RENAL ALLOGRAFT SURVIVAL IN PATIENTS WITH CONGENITAL OBSTRUCTION OF THE POSTERIOR URETHRA

In an attempt to clarify the influence of dysfunctional bladders on renal allograft outcome, graft survival was studied retrospectively in patients with congenital posterior urethral obstruction (posterior urethral valves). Using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), 25 index patients were compared to all other transplant recipients of the same age range. Three instances of abnormal bladder function leading to graft function deterioration were found, therefore we would recommend investigation of bladder function in all boys with congenital urethral obstruction prior to renal transplant, and as part of the work-up of graft failure, where the cause is otherwise not obvious.     

EFFECT OF IMMUNOSUPPRESSION ON THE URINARY EXCRETION OF BK AND JC POLYOMAVIRUSES IN RENAL ALLOGRAFT RECIPIENTS

Sixty-five renal allograft recipients on immunosuppressive therapy were examined for BK and JC viruria using Southern blot hybridization. The incidence and degree of BK and JC viruria were compared between this population (group RTR) and, an age- and sex-matched population of non-immunosuppressed individuals (group CTR). In the results, the incidence of BK viruria was significantly increased in the RTR group compared with the CTR group, while that of JC viruria was similar in the 2 groups. The proportion with a high level of JC viruria, however, was greater in the RTR group compared with the CTR group. Additionally, it was also demonstrated that the incidence of both BK and JC viruria was not affected by the characteristics of renal transplant recipients, such as differences in the donor source (living-related vs cadaveric), type of immunosuppressive agents used, or the time post-transplantation.     

THE MITROFANOFF PROCEDURE IN PAEDIATRIC URINARY TRACT RECONSTRUCTION

Methods : Between 1991 and 1996, 23 children underwent urinary tract reconstruction of varying complexity together with a continent diversion according to the Mitrofanoff principle. The appendix was used in 14 patients and the ureter in seven. Two patients had previously had an appendicectomy and the ureters were not suitable. One had a catheterizable channel made from an isolated segment of colon and the other had a detrusor tube constructed. Background : Urinary tract reconstruction is required in many congenital and some acquired urological conditions in childhood. The majority are managed by clean intermittent catheterization (CIC), for which purpose the appendix or other tubular structure may be used to provide a continent catheterizable abdominal stoma. Results : Twelve patients with an appendix conduit, six with a ureteric conduit, and one with a colonic tube are continent, although the latter has had some problems with stomal stenosis. All manage CIC with comfort, the older children doing the procedure themselves. One appendix conduit has stomal incontinence and another was inadvertently divided during renal transplantation. The detrusor tube strictured and was removed. Conclusions : A continent abdominal stoma using the Mitrofanoff principle gives reliable results in children and is well tolerated. It should be considered in the management of children undergoing urinary tract reconstruction when CIC is necessary. The appendix is eminently suitable for this purpose but the ureter provides a satisfactory alternative in selected cases. When neither is available, alternative techniques for constructing a catheterizable continent channel may be considered.     

THE CURRENT PRACTICE OF PAEDIATRIC SURGERY IN MALAYSIA

This 10-year review of surgical conditions In Infants at the University Hospital, Kuala Lumpur, highlights some of the more common problems encountered and outlines their management. Anorectal agenesis and Hirschsprung's disease were seen relatively more frequently than other anomalies of the gastrointestinal tract. The management of these two conditions and the operation of colostomy and its complications are singled out and presented In some detail.     

COMPUTED TOMOGRAPHY IN THE MANAGEMENT OF PAEDIATRIC ABDOMINAL TRAUMA

Since the installation of a whole body computed tomography (CT) unit at the Royal Alexandra Hospital for Children in March 1978, it has been shown to play an invaluable role in the management of abdominal trauma in selected cases. Our experience with 16 cases is presented, and the advantages of CT over alternative diagnostic aids are discussed.     

THE HUMPHREY ADE SYSTEM: EVALUATION IN PAEDIATRIC USE

The Humphrey ADE single lever parallel form breathing systemwas evaluated in 17 children whose lungs were ventilated mechanically,mean age 28 (range 9–58) months, weight 13.3 (8.3–18.0)kg and in 10 spontaneously breathing children, age 50.7 (18–99)months and weight 17.5 (10.9–24.3) kg. During controlledventilation in the E mode, the ADE behaved in a manner similarto the Jackson-Rees modification of Ayre's T-piece with thefresh gas flows (FGF) set either according to weight or at astandard 3 litre min^–1. After 5 min hand ventilation inthe A mode with FGF 3 litre min^–1 the mean end-tidal partialpressure of carbon dioxide was 5.3 (SD 0.8) kPa (range 4.1–7.7kPa). Whilst breathing spontaneously in the A mode, no patientexperienced rebreathing at FGF 3 litre min^–1; rebreathingstarted at 124 (31.6) ml kg^–1 min^–1. The ADE circuitperformed satisfactorily in all three modes. During controlledventilation in the E mode, FGF should be adjusted accordingto the standard formulae recommended for the T-piece circuit.During hand ventilation in the A mode, an FGF greater than 3litre min^–1 should be used.     

低温冷冻异体骨移植在髋关节翻修术中的应用

髋关节因各种原因行人工关节置换术后，由于假体的磨损和松动常引起骨质腐蚀和溶解，导致严重的骨缺损。报道从１９７２年～１９９０年１月，应用大块冷冻异体骨移植的髋关节翻修术２１２例，获随访１年以上的１８７例（１９８个髋），总有效率达８５％。讨论了髋关节翻修术中常见的骨缺损类型及异体骨移植方法，以及异体骨的切取和保存，移植亏的免疫反应和转归等。     

TREATMENT OF ACUTE REJECTION EPISODES IN DOG RENAL ALLOGRAFT RECIPIENTS RECEIVING CYCLOSPORIN A: ATG VS PREDNISOLONE

Prednisolone and antithymocyte globulin (ATG) were compared for their abilities to reverse acute rejection in cyclosporin A-treated canine graft recipients. Outbred dogs bearing kidney allografts were treated with a suboptimal dose of cyclosporin A (10 mg kg^-1); at the onset of an acute rejection episode, animals received daily prednisolone (40 mg kg^-1 or ATG (20 mg kg^-1 until serum creatinine levels decreased. In seven untreated allograft recipients, rejection was first diagnosed at a mean 4.4 days post-transplant. In 23 dogs receiving cyclosporin A, rejection was first diagnosed in all dogs at a mean 43.6 days post-transplant. Compared to ATG, prednisolone was more successful in the reversal of primary acute rejection episodes (5/8 and 7/8 reversals, respectively) and produced a quicker return to normal renal function (mean 15.4 and 6.8 days, respectively). ATG therapy, however, resulted in fewer subsequent acute rejection episodes than prednisolone therapy (mean 1/5 and 6/7 developed secondary rejection episodes, respectively); the possible advantage of ‘clonal depletion’ following ATG therapy is discussed.     

PAEDIATRIC RENAL TRAUMA: CAUTION WITH CONSERVATIVE MANAGEMENT OF MAJOR INJURIES

Background: The kidney is the most frequently injured abdominal organ in children and controversy surrounds some aspects of management. This study looks at the experience of our institution and reviews the literature towards developing an optimal strategy for managing this common childhood injury. Methods: One hundred and forty-two cases of paediatric renal trauma are reported from a catchment population of approximately 240 000 children < 14 years of age over a 12 year period. Injuries were classified into four groups: groups 1 and 2 were regarded as minor injuries (85%) and group 3 and 4 injuries were those with extravasation of urine or pedicle injury (15%). Results: The male:female ratio was 2:I with an average age of 8.5 years. Major renal injuries frequently required large amounts of resuscitation fluid. Associated injuries were present in 41% of all cases with an average of two injuries each. With one exception in each case, the development of complications and the need for early surgery were confined to major injuries. There were no long-term complications. The renal loss rate was 2.1%. Conclusions: Renal injuries can be usefully classified into major or minor by determining whether extravasation of urine or pedicle injury is present. Minor injuries should be managed conservatively. Major injuries causing ongoing haemorrhage require urgent surgery. Other major injuries should be imaged regularly and patients with more severe urinomas benefit from early elective surgery at 2–5 days. In cases where extravasation of urine has not shown clear evidence of settling by 5 days' elective surgery probably results in less morbidity and fewer complications than protracted conservative treatment.     

自体皮与异体皮混合移植中的层粘蛋白表达

目的　通过对大张异体皮打洞嵌植小块自体皮混合移植皮片中层粘蛋白 (L N )的表达研究 ,探讨自体皮与异体皮混合移植促进 度烫伤创面愈合的机制。方法　清洁级 SD大鼠背部脱毛后 ,造成占体表总面积10 %～ 15 %的 度烫伤。伤后 3天切痂 ,移植大张打洞的异体皮。异体皮移植后第 3天 ,嵌植小块自体皮 ,完成皮肤混合移植。在异体皮移植后 3、5、7、14和 2 1天 ,采用免疫组织化学方法测定移植皮片中 L N的表达。结果　异体皮移植后第 7天出现排异反应 ,表现为异体表皮逐渐被爬行而来的自体表皮所铲除替代 ,异体真皮表面仍可见 L N阳性表达。异体皮移植后第 14天 ,从自体皮岛迁移来的表皮细胞下有零星 L N表达 ,异体皮中的 L N仍基本保持完整。异体皮移植后第 2 1天 ,自体表皮已基本覆盖异体皮区 ,L N表达已基本完整。结论　大张异体皮打洞嵌植小块自体皮混合移植中的异体皮为创面愈合提供了基底膜成分 ,有助于改善创面愈合的外观和功能     

PERCUTANEOUS NEPHROLITHOTOMY IN THE PEDIATRIC POPULATION

PURPOSE: Percutaneous nephrolithotomy is an established technique used in children with renal calculi. We review our experience with percutaneous nephrolithotomy for treating nephrolithiasis in childhood. MATERIALS AND METHODS: We retrospectively reviewed the records of children who underwent percutaneous nephrolithotomy procedures for renal calculi from 1985 to 1996. Antegrade percutaneous access was obtained in all patients and the tract was dilated to 24F. Grasper forceps, ultrasound and/or electrohydraulic lithotripsy was used to remove and disintegrate stones. In all patients a nephrostomy tube was placed intraoperatively, and a plain abdominal x-ray and nephrostogram were done postoperatively. The nephrostomy tube was removed after ensuring free drainage down the ureter and no untoward effects from clamping. Complete anatomical and metabolic evaluation was performed in all cases. Patients were followed 2 to 6 weeks, and 3 and 6 months postoperatively with a plain abdominal x-ray and excretory urography or renal ultrasound. RESULTS: In 5 boys and 3 girls (9 renal units) 4 to 11 years old (mean age 6.4) a total of 10 percutaneous nephrolithotomy procedures were performed. At presentation 6 children had flank and/or abdominal pain, 5 gross hematuria and 3 urinary tract infection. Three patients had associated metabolic abnormalities. One patient with a staghorn calculus had hydronephrosis and multiple infundibular stenoses. No underlying urological anatomical abnormalities were noted in the remaining cases. Four renal units that were obstructed at presentation required initial nephrostomy tube insertion. Average operative time was 131.8 minutes (range 58 to 240). An 87.5% stone-free rate was achieved using percutaneous nephrolithotomy monotherapy. Percutaneous nephrolithotomy was not successful for eradicating a staghorn stone in 1 patient. Hypothermia developed in 2 patients in whom operative time exceeded 150 minutes. No blood transfusions were required. CONCLUSIONS: Percutaneous nephrolithotomy is safe and effective in children, and should be considered a viable management option. However, staghorn calculi may require alternative management, particularly in the setting of underlying anatomical abnormalities. Children with renal calculi should undergo a complete anatomical and metabolic assessment with the institution of medical therapy, as appropriate.     

PARENTERAL FLUIDS IN PAEDIATRIC SURGERY

The following account is intended as a guide to the managementof intravenous fluid therapy in paediatric surgery. Essentialbiochemical and physiological data are quoted and importantdifferences between children and adults emphasized. Generalguidance is given on how to determine the requisite amount andtype of fluid to be administered and a chart included from whichmaintenance requirements of fluid and electrolytes can be rapidlyascertained. Only simple intravenous solutions are used; massproduced polyionic solutions are not recommended for routineuse. Illustrative case reports, practical hints and commentson common avoidable errors supplement the general discussion.A list of references and a short bibliography are included asa guide to further reading. ^*Based on a paper read at a meeting of the Faculty of Anaesthetists,Royal College of Surgeons in Ireland, held in Dublin June 2,1962.     

DEADSPACE IN PAEDIATRIC ANAESTHETIC APPARATUS

The effective apparatus deadspace of the Magill, Potter andCape Town gas circuits has been investigated using a model systemsimulating 3- and 8-year-old children. The Cape Town system is more suitable for smaller children. The Potter system is more suitable for larger children. A generous fresh gas flow will decrease the deadspace of thePotter and the Cape Town systems. A flow of double the minutevolume is suggested. There is no place for the Magill system in anaesthesia of children,and it might be better to supplant it with the Potter systemin adults too.     

异体周围神经移植研究进展

目的介绍近期国内外有关异体周围神经移植的研究进展. 方法广泛查阅近期相关文献,综合分析对移植神经和受体的处理方法. 结果应用物理、化学及生物学方法均可降低移植神经的免疫原性;给予受体免疫抑制治疗也可减轻免疫排斥反应,促进神经再生. 结论目前异体神经移植的效果不及自体神经移植理想,成功诱导受体对移植神经产生终身免疫耐受,可望解决这一问题.