPY-IR nerves is identical to that in controls. However, the antigenicity of PGP in the reflux specimens appears to be masked in some regions by an unknown factor.

Versatility of the adult psoas hitch ureteral reimplantation

PURPOSE

The psoas hitch ureteral reimplant has been described in the literature as an excellent method to restore ureterovesical continuity in patients with ureteral defects of various etiologies. However, long-term data on the durability of this procedure are lacking. We retrospectively reviewed patients who underwent ureteral reconstruction using the psoas hitch reimplantation to determine long-term efficacy.

MATERIALS AND METHODS

Ureteral reimplantation in the adult is frequently performed in the setting of ureteral tissue loss secondary to resection or injury. The psoas hitch reimplantation is a simple, versatile technique that avoids the inclusion of intestinal segments and can be used in most patients requiring reimplantation. Indications for surgery and the long-term followup were examined in 20 patients undergoing reimplantation using the psoas hitch.

RESULTS

The indications for ureteral reconstruction included surgical injury in 13 cases, recurrent pyelonephritis with reflux in 1, obstruction secondary to cancer in 2, trauma in 1, retroperitoneal fibrosis in 1 and ureteral stricture in 2. At followup of 1 to 14 years (mean 6) 17 patients have not required further intervention for urological problems and have retained normal renal function. In the 2 patients with cancer ileal conduit was performed later and in 1 flank pain persisted despite negative urological evaluation.

CONCLUSIONS

Psoas hitch ureteral reimplantation can be used successfully for bridging various ureteral defects in difficult clinical situations. Adequate renal and bladder mobilization will allow reconstruction despite long ureteral defects.

Expression of epidermal growth factor receptor in fetal mouse submandibular gland detected by a biotinyltyramide-based catalyzed signal amplification method

Branching morphogenesis of the fetal mouse submandibular gland (SMG) can be modulated in vitro by stimulation or inhibition of the epidermal growth factor receptor (EGFR). Because the mRNAs for EGF and EGFR are detectable in RNA of SMG rudiments isolated directly from fetuses, the EGF system probably operates physiologically as a regulator of SMG morphogenesis. However, neither EGFR protein nor its precise cellular localization has been characterized in the fetal SMG. Here we show EGFR protein in fetal mouse SMG by immunoprecipitation, affinity labeling, ligand-induced autophosphorylation, and immunohistochemistry. SMGs from E16 fetuses (day of vaginal plug = E0) were labeled with [35S]-cysteine/methionine and homogenized. After addition of specific antibody to EGFR, the immunoprecipitate was isolated, resolved by polyacrylamide gel electrophoresis, and detected by autoradiography. A single band of 170 kD was detected, corresponding to the EGFR protein. Affinity labeling with [125I]-EGF of the membrane fraction of E18 SMG also revealed a prominent band at 170 kD, showing that this EGFR protein can bind specifically to its ligand. Incubation of SMG membranes from E18 fetuses with EGF in the presence of [gamma-32P]-ATP, followed by immunoprecipitation with anti-phosphotyrosine antibody also showed a single band at 170 kD, demonstrating autophosphorylation of the EGFR in response to binding of its ligand. Immunohistochemical localization of the cellular sites of EGFR in the fetal SMG required use of a catalyzed signal amplification procedure, with biotinyltyramide as the amplifying agent. EGFR was localized predominantly, if not exclusively, in cell membranes of epithelial cells of the rudiment, whereas staining of mesenchymal cells was equivocal. Staining was strongest on duct cells, and weak on cells of the end-pieces. These findings clearly show that a functional EGFR protein is expressed in fetal SMG chiefly, if not exclusively, on epithelial cells.

Immunohistochemical and ultrastructural study of rhabdosphincter component of the prostatic capsule

PURPOSE

There has been no complete agreement on functional anatomy of muscular components of the urethral sphincteric mechanism, particularly in the male patient. The prostatic capsule was studied to define its histological structure and to determine whether its rhabdosphincter component (prostatocapsular rhabdosphincter) consists only of slow twitch or slow and fast twitch striated myofibers.

MATERIALS AND METHODS

We studied 11 whole prostates, including 1 obtained at autopsy and 10 by radical prostatectomy. Samples of prostatic capsule from 4 operative specimens were studied by electron microscopy. Whole mount paraffin sections from transverse slices of the remaining 7 prostates were double labeled with avidin biotin conjugate immunostaining using the primary monoclonal antibodies anti-alpha smooth muscle actin plus anti-alpha sarcomeric actin (all striated myofibers) or antiskeletal myosin fast (fast myofibers only). Tissue components of the prostatic capsule, including smooth muscle and slow versus fast twitch striated myofibers, were quantified by computerized image analysis.

RESULTS

The prostatic capsule consisted of collagen, smooth muscle and striated myofibers. It varied in thickness and proportion of the 3 components among specimens, and in each in relation to transverse circumferential aspect and craniocaudal (horizontal) level of the prostate. Collagen and smooth muscle were equally important components. Striated muscle elements within the capsule consisted of fast twitch and dominant slow twitch myofibers, and were much more abundant in the caudal (distal, lower) than the cranial (proximal, upper) half of the capsule, where they were deficient ventrally (anteriorly) and dorsally (posteriorly). The prostatocapsular rhabdosphincter thus had a butterfly-like appearance, with a thick posteriorly open ring at the apex and 2 thinner, divergent leaflets tapering toward the base at the bladder neck. The fast myofiber population decreased progressively from apex to base of prostate.

CONCLUSIONS

Proof is provided for mixed slow and fast twitch myofiber structure of the prostatocapsular component of human male rhabdosphincter. Sustained (tonic) contraction of slow myofibers probably reinforces the role of urethral smooth muscle in maintaining continence during bladder filling. Swift contraction of fast myofibers that abound caudally in the capsule probably supplements urethral closure by the bulkier membranous urethral part of the rhabdosphincter in preventing leakage of urine under stress when voiding is imminent or willfully withheld.

Metabolic complications secondary to obstruction of a Kock pouch afferent limb

Metabolic complications are frequently seen following urinary diversion with an intestinal segment. Afferent limb complications are noted in 10% of patients undergoing continent Kock urinary diversion. We present a patient with cloacal exstrophy with developed significant hypocalcemic tetany and metabolic acidosis related to a nondraining afferent limb of a Kock pouch created to achieve continence.

Sigmoid "tail" modification for bladder augmentation

OBJECTIVES

The sigmoid colon lends itself well to bladder augmentation particularly in patients requiring reimplantation of ureters or Mitrofanoff valves for continence. We have modified the sigmoid augment to improve ease of catheterization and ureteral reimplantation.

METHODS

Seven children underwent sigmoid "tail" bladder augmentation for various indications. Appendix or tapered ileum was used to create the catheterizable stoma. This technique uses a 3 to 5-cm segment of nondetubularized colon, fixed to the abdominal wall to ease catheterization. Durability of the modification and ease of catheterization were assessed.

RESULTS

All patients are dry day and night with intermittent catheterization. One patient with mild leakage has been managed with pseudoefedrine. Postoperative bowel obstruction and abscess developed in 1 patient.

CONCLUSIONS

The sigmoid "tail" modification does not appear to confer increased morbidity and the short nondetubularized segment fixed to the posterior aspect of the anterior abdominal wall stabilizes the catheterizable stoma improving ease of catheterization.

Increased G alpha q/11 immunoreactivity in postmortem occipital cortex from patients with bipolar affective disorder

As disturbances in guanine nucleotide binding (G) protein-coupled phosphoinositide second messenger systems have been implicated in bipolar disorder, we examined whether the abundance of G alpha q/11 and phospholipase C (PLC)-beta 1 two key transducing proteins in this signaling pathway, are altered in this disorder. Compared with the controls, immunoreactive levels of G alpha q/11 were significantly elevated by 62% (p = .047) in occipital cortex of bipolar subjects. A similar increase (52%) in the PLC-beta 1 immunolabeling was also found in the occipital cortex of the bipolar subjects, but only reached marginal statistical significance (p = .07). In contrast, frontal and temporal cortex G alpha q/11 or PLC-beta 1 immunolabeling did not differ between bipolar and control subjects. Cerebral cortical immunoreactive levels of G beta 1 or G beta 2, included as a negative control, were not different between comparison groups. These findings support and extend earlier observations suggesting that disturbances in G protein-coupled second messenger signaling pathways may play an important role in the pathophysiology of bipolar affective disorder.

Initial experience with the modified vaginal wall sling in the treatment of female stress urinary incontinence

From March 1995 to March 1996 24 women aged 29-73 years with stress urinary incontinence underwent a modified vaginal wall sling procedure following videourodynamic evaluation. Of these 24, 2 had stress urinary loss due to urethral hypermobility (UH), 3 had intrinsic sphincter deficiency (ISD) and 19 had both UH and ISD. Thirteen (54%) had preoperative urge incontinence, 13 (54%) had associated pelvic floor weakness, including cystocele, and 12 (50%) had had previous pelvic surgery and bladder neck suspension. Twenty-two patients were evaluable for a mean follow-up of 14 months (range 9-21 months). Stress urinary incontinence was resolved in all patients (100%). Of the patients with preoperative urge symptoms, 58% reported resolution but in 42% the urge symptoms remained unresolved. One new patient developed urge and occasional urge incontinence. Out of 22 patients 20 (90.9%) are totally continent; 2 (9.1%) are incontinent and both have documented detrusor instability and occasionally wear pads. The vaginal wall sling is an ideal procedure for the treatment of the various forms of stress urinary incontinence in women. In our series the early results indicate excellent patient acceptability and continence. Long-term follow-up will determine the durability of the procedure.

Seven-year follow-up of speech/language impaired and control children: psychiatric outcome

This study examined the 7-year psychiatric outcome of 202 speech/language (S/L) impaired and control children selected from a community sample at age 5 years. Children with S/L at age 5 years were more likely to be psychiatric cases at age 12.5 years than were normal controls, even if their S/L improved. Controlling for concurrent psychiatric disorder, S/L impairment at age 5 years was still associated with an increased rate of psychiatric disorder at 12.5 years. Psychiatric disorder at age 12.5 years was more likely to co-occur with language disorder than with speech disorder.

Cyclophosphamide in the treatment of toxic epidermal necrolysis

A patient with non-small cell lung carcinoma and recent radiotherapy for brain metastases developed toxic epidermal necrolysis (TEN) shortly after therapy with phenytoin was initiated for a seizure. Exfoliation progressed to involve 90% of her body surface despite treatment with high-dose corticosteroids for 5 days, but sloughing and systemic toxicity ceased within 2 days of initiating therapy with intravenous cyclophosphamide (300 mg/day). Reepithelialization rapidly followed. This experience and the reports of others suggest that intravenous cyclophosphamide is helpful in the treatment of TEN.

Minimal surgery with renal preservation in anomalous complete duplicated systems: is it feasible?

From 1985 to 1993, 33 female and 4 male patients 0 to 3 years old presented with abnormal complete duplex systems of whom 25 had a prenatal diagnosis of hydronephrosis. Diagnosis in 40 ureteral moieties included ureteroceles in 10, ectopic ureteral insertions with reflux and obstruction in 17, and refluxing lower ureters in 13. Of 40 renal units only 6 (15%) required upper pole moiety ablation for pyelonephritis or nonfunction. None of the ablated renal tissue showed evidence of dysplasia. With the advent of prenatal diagnosis and minimal surgical intervention complete duplex anomalous urinary systems can be salvaged with preservation of altered renal units.

Modification of Dornier HM-4 lithotriptor for pediatric extracorporeal shockwave lithotripsy

Extracorporeal shockwave lithotripsy has enjoyed increasing acceptance and utility in pediatric urology. The Dornier HM-4 lithotriptor has had good results in adults, but the gantry design does not allow smaller children to be treated. We have employed a specially designed yet simple 'spacer' to allow smaller children to be treated safely. The device may also have application in other patients with deformities who could not be treated in the past.

Application of biomechanics to tendon transfers

This article has focused on considerations important in the application of biomechanics to tendon transfers and has used an example protocol. Different surgeries require different protocols. What is most important is that specific protocols are used, and that they are both safe and effective. The communication among the therapist, surgeon, and patient is essential with the use of any protocol. As Brand has stated, "A hand is a very personal thing. It is the interface between the patient and his or her world. It is an emblem of strength, beauty, skill, sexuality, and sensibility. When it is damaged it becomes a symbol of the vulnerability of the whole person." For the patient who has damage from nerve palsy, paralysis, or injury resulting in a dysfunctional hand, a tendon transfer procedure may prove to be a viable option to restore balance and function, especially if the biomechanics of deformity and correction are considered.

Seven-year follow-up of speech/language-impaired and control children: speech/language stability and outcome

OBJECTIVE

This study examined the 7-year outcome of speech/language (S/L) impaired and control children selected from a community sample at age 5 years.

METHOD

Two hundred fifteen children completed a variety of speech and language tests at age 12 years. Children with S/L impairment were further classified as "speech only," "language only," or "speech and language impaired."

RESULTS

More than 72% of children who had S/L impairment at age 5 remained impaired at age 12. Children with both speech and language problems were most likely to remain S/L impaired; 81% had some kind of S/L impairment at follow-up. Similarly, children with both expressive and receptive language impairment were more likely to show expressive or receptive impairment at follow-up than children with expressive impairment alone. One third of time 1 controls had S/L problems at follow-up, and of these 82% had speech impairment only.

CONCLUSIONS

S/L impairment identified at age 5 has long-lasting effects. More pervasive problems were associated with poorer outcomes. Screening at age 5 may be useful, as most serious S/L problems that emerged by middle childhood could be identified at age 5. The effects of S/L treatment require further study.

Inhibitory grids and the assignment problem

A family of symmetric neural networks that solve a simple version of the assignment problem (AP) is analyzed. The authors analyze the suboptimal performance of these networks and compare the results to optimal answers obtained by linear programming techniques. They then use the interactive activation model to define the network dynamics-a model that is closely related to the Hopfield-Tank model. A systematic analysis of hypercube corner stability and eigenspaces of the connection strength matrix leads to network parameters that give feasible solutions 100% of the time and to a projection algorithm that significantly improves performance. Two formulations of the problem are discussed: (i) nearest corner: encode the assignment numbers as initial activations, and (ii) lowest energy corner: encode the assignment numbers as external inputs.

Primary lymphoma of the rectum

Primary lymphoma of the rectum is rare. Its usual grouping with primary lymphoma of the gastrointestinal tract leaves little in the literature that deals specifically with a primary rectal lymphoma. Various treatments have been reported ranging from abdominoperineal resection with adjuvant chemotherapy and radiation therapy to chemotherapy or radiation therapy alone. A case of primary rectal lymphoma is presented and the literature is reviewed. In the few cases reported in the literature, patients treated surgically had a better prognosis than those treated nonsurgically with an overall 5-year survival of 50 per cent. Recommended treatment includes varying forms of surgical therapy ranging from local resection to abdominoperineal resection. Adjuvant chemotherapy, radiation therapy, or both should be considered.