Quality of life of pediatric patients with lower urinary tract dysfunction and their caregivers

The interest in quality of life (QoL) studies has increased as they are useful instruments to evaluate and compare medical care delivery and the impact of health interventions. The perception of QoL differs among individuals. Its characterization is especially difficult in the pediatric age group as each developmental stage presents specific demands. The prevalence of congenital lower urinary dysfunction is high and their management changes the daily routine of the patients and their families. In a cross-sectional study, we evaluated the QoL of 28 children and adolescents with urinary malformations and their caregivers using the Autoquestionnaire Qualité de Vie Enfant Imagé (AUQUEI) and Short-Form 36 (SF-36), respectively, and compared the results with 38 healthy control age-paired children/caregivers. Four questions were added to patients' questionnaire to evaluate issues related to their urological management. Our results show lower AUQUEI total scoring in the patients’ group (p < 0.0213, Fisher’s exact test), who also present problems in dealing with social aspects, such as being at classroom, manifest negative feelings in relation to diurnal urinary losses but seem to be well adapted to intermittent urethral catheterization. A tendency for worse QoL scores in the patients’ group caregivers was detected in the SF-36 pain and physical limitation domains.     

Surgical treatment of complications associated with the Angio-Seal vascular closure device

Vascular closure devices are used to provide quick hemostasis and early ambulation after percutaneous interventions. The Angio-Seal (AS) vascular closure device forms a mechanical seal by closing the puncture site located between a bioabsorbable anchor within the lumen and a collagen sponge on the adventitia. Although morbidities associated with AS are reportedly infrequent, even the slightest inaccuracy in device implantation may result in displacement of these device components, leading to sudden and severe complications. We report the surgical treatment of complications associated with the use of AS in four patients, including acute limb ischemia, pseudoaneurysm formation, significant hemorrhage, and hypovolemic shock. A common factor in all these cases was that the components of the AS device were displaced from their original site of implantation, stressing the importance of proper device placement. All patients underwent successful surgical vascular repair. Our report highlights the need for exercising extreme care during device implantation, and also the requirement for vigilant inspection for any associated vascular complications commencing immediately after device implantation. It is vital that these device components are actively looked for and removed during surgical exploration so as to prevent future complications.     

Defective differentiation of regulatory FoxP3+ T cells by small-intestinal dendritic cells in patients with type 1 diabetes

OBJECTIVE

The gut environment modulates the pathogenesis of type 1 diabetes (T1D), but how it affects autoimmunity toward pancreatic β-cells, a self-tissue located outside the intestine, is still unclear. In the small intestine, lamina propria dendritic cells (LPDCs) induce peripheral differentiation of FoxP3⁺ regulatory T (Treg) cells. We tested the hypothesis that the intestinal milieu impinges on human T1D by affecting differentiation of FoxP3⁺ Treg cells.

RESEARCH DESIGN AND METHODS

We collected duodenal biopsies of 10 T1D patients, 16 healthy subjects, and 20 celiac individuals and performed a fluorescent-activated cell sorter analysis to measure percentages of various immune cell subsets, including CD4⁺ and CD8⁺ T cells, NK cells, γδ T cells, CD103⁺CD11c⁺ LPDCs, and CD4⁺CD25⁺FoxP3⁺CD127⁻ Treg cells. In parallel, we assessed the tolerogenic function (i.e., capacity to induce differentiation of FoxP3⁺ Treg cells) by LPDCs of T1D patients and control subjects.

RESULTS

Our analysis revealed a significant reduction in the percentage of intestinal CD4⁺CD25⁺FoxP3⁺CD127⁻ Treg cells in T1D patients compared with healthy subjects (P = 0.03) and celiac individuals (P = 0.003). In addition, we found that LPDCs from T1D patients completely lacked their tolerogenic function; they were unable to convert CD4⁺CD25⁻ T cells into CD4⁺CD25⁺FoxP3⁺CD127⁻ Treg cells.

CONCLUSIONS

Our data indicate that T1D patients have a reduced number of intestinal FoxP3⁺ Treg cells as a result of their defective differentiation in the gut. These findings suggest that intestinal immune regulation is not only calibrated to tolerate commensal bacteria and food components but also is instrumental in maintaining immune tolerance toward pancreatic β-cells and preventing T1D.Type 1 diabetes (T1D) is a destructive islet β-cell specific autoimmune disease resulting from a yet undefined interaction between genetic and environmental factors (1). A dramatic increase in T1D incidence was recorded in most developed countries in the past 40 years (e.g., a threefold increase in Western countries) (2,3). The steady and rapid increase in T1D incidence cannot be ascribed to genetic variations and, thus, it must be related to environmental changes. Environmental agents such as viral infections (i.e., enteroviruses and rotaviruses) (4,5), reactions to dietary antigens (i.e., cow’s milk and gluten) (6–8), and microbiota alterations (9) that act at the intestinal level have been observed in association with, or as risk factors for, the development of T1D. The observation that development of clinical diabetes in patients is preceded by intestinal alterations such as increased permeability, immune activation, and ultrastructural abnormalities of the epithelium (10–16) provides additional evidence on the crucial role of the gut environment in human T1D. Although existing evidence is suggestive of a causative link between the gut milieu and the pathogenesis of T1D, it is still unclear whether and by which mechanism(s) a dysfunction in the intestine promotes autoimmunity elsewhere (i.e., in the pancreatic β-cells) and if it does, how this process occurs.Important immune regulatory mechanisms reside in the intestinal mucosa. FoxP3⁺ regulatory T (Treg) cells, a Treg cell subset that is instrumental to controlling T1D (17), arise centrally in the thymus and peripherally in the gut (18). Specifically, lamina propria CD103⁺CD11c⁺ dendritic cells (LPDCs) are responsible for extrathymic FoxP3⁺ Treg cell development and expansion (18,19). Considering the key immune regulatory role of FoxP3⁺ Treg cells, it is clear that their defective peripheral differentiation in the gut could lead to failure of self-tolerance and autoimmune disease, particularly in tissues such as pancreatic islets and lymph nodes that are directly connected to the intestinal mucosa and gut-associated lymphoid tissue (20).Here we demonstrate that the extrathymic differentiation of FoxP3⁺ Treg cells by gut-resident CD103⁺CD11c⁺ dendritic cells (DCs) is selectively impaired in humans affected by T1D. Our findings indicate that organ-specific autoimmune diseases such as T1D could be initiated and possibly maintained by virtue of changes in peripheral FoxP3⁺ Treg cell differentiation and/or expansion in the gut.     

Immune response to perforated and partially demineralized bone allografts

Immune responses have been shown to be involved in the pathogenesis of clinical complications of cortical bone allografts. In an attempt to reduce the immunogenicity of these allografts, we evaluated cortical bone allografts modified by laser perforation and partial demineralization transplanted orthotopically into sheep tibiae. The recipient animals were divided into three groups, of eight animals each, according to the type of cortical allograft that was transplanted: group 1, no treatment (control); group 2, demineralization only; and group 3, laser perforation and partial demineralization. All animals were tissue-typed by biochemical definition of MHC class I molecules, using unidimensional isoelectric focusing and Western blotting. Mismatches of donors and recipients were assessed by testing samples of each donor and recipient pair in parallel and by comparing their individual bands. Donor-specific alloantibodies were detected by a similar technique, using an enzyme-linked immunosorbent assay (ELISA) format. Negative controls were included in all tests. All grafts were poorly immunogenic, whether they were untreated, processed by partial demineralization, or processed by both laser perforation and partial demineralization. Only two recipient animals showed a transient, antibody-mediated donor-specific immune response. One of these animals had received a control allograft, whereas the other animal had received a laser-perforated and partially demineralized bone allograft. All of the grafts in this study, including control grafts, were stripped of soft tissues and their bone marrow was removed; cellular sources of alloantibody stimulation may have been eliminated by these processes. The results of this study suggest that immune responses to bone allografts may be reduced by removing the bone marrow and adjacent soft tissues. The processing of cortical bone allografts by laser perforation and partial demineralization appeared to have little effect on immune responses.     

Indications, results and techniques of permanent prostate brachytherapy for localized prostate cancer

Introduction and objectiveProstate brachytherapy is a first-line therapeutic approach for localized prostate cancer in selected patients. We present our experience in brachytherapy and a thorough review of the literature.Materials and MethodsA review of the literature and evaluation of patient’s selection was done. Furthermore the implantation technique, oncological results according to the different risk groups and acute and chronic complications were also analyzed.ResultsThe biochemical relapse-free 10 year survival rate was 87-96% in low risk tumours and 63-86% in intermediate risk tumours. A total of 3-24% underwent urinary retention that required TURP in 0-8,7%. Other complications were urinary incontinence in 0-6,7%, proctitis in 0-15,5%, erectile dysfunction in 6,3-30%, rectal ulcer/fistula in 0-5,4%.ConclusionsProstate brachytherapy is a safe and effective treatment in low and intermediate risk patients with prostate cancer.     

Evaluation of elbow and shoulder problems in professional baseball pitchers

When a professional athlete injures an elbow or shoulder, the uninjured joint must receive as much attention as the injured joint. Is there a relationship between injury of one joint and subsequent injury of the other joint? In the prospective study reported here, we created a database (a) to determine whether injury to one joint was more likely to result in a problem with the other joint and (b) to analyze for trends and correlations. A survey was administered to all pitchers on a professional baseball team to collect data about shoulder and elbow problems during their careers. Eighty-four pitchers (737 seasons of experience, 52 index injuries) were evaluated. Of the injured players, 27 were treated surgically. Risk for later injury was 4.6 times larger for players who had an index surgery than for those who had not. Of the players who had ulnar collateral ligament (UCL) reconstruction, 42% later sustained a shoulder injury. No player with rotator cuff surgery sustained a subsequent elbow or shoulder injury. There were significantly more upper extremity injuries with right-handed throwers. An elbow injury was more likely to result in shoulder problems, specifically after UCL reconstruction. Players who required surgery were almost 5 times more likely to have a later injury or surgery than players who did not require surgery.     

A biomechanical comparison of scaphoid fixation with bone grafting using iliac bone or distal radius bone

PURPOSE: Although many scaphoid fractures may be treated by immobilization, complex scaphoid fractures generally require bone grafting with internal fixation. A preferred source of bone graft for scaphoid grafting is the iliac crest. Donor site morbidity from iliac crest harvest, however, is a known complication, and the comparable strength and osteogenic properties of bone harvested from other sites are unclear. To this end, we have conducted a cadaveric comparative investigation of the strength of scaphoid nonunions with bone graft and internal fixation using either iliac crest bone or distal radius bone. METHODS: Ten paired, human, fresh-frozen cadaveric wrists were used to create a standard midwaist wedge osteotomy into which identically shaped distal radius or iliac crest bone wedges were internally fixed using headless compression screws. After bone density and computed tomography assessment of the bones, benchtop biomechanical testing was conducted to compare the strength of the scaphoids after iliac and distal radius grafting, at 2-mm displacement, and at failure. RESULTS: Analysis of scaphoid length, width, height, weight, density, and screw placement revealed no statistical differences between both bone graft groups. Although not significant, scaphoid nonunions grafted with distal radius bone evidenced a reduced load (3.23 +/- 0.26 Nm) to 2-mm displacement compared with iliac crest bone (5.97 +/- 0.68 Nm). Similarly, though not significant, scaphoids grafted with distal radius bone showed a reduced load (4.18 +/- 0.30 Nm) to failure compared with iliac crest bone grafting (6.42 +/- 0.66 Nm). Although no significance was found between the 2 grafting methods, a trend toward greater strength in the iliac crest graft group was observed. CONCLUSIONS: Given the comparable biomechanical strength shown between iliac and distal radius bone in this study and the simplified surgical technique of distal radius harvesting, the data justify use of distal radius bone as a viable alternative donor source in scaphoid fracture treatment.     

A randomized controlled trial of the effect of spironolactone on left ventricular mass in hemodialysis patients

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Re‐examination of the Lymphocytotoxic Crossmatch in Liver Transplantation: Can C4d Stains Help in Monitoring?

C4d-assisted recognition of antibody-mediated rejection (AMR) in formalin-fixed paraffin-embedded tissues (FFPE) from donor-specific antibody-positive (DSA+) renal allograft recipients prompted study of DSA+ liver allograft recipients as measured by lymphocytotoxic crossmatch (XM) and/or Luminex. XM results did not influence patient or allograft survival, or cellular rejection rates, but XM+ recipients received significantly more prophylactic steroids. Endothelial C4d staining strongly correlates with XM+ (<3 weeks posttransplantation) and DSA+ status and cellular rejection, but not with worse Banff grading or treatment response. Diffuse C4d staining, XM+, DSA+ and ABO- incompatibility status, histopathology and clinical-serologic profile helped establish an isolated AMR diagnosis in 5 of 100 (5%) XM+ and one ABO-incompatible, recipients. C4d staining later after transplantation was associated with rejection and nonrejection-related causes of allograft dysfunction in DSA- and DSA+ recipients, some of whom had good outcomes without additional therapy. Liver allograft FFPE C4d staining: (a) can help classify liver allograft dysfunction; (b) substantiates antibody contribution to rejection; (c) probably represents nonalloantibody insults and/or complete absorption in DSA- recipients and (d) alone, is an imperfect AMR marker needing correlation with routine histopathology, clinical and serologic profiles. Further study in late biopsies and other tissue markers of liver AMR with simultaneous DSA measurements are needed.