Low birth weight,but not postnatal weight gain,aggravates the course of nephrotic syndrome

Clinical and animal studies have shown a higher risk of an aggravated course of renal disease in childhood after birth for babies small for gestational age (SGA). In addition relative “supernutrition” and fast weight gain in early infancy seem to support the development of later disease. In a retrospective analysis of 62 cases of idiopathic nephrotic syndrome treated between 1994 and 2004 at a university centre for paediatric nephrology, we related the course of disease to birth weight and to the weight gain in the first 2 years of life. Six children were born SGA (birth weight <−1.5 standard deviation score), and 56 were born as appropriate for gestational age (AGA). In all SGA children renal biopsy was performed, while only 55% of the AGA children underwent renal biopsy (P = 0.07), showing no difference in renal histology. In the SGA group, four of six patients developed steroid resistance (vs 12/56 AGA, P < 0.05). Of the SGA children, 83% needed antihypertensive treatment in the course of the disease compared to 39% of the AGA children (P = 0.07). The extent of weight gain between birth and 24 months of age did not influence the course of disease. In conclusion, we were able to find evidence for an aggravated course of idiopathic nephrotic syndrome in former SGA children. Independently of birth weight, weight gain in the first 2 years of life did not influence the course of disease.     

Fifteen-year remission of a steroid-resistant nephrotic syndrome sustained by cyclosporine A

Many children with a late steroid-resistant nephrotic syndrome (SRNS) and focal glomerulosclerosis have a poor prognosis and enter end-stage renal failure (ESRF) within five years. Reports are scarce on the long-term follow-up of patients entering remission while receiving immunosuppressive therapy after steroids have failed. A two-year-old boy with focal and segmental glomerulosclerosis having both late steroid and cyclophosphamide resistance entered complete remission of the SRNS almost two years after starting induction therapy with cyclosporine A (CSA). During the 15-year follow-up, the patient experienced five relapses during CSA maintenance therapy. All relapses were successfully treated within 10 days by intravenous methylprednisolone pulses in addition to CSA. The relapses were accompanied by a drop in the glomerular filtration rate (GFR). At the age of 18 years, the patient had grade II chronic kidney disease (GFR=61 ml/min/1.73 m²). At the age of 14 years, mycophenolate mofetil (MMF) was added to the maintenance therapy and the CSA dosage was reduced. Two renal biopsies at the ages of 10 and 18 years failed to detect CSA nephrotoxicity. We conclude that children with SRNS may have long-term benefit from a combination therapy using intravenous methylprednisolone pulses and CSA.     

Rising PSA in patients with minor LUTS without evidence of prostatic carcinoma: a missing link?

Objectives To determine the role of pressure flowmetry in patients without bothersome lower urinary tract symptoms (LUTS), rising prostate-specific antigen (PSA) levels and diagnosed as having clinical benign prostatic hyperplasia (BPH) after negative (multiple) extended multi-site biopsy. Methods The study enrolled patients with minor LUTS who were referred to our urological practice by their general practitioner because of a rising PSA level (≥4 ng/ml). After exclusion of clinical prostatic carcinoma by digital rectal examination and transrectal ultrasound, all patients underwent at least one set of extended multi-site biopsies to exclude T1c prostate cancer. Patients with negative biopsies (clinical BPH) were subjected to pressure flowmetry whereafter those with bladder outlet obstruction underwent TURP. Results The study included 82 patients, with a mean age of 64.8 years (50.2–78.2 years), satisfying the inclusion criteria. Urodynamic analysis showed that all patients had bladder outlet obstruction. After TURP, eight patients (9.8%) were diagnosed as having histologically proven prostate cancer; 74 patients (90.2%) were diagnosed as having BPH. Patients of the BPH group had a mean preoperative PSA level of 8.8 ng/ml (4.3–25.8 ng/ml) and a mean international prostate symptom score of 8.8 (2–18). The mean detrusor pressure at maximum flow in BPH patients was 89.5 cmH₂O (20–200 cmH₂O). Conclusions An increased PSA in patients with minor or no LUTS, clinical BPH and negative extended multi-site prostate biopsy is strongly correlated to bladder outlet obstruction. Therefore, patients with these characteristics should be treated with TURP.     

Sexual function in women after rectocele repair with acellular porcine dermis graft vs site-specific rectovaginal fascia repair

The objective of the study was to compare preoperative and postoperative sexual function between women undergoing rectocele repair with porcine dermis graft and women undergoing site-specific repair of rectovaginal fascia. A standardized, validated questionnaire (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire [PISQ]) was used to collect preoperative sexual function data from 100 patients with rectocele pelvic organ prolapse quantification stage 2 or greater. Fifty women underwent rectocele repair utilizing porcine dermis graft (group 1) and 50 women underwent a site-specific repair of the rectovaginal fascia (group 2). The same questionnaire was administered to all subjects 6 months after surgery. The two groups were similar in age, race, parity, prior hysterectomy, and postmenopausal hormone use. Preoperative sexual function scores were similar in the two groups (group 1 81.4 ± 7.3 and group 2: 83.6 ± 8.2, p = 1.0). Six months after surgery, PISQ scores in group 1 significantly increased (score increase 19.9 ± 2.2, p = 0.01). The mean increase in PISQ scores for group 2 was 6.9 ± 3.1 (p = 0.08). When compared with group 2, subjects undergoing rectocele repair with porcine dermis graft scored significantly higher on the PISQ 6 months after surgery (group 1 101.3 ± 6.4 and group 2 89.7 ± 7.1, p = 0.01). We conclude that rectocele repair using porcine dermis graft is associated with improved sexual functioning when compared with site-specific rectovaginal fascia repair.     

The Utility of Intraoperative Evaluation of Sentinel Lymph Nodes in Breast Cancer

Background In breast cancer treatment, intraoperative sentinel lymph node (SLN) evaluation is used to identify patients who may potentially benefit from immediate completion of axillary lymph node dissection. Methods Prospectively collected breast cancer registry data identified 516 SLN biopsies between January 2003 and December 2005. Intraoperative evaluation (IE) of the SLNs was performed in 479 axillae. Final pathology by hematoxylin and eosin and, for negative nodes, by immunohistochemical stains was compared with the IE result. The effect of IE and final pathology on surgical treatment was examined. Results The sensitivities for IE of N0(i+) (n = 39), N1mi (n = 41), and N1a–3a (n = 89) metastases were 0%, 5%, and 63%, respectively. The specificity was 99.7%. IE identified 57 (44%) of SLN-positive (N1mi and N1a–3a) axillae, thus resulting in synchronous axillary lymph node dissection for those patients. Reoperation for false-negative IEs (N1mi or N1a–3a with negative IE) occurred in only 27 axillae (39%). Conclusions IE of SLNs has adequate sensitivity and excellent specificity. In addition to allowing patients to benefit from synchronous surgery, IE helped patients to receive care in concordance with recommended practice guidelines. The false-negative IE of SLNs highlights uncertainty with the clinical significance of axillary nodal staging when only small amounts of metastatic disease are identified in the axilla.     

Undifferentiated Sex Cord—Stromal Tumor in a Young Adult

Undifferentiated sex cord-stromal tumor in post-puberty male is extremely rare. There were only three reported cases in the literature. We reported a 19-year-old patient presented with an asymptomatic right testicular nodule with normal level of serum marker for germ cell tumor. Excisional biopsy and subsequent orchidectomy was preformed and the final pathology supported the diagnosis of undifferentiated sex cord-stromal tumor. He was then put on regular surveillance with no adjuvant therapy given. He remained disease free 18 months after the operation. A summary of the literatures and discussion on the management of this rare tumor was provided.     

Sexual function following surgery for urodynamic stress incontinence

The objective of this study was to compare sexual function in women before and after surgery for urodynamic stress incontinence in the absence of pelvic organ prolapse. This was a prospective questionnaire survey. Fifty-four women undergoing surgery (tension-free vaginal tape/tension-free vaginal tape-obturator) for urodynamic stress incontinence with no evidence of detrusor overactivity or concomitant prolapse were assessed preoperatively and 6 months post operatively. Assessment was based on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ), the International Consultation on Incontinence Questionnaire (ICIQ) and the Patient Global Impression of Improvement. Paired t-tests were used for comparing pre- and post-op scores and unpaired t-tests for comparing observations between groups. Spearman’s rank correlation was used for testing whether two numerically scored items were related, and McNemar test was used to compare pre- and postoperative responses to individual questions. ICIQ scores showed significant improvement after surgery (p < 0.001). Women completing PISQ were significantly younger (mean = 54) than those who did not (mean = 65; p < 0.001). The total PISQ score was better postoperatively (preoperative = 87.2, postoperative = 92.7; p < 0.001), with improvements in both the physical (preoperative = 31.0, postoperative = 35.2; p < 0.001) and partner-related domains (preoperative = 18.8, postoperative = 19.9; p = 0.002) but no improvement in behaviour emotive domains (preoperative = 37.3, postoperative = 37.6; p = 0.70). There was a reduction in episodes of coital incontinence postoperatively (preoperatively = 16/54, postoperatively = 39/54; p < 0.002). Previous vaginal surgery, oestrogen status of respondents and hysterectomy status did not affect the PISQ. Surgical correction of stress incontinence is associated with an improvement in sexual function.     

Normative data on the Bonn Risk Index for calcium oxalate crystallization in healthy children

Bonn Risk Index (BRI) is being used for the assessment of urinary calcium oxalate (CaOx) crystallization. There are no published data regarding BRI during growth. The objective of this study was to establish age- and sex-dependent BRI values in healthy children and adolescents. A total of 1,050 Caucasian subjects aged 3–18 years (525 males, 525 females) without a history of kidney stone disease were enrolled in the cross-sectional study. The study group was divided into 15 ranges according to age, each comprising 70 subjects. Urinary ionized calcium [Ca²⁺] was measured using a selective electrode while the onset of spontaneous crystallization was determined using a photometer and titrating with 40 mmol/L ammonium oxalate (Ox²⁻). The calculation of BRI value was based on the ratio of [Ca²⁺] to the required amount of ammonium oxalate added to 200 ml of urine to induce crystallization. The median BRI was 0.26 1/L and the values of the 5th and 95th percentiles were 0.06 1/L and 1.93 1/L, respectively. BRI correlated positively with body-area-related BRI (1/L × 1.73 m²) (R = 0.18; P < 0.05), whereas a negative correlation was found between BRI and body weight (1/L × kg) (R = −0.85; P < 0.05). Neither sex nor age differences were detected in BRI across studied children and adolescents. The values of Bonn Risk Index were constant during growth and there was a limited influence of age and sex on BRI in children over 3 years of age. The BRI may be valuable in the evaluation of pediatric patients at risk for kidney stones, particularly if the BRI from stone formers is demonstrated to be higher than in normal children.     

Trends and Predictors for Vagotomy When Performing Oversew of Acute Bleeding Duodenal Ulcer in the United States

Background In the era of Helicobacter pylori treatment, the role of vagotomy in bleeding duodenal ulcers is debatable. National outcomes were evaluated to determine the current surgical treatment and use of vagotomy for bleeding duodenal ulcers. Methods Data from the Nationwide Inpatient Sample (NIS) were used from years 1999 to 2003. Patients were selected using diagnostic codes for acute duodenal ulcer bleed and procedure codes for simple oversew of a bleeding ulcer and vagotomy. Data were analyzed using multiple linear and logistic regression. Results Between 1999 and 2003, 100,931 patients with an acute bleeding duodenal ulcer were identified. Over time, there was a decrease in the number of acute bleeding ulcers (p = 0.027) and a decrease in the number of vagotomies (p = 0.027). A high co-morbidity index [odds ratio (OR), 0.60, p = 0.017], operation in the Midwest (OR 0.50, p < 0.001) and operation in the West (OR 0.68, p = 0.034) were predictive of no vagotomy during surgery for a bleeding duodenal ulcer. Conclusions A vagotomy is not commonly performed during surgical treatment of an acute bleeding duodenal ulcer. This variation in practice was not fully explained by patient characteristics. We must seek new evidence to determine the safety of combined medical and surgical management of this clinical problem. Presented at DDW/SSAT May 20–24, Los Angeles, California.     

Characterization of an in vitro intervertebral disc organ culture system

Intervertebral disc organ culture has the capacity to control mechanical and chemical boundary conditions while keeping the tissue largely intact, and allowing interventions that would be impossible or unethical on animal studies. Recent studies on ex vivo organ culture has mostly involved small animals, or been limited to development and validation studies. In this study, bovine caudal discs were used. The large animal model design ensures that sufficient tissue is available for measurement of multiple dependent variables on the same disc, and a similar aspect ratio, diffusion distance, composition and rate of proteoglycan synthesis to human lumbar discs. The first goal of this study was to refine a set of dependent variables capable of characterizing the response of the intervertebral disc to culturing and to develop a technique to measure cell viability in all three regions of the disc. The second goal was to use these variables to compare static and diurnal loading as a method of maintaining intervertebral disc structure, composition, and cell metabolism similar to the in vivo state. Static (0.2 MPa) and diurnal loading (0.1 and 0.3 MPa alternating at 12 h intervals) were applied and intervertebral discs were examined after 4 or 8 days with dependent variables including changes in geometry (disc height and diameter), composition (tissue water content, tissue proteoglycan content and proteoglycan content lost to the culture media), cell viability and metabolism (proteoglycan synthesis). Results indicate that there was a decrease in disc height and water content after culture regardless of culture duration or loading condition. Cell viability significantly decreased with culture duration in the inner annulus and nucleus; however, a significant reduction in cell viability for the diurnal versus static loading condition was only observed after 8 days in the nucleus region. No significant differences were seen in viability of the outer annulus region with time, or in any loading groups. We conclude that our system is capable of keeping bovine caudal discs alive for at least 8 days without significant changes in GAG content, or cell metabolism, and that static loading was slightly better able to maintain cell viability than diurnal loading. This system offers promise for the future studies on large intervertebral discs requiring measurements of multiple mechanical and biological dependent variables on the same tissue.