STRATEGIES FOR RECONSTRUCTION AFTER UNSUCCESSFUL OR UNSATISFACTORY PRIMARY TREATMENT OF PATIENTS WITH BLADDER EXSTROPHY OR INCONTINENT EPISPADIAS

PURPOSE: Following unsuccessful or unsatisfactory primary treatment in patients with the epispadias/exstrophy complex, the options for a surgical solution to preserve the upper urinary tract, to achieve complete continence, and to reconstruct the external and female internal genitalia are limited. We reviewed the records of the patients treated at our institution to determine a surgical compromise between ingenious operative constructions and patient desires, both of which are secondary to stabilization of renal function. MATERIALS AND METHODS: From 1967 to December 1997, 128 patients with bladder exstrophy/epispadias complex were treated, of 80 whom had received previous unsuccessful or unsatisfactory treatment. Of these patients 72 were followed for an average of 22.4 years after the first surgical intervention. There were 40 patients referred to our institution after primary bladder closure and bladder neck reconstruction, 10 after rectal bladder, 7 after ureterosigmoidostomy and 5 after incontinent diversion. RESULTS: At the latest followup 19 patients had a rectal reservoir, 38 an ileocecal pouch, 12 a conduit diversion and 3 an augmented Young-Dees procedure. The upper urinary tract remained stable in 95% of the renal units with rectal reservoir, 95% with ileocecal pouch, 96% with a colonic conduit and 100% with an augmented Young-Dees procedure. Day and night continence was achieved in 95% of the patients with a rectal reservoir and 97% of those with an ileocecal pouch were continent, whereas only 2 of the 3 patients with an augmented Young-Dees procedure were continent. Of the women 16 were satisfied with the cosmetic results and 6 delivered 8 children by cesarean section. Only 1 man was dissatisfied with the final cosmetic result. All adults but 1 engaged in sexual intercourse. CONCLUSIONS: The first operative intervention in patients with bladder exstrophy/epispadias complex determines their fate. After failure of primary treatment, the upper urinary tract must be stabilized. In patients with severely impaired renal function the colonic conduit is our method of choice while in those with a normal or slightly dilated upper urinary tract and intact anal sphincter we performed a rectal reservoir. In the remaining patients an ileocecal pouch guarantees continence day and night. The results of genital reconstruction are satisfactory.     

Tracking Diabetes: New York City's A1C Registry

Context: In December 2005, in characterizing diabetes as an epidemic, the New York City Board of Health mandated the laboratory reporting of hemoglobin A1C laboratory test results. This mandate established the United States’ first population‐based registry to track the level of blood sugar control in people with diabetes. But mandatory A1C reporting has provoked debate regarding the role of public health agencies in the control of noncommunicable diseases and, more specifically, both privacy and the doctor‐patient relationship. Methods: This article reviews the rationale for adopting the rule requiring the reporting of A1C test results, experience with its implementation, and criticisms raised in the context of the history of public health practice. Findings: For many decades, public health agencies have used identifiable information collected through mandatory laboratory reporting to monitor the population's health and develop programs for the control of communicable and noncommunicable diseases. The registry program sends quarterly patient rosters stratified by A1C level to more than one thousand medical providers, and it also sends letters, on the provider's letterhead whenever possible, to patients at risk of diabetes complications (A1C level >9 percent), advising medical follow‐up. The activities of the registry program are similar to those of programs for other reportable conditions and constitute a joint effort between a governmental public health agency and medical providers to improve patients’ health outcomes. Conclusions: Mandatory reporting has proven successful in helping combat other major epidemics. New York City's A1C Registry activities combine both traditional and novel public health approaches to reduce the burden of an epidemic chronic disease, diabetes. Despite criticism that mandatory reporting compromises individuals’ right to privacy without clear benefit, the early feedback has been positive and suggests that the benefits will outweigh the potential harms. Further evaluation will provide additional information that other local health jurisdictions may use in designing their strategies to address chronic disease.     

Influence of external cardiac pacing on cerebral oxygenation measured by near‐infrared spectroscopy in children after cardiac surgery

Background: The brain of children in the early period after repair of congenital heart defects with cardiopulmonary bypass (CPB) may be more vulnerable to hemodynamic changes because of impaired cerebral autoregulation. During postoperative testing of the external temporary safety pacer, we performed desynchronizing ventricular pacing (VVI) while monitoring cerebral oxygenation using near‐infrared spectroscopy (NIRS). Methods: We prospectively investigated 11 children (6 girls, 5 boys). Mean age was 6.1 months (±3.8 months) and mean weight: 5.3 kg (±1.5 kg). We performed measurements at four study steps: baseline I, VVI pacing, baseline II and atrial pacing (AOO) to exclude effects of higher heart rate. We continuously measured the effects on hemodynamic and respiratory parameters as well as on cerebral tissue oxygenation index (TOI). Hemoglobin difference (HbD) was calculated as a parameter for cerebral blood flow (CBF). Results: Ventricular pacing leads to a significant decrease in arterial blood pressure and central venous saturation accompanied by an immediate and significant decrease in TOI (63.3% ± 7.6% to 61.5% ± 8.4% [P < 0.05]) and HbD (0.51 ± 1.8 μmol·l⁻¹ to −2.9 ± 4.7 μmol·l⁻¹ [P < 0.05]). Conclusion: Cardiac desynchronization after CPB seems to reduce CBF and cerebral oxygenation in children.     

THE ROLE OF PROLACTIN IN THE RESTORATION OF OVARIAN FUNCTION DURING THE EARLY POST-PARTUM PERIOD IN THE HUMAN FEMALE

Serial plasma levels of prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), 17β-oestradiol (E) and progesterone (P) were determined by radioimmunoassay in ten healthy women during late pregnancy and puerperium until the occurrence of the first menstruation, at which moment an endometrial biopsy was taken. Prolactin concentrations, which were high during late pregnancy and the early post-partum period, declined thereafter but remained above 30 ng/ml plasma during the period of breast-feeding. FSH was nearly undetectable during late pregnancy and the first week post-partum but returned to normal levels between days 7 and 18. Thereafter relatively high FSH levels were found during the period of hyperprolactinaemia. Following clearance of human chorionic gonadotrophin (HCG) during the first 2 weeks post-partum, LH remained below the normal cyclic range in all cases for at least 28 days. Placental E and P were fully cleared within 7 days. In spite of relatively high levels of FSH, E remained low as did LH during the period of hyperprolactinaemia. Thereafter E increased followed by an increase of LH, suggesting a positive feedback of E on LH release. The first menses observed in five subjects during the study were preceded by (subnormal P levels for a relatively short period although the endometrial biopsies showed only late proliferative changes.     

The Clinical Utility of Entrainment Pacing

Entrainment mapping is an important concept in electrophysiology that allows clinicians to characterize and treat reentrant arrhythmias. Entrainment mapping has been particularly useful for the treatment of atrial flutter, reentrant atrial tachycardias, and scar-related ventricular tachycardia. In this article, we outline the conduction properties of reentrant rhythms that permit entrainment mapping to be a useful technique. In addition, we highlight the differences between manifest and concealed entrainment. Finally, we describe useful strategies for diagnosing and treating atrial flutter and ventricular tachycardia.     

Direct Recording of Concealed Ventricular Extrasystoles Producing Pacer Inhibition

We report a case of concealed extrasystoles recorded from a pacing lead. The concealed extrasystoles were observed with right ventricular pacing, biventricular unipolar, and biventricular bipolar pacing. The simultaneous surface EKG did not show manifest ventricular extrasystoles with the concealed intracardiac potentials. This case highlights a cause of oversensing that has been theoretically reported in the literature but never directly observed.     

VASECTOMY REVERSAL ASSOCIATED WITH INCREASED REACTIVE OXYGEN SPECIES PRODUCTION BY SEMINAL FLUID LEUKOCYTES AND SPERM

Purpose

Reactive oxygen species, which are primarily produced by leukocytes, are generally detrimental to sperm. High reactive oxygen species levels are found in men with abnormal sperm function. Since men often have poor sperm characteristics and infertility after vasectomy reversal, fertile men to determine if reactive oxygen species were elevated in the former group.

Materials and Methods

We studied semen samples of men with proved fertility (39) and those with previously proved fertility who had undergone vasectomy reversal (45). The presence of leukocytes was determined by Bryan-Leishman staining. Reactive oxygen species endogenous activity was monitored by luminol dependent chemiluminescence in washed cells, including all cells in the semen, and Percoll density gradient purified sperm.

Results

After vasovasostomy men had significantly lower sperm concentration, motility and computerized motility measurements than fertile men. Mean reactive oxygen species in washed seminal cells after vasovasostomy was 684 relative light units per second compared to 49 for fertile controls (p <0.0001). Density gradient purified sperm had 53 and 0.64 relative light units per second, respectively (p <0.0001). When men with leukocytospermia were excluded from analysis, differences between the groups remained, although 9 times more reactive oxygen species were detected in men after vasectomy reversal with than those without leukocytes in semen.

Conclusions

Higher levels of reactive oxygen species are found in washed seminal cells and purified sperm after vasectomy reversal than in those of fertile men. Although leukocytes are probably a significant source of reactive oxygen species in these groups, they may not account for all of the increased reactive oxygen species after vasovasostomy. Low motility after vasectomy reversal may be related to the detrimental effects of reactive oxygen species produced by leukocytes or sperm, even in men without clinical leukocytospermia.     

TRIANGULATION END-TO-SIDE VASOEPIDIDYMOSTOMY

Purpose

A technique and the preliminary results of triangulation vasoepididymostomy are described.

Materials and Methods

Triangulation vasoepididymostomy is performed by placing 3 double-armed 10-zero nylon sutures into the epididymis so that each suture forms 1 side of a triangle. An opening in the tubule is made between the sutures and they are brought inside-out, invaginating the epididymal tubule into the vas deferens.

Results

Triangulation end-to-side vasoepididymostomy was performed bilaterally in 12 men, and sperm was found in the postoperative ejaculate of 11 (92%). Operative time was 156 +/− 14 minutes.

Conclusions

Triangulation vasoepididymostomy is reasonably successful in restoring sperm to the ejaculate and should be considered as an alternative method of vasoepididymostomy.