Surgical management of urinary incontinence in children with anatomical bladder-outlet anomalies

BACKGROUND: Pediatric urinary incontinence secondary to anatomical anomalies of the bladder outlet is relatively rare, and there is no consensus on its surgical treatment. We reviewed the clinical courses and surgical management of children with this pathology. METHODS: From 1991 to 2001, we performed bladder neck reconstruction on seven children (three boys and four girls). The mean age at the first intervention was 7 years (range 5-12 years). The underlying diagnosis was bladder exstrophy in two children, pseudoureterocele-type ectopic ureter in three, bladder neck incompetence from unknown etiology in one boy with hypospadias, and bilateral single ectopic ureter associated with cloacal malformations in one child. Lower urinary tract was evaluated through various imagings, endoscopy, and urodynamic studies. RESULTS: The methods used to reconstruct the bladder neck was the Young-Dees-Leadbetter procedure (performed on four children); the Kropp procedure (two children); and the Pippi-Salle procedure (one child). Bladder augmentation with intestinal segment was performed on four children; Mitrofanoff continent stoma was created in all patients. Urethral catheterization could not be routinely used in all patients, because of pain, stricture, or complicated urethral anatomy. All patients achieved urinary continence. CONCLUSION: The treatment of pediatric urinary incontinence from anatomical anomalies is technically challenging. Depending on the underlying disorders and anatomy, one needs to decide which method of reconstruction to perform. It would be safer to employ simultaneous augmentation and to create catheterizable continent stoma.     

Esthetic Provisional Restorations for Porcelain Veneer Preparations

A method to provisionalize porcelain laminate veneers, similar to previously described methods for provi-sionalizing crowns, is presented. The advantages of this system include the ability to have a prototype restoration for evaluation of esthetics and phonetics, thermal protection, and protection from preparation fracture. Additional advantages include improved tissue health and ease of progressing from the provisionaliza-tion stage to the final bonding stage.     

Correlation of the Endocardial Fragmented Electrogram with Body Surface Signal-Averaged Electrocardiographic Mapping

We compared signal-averaged electrocardiography (SAE), SAE mapping, and left ventricular catheter mapping in 60 patients with ischemic heart disease. Using the data obtained in patients with no fragmented electrograms (EE) in the left ventricle, the late potential was defined by SAE as a filtered QRS duration > 131 msec or a root mean square voltage < 16 μV for the last 40 msec of the QRS complex. SAE mapping was performed by recording the signal-averaged electrocardiogram at 48 sites on the body surface. With SAE mapping, the filtered QRS duration and the area in the last 20 msec of the QRS complex were significantly different between the patients with and without EEs. The late potential was defined by SAE mapping as a filtered QRS duration > 136 msec or an area < 28 μV.msec for the last 20 msec of the QRS complex. The sensitivity and specificity of detecting FEs were 46% and 88%, respectively, by the SAE filtered QRS criterion, while they were 66% and 88% by the root mean square criterion. In contrast, SAE mapping gave values of 66% and 92% by the filtered QRS criterion, as well as values of 100% and 92% by the area criterion. Thus, SAE mapping provided better detection of the EE and was more closely correlated with the results of catheter mapping, suggesting its potential for clinical application.     

Trial of docosahexaenoic acid supplementation on a Japanese patient with a peroxisome biogenesis defect

A female Japanese patient diagnosed with peroxisome biogenesis defect (PBD), who had hypotonia and craniofacial dysmorphism, was given supplementation of docosahexaenoic acid (DHA). Accumulation of very long chain fatty acids was revealed, and a diagnosis of PBD was made at 2 months of age because of the absence of peroxisomes, a defect in peroxisomal β-oxidation enzymes and a decreased level of DHA in the erythrocytes. Supplementation of DHA was introduced at 3 months of age. For the first several months, psychomotor development was fairly good. The patient could laugh, brush off a blanket and play with toys at 6 months of age. However, neurological regression and convulsions occurred after 7 months of age. After recurrent respiratory infections and disturbance of the circadian rhythm, the patient died of liver failure and disseminated intravascular coagulopathy at 20 months of age. DHA may have a favorable effect on the early development of patients with PBD, but neurological deterioration cannot be prevented. Patients with a milder phenotype would be better candidates for DHA supplementation.     

Serum α2-macroglobulin–trypsin complex and early recognition of severe acute pancreatitis after endoscopic retrograde pancreatography

Serum α₂-macroglobulin-trypsin complex (α₂M-T) was measured to differentiate the elevation of serum pancreatic enzymes caused by severe acute pancreatitis from simple elevation after endoscopic retrograde pancreatography (ERP). A patient with severe acute pancreatitis demonstrated marked elevation of serum α₂M-T. In patients without severe acute pancreatitis, serum αM-T did not rise in spite of elevated serum pancreatic enzymes. In conclusion, abdominal pain with elevated serum α₂M-T can be an early diagnostic clue to severe acute pancreatitis after ERP.     

Spontaneous occurrence of autoimmune cholangitis in senescent mice

Abstract The biliary lesions that developed spontaneously in senescent female C57BL/6NCrj mice were investigated. Degeneration of the bile duct epithelium was observed in 12 of 13 mice (92%), destruction of bile duct epithelial cells was seen in six of 13 mice (46%) and chronic non-suppurative destructive cholangitis was found in three of 13 mice (23%). The biliary lesions were characterized by prominent round cell infiltrates in the portal areas. Extra-hepatic lesions such as sialoadenitis were observed in six mice (46%) and pancreatitis in seven (53%). IgM class antipyruvate dehydrogenase antibody was positive in one of three C57BL/6NCrj mice not given anti-Lyt 2 antibody and in three of six C57BL/6NCrj mice injected with anti-Lyt 2 antibody. These lesions were not observed in male C57BL/6NCrj mice, young female C57BL/6NCrj mice, or ICR mice. However, by transferring the splenic cells of senescent female C57BL/6NCrj mice to 6 week old females, the biliary lesions could be transferred at the rate of 6/9. The lymphocytes infiltrating in the bile ducts were CD8 positive lymphocytes. Moreover, in the ultrastructural immunocytochemical analysis of lymphocytes infiltrating bile duct epithelia, CD8 positive lymphocytes often formed broad contacts with the epithelial cells. The biliary lesions developing spontaneously in these mice are similar to those found in human primary biliary cirrhosis.     

Immunoglobulin G subclasses of antibodies to hepatitis B core antigen in HBs antigen positive liver diseases

Serum immunoglobulin G (IgG) subclasses of hepatitis B core antibody (anti-HBc) in 54 patients with different types of hepatitis B surface antigen positive (HBsAg+) liver diseases (asymptomatic carrier (ASC), acute hepatitis (AH), chronic hepatitis (CH) and liver cirrhosis (LC)) and 18 normal controls were estimated by enzyme-linked immunosorbent assay (ELISA) using subclass specific anti-human mouse monoclonal antibodies. In 11 cases, the estimations were carried out at both exacerbation and remission stages of chronic active hepatitis (CAH). In 4 cases of CAH, serial observations of anti-HBc IgG subclasses were made according to the clinical course. In 5 cases of CAH, the estimations were carried out at the HBe antigen positive (HBeAg+) stage and after sero-conversion to anti-HBe positive (anti-HBe+) stage. In ASC the main anti-HBc IgG subclasses were restricted to one subclass--anti-HBc IgG1. In AH on the other hand, all the subclasses were represented. In CH all the subclasses were detected under different diagnostic conditions but anti-HBc IgG1 was the main subclass. In LC the mean concentration of anti-HBc IgG3 was higher than the concentration of anti-HBc IgG1. In exacerbation stages of CAH, the different anti-HBc IgG subclasses had higher concentrations than in remission stages. The concentrations of different anti-HBc IgG subclasses fell just after seroconversion from HBeAg+ stage to anti-HBe+ stage. These data suggest that the estimation of anti-HBc IgG subclasses may be helpful in establishing the diagnosis of different types and stages of HBsAg+ liver diseases.     

Anti-HCV immunoglobulin M antibody in patients with hepatitis C

Anti-hepatitis C virus (HCV) immunoglobulin M antibody titres were measured by an enzyme-linked immunosorbent assay method in 16 patients with non-A, non-B acute hepatitis (NANB AH), 13 with non-A, non-B fulminant hepatitis (NANB FH) and nine with type C chronic hepatitis. Anti-HCV IgM was positive in one of the 16 patients with NANB AH, six of the 13 with NANB FH, and five of the nine with type C chronic hepatitis. Anti-HCV IgG was positive in eight of the 16 patients with NANB AH and eight of the 13 with NANB FH. Either anti-HCV IgM or anti-HCV IgG were positive in 10 of the 13 patients with NANB FH. All of the five anti-HCV IgM positive patients with type C chronic hepatitis were undergoing an exacerbation of the diseases, while all of the anti-HCV IgM negative patients were in a remission stage which had lasted for more than 6 months. The findings of this study suggest that anti-HCV IgM is useful for the early diagnosis of type C FH and may be a useful marker of diseases activity in type C chronic hepatitis.     

Evaluation of renal function after laparoscopic partial nephrectomy with renal scintigraphy using 99mtechnetium-mercaptoacetyltriglycine

AIM: We evaluated the functions of an affected kidney after laparoscopic partial nephrectomy (LPN) using renal scintigraphy with (99m)technetium-mercaptoacetyltriglycine ((99m)Tc-MAG3). METHODS: Split renal function of 10 patients who underwent LPN for renal tumors was assessed using renal scintigraphy with (99m)Tc-MAG3 before surgery, and 1 week and 3 months post-surgery. RESULTS: Median operating time was 196.5 min, median tumor diameter was 2.3 cm, mean blood loss was 64 mL and mean ischemic time was 38.5 min. Median change in serum creatinine level pre- to post-surgery was 0.15 mg/dL. Median contribution of the affected kidney to total renal function (calculated using (99m)Tc-MAG3) was 50.0%, 41.7% and 36.1% before surgery, 1 week and 3 months after LPN, respectively. In one patient, the tumor was resected after cooling of the affected kidney with ice slush for 15 min, and the split renal function ratio remained as high as 50% at 3 months post-operatively despite a total ischemic time of 61 min. CONCLUSIONS: This paper evaluated renal function on the affected side before and after surgery by measuring split renal function with renal scintigraphy using (99m)Tc-MAG3. Risk factors for renal dysfunction in the affected kidney after LPN include age over 70 years with more than 30 min warm ischemic time, re-clamping of the renal artery procedure, and a warm ischemic time greater than 60 min. We believe that renal cooling with slush ice prevents renal dysfunction of the affected kidney after LPN with longer warm ischemic times. However, an easier renal cooling technique should be sought for regular use of cooling procedures in LPN.     

Effect of Chitosan on Renal Function in Patients with Chronic Renal Failure

The effects of chitosan have been investigated on eighty patients with renal failure undergoing long-term stable haemodialysis treatment. The patients were tested after a control treatment period of 1 week. Half were fed 30 chitosan tablets (45 mg chitosan/tablet) three times a day. Ingestion of chitosan effectively reduced total serum cholesterol levels (from 10.14 ± 4.40 to 5.82 ± 2.19 mm ) and increased serum haemoglobin levels (from 58.2 ± 121 to 68 ± 9.0 g L^?). Significant reductions in urea and creatinine levels in serum were observed after 4 weeks of chitosan ingestion. The feeling of physical strength, the appetite and the sleep of patients in the treatment group had improved significantly after 12 weeks of ingestion, compared with those of patients in the control group. During the treatment period, no clinically problematic symptoms were observed. These data suggest that chitosan might be effective treatment for renal failure patients, although the mechanism of the effect should be investigated further.