Management of post-traumatic arterial priapism in children: Presentation of a case and review of the literature

In this article, a 9-year-old boy with arterial priapism is presented. The patient was managed with the conservative measures including imipramine hydrochloride and a favorable outcome was achieved after 2 months of follow-up. The pathophysiology, diagnostic tools and treatment alternatives are discussed.     

Objective and early diagnosis of chylous fistula in the postoperative period.

OBJECTIVE: The study goal was to evaluate whether quantitative analysis of neck drainage contents is an important parameter of objective and early diagnosis of chylous fistula (CF) in the postoperative period. STUDY DESIGN AND SETTING: We prospectively evaluated 103 consecutive neck dissections during a 2-year period at a tertiary academic referral center. Six of the patients (5.8%) had CF. The data obtained from the patients with CF were matched with normal data obtained from patients without CF. RESULTS: A statistically significant difference was found between total drainage volumes of the patients with and those without CF (P < 0.05). In almost all patients with CF, drainage levels of triglycerides and cholesterol on postoperative day 1 were higher than serum levels. The difference between the drainage levels of triglycerides and cholesterol of the patients with and without CF was highly significant (P < 0.001). CONCLUSIONS: Serum and drainage levels of triglycerides and cholesterol on postoperative day 1 can be used as objective and early predictive parameters of CF.     

Extra-axial cavernomas of the cerebellopontine angle involving the seventh-eighth nerve complex

Extra-axial cavernous malformations (cavernomas) of the central nervous system are rare. Although occasional cases located in different parts of the central nervous system have been reported, only five cases of extra-axial cavernous malformation in the cerebellopontine angle are to be found. We describe here two additional cases of cavernomas in the cerebellopontine angle causing hearing loss and tinnitus presenting as vestibular schwannoma. Electronic Publication     

The use of low-dose cyclophosphamide followed by AZA/MMF treatment in childhood lupus nephritis

Cyclophosphamide (CYC) has been the landmark in the treatment of lupus nephritis. However, long-term treatment with CYC is associated with significant side effects. We aimed to evaluate the efficacy of short-term intravenous (IV) CYC treatment as a remission induction treatment followed by azathioprine (AZA) or mycophenolate mofetil (MMF) as a maintenance treatment. Twenty patients (18 girls) with biopsy-proven class III (5) and IV (15) lupus nephritis were included in to the study. Detailed clinical and laboratory data and patient outcomes were evaluated. All patients received three methylprednisolone (MP) IV pulses, followed by oral prednisone 0.5−1 mg/kg per day and one IV pulse of CYC per month for 6 months. Azathioprine was started as a remission-maintaining treatment. In ten of 20 patients, treatment was switched to MMF. The mean age at the time of diagnosis was 16.11 ± 3.49 years, and the mean duration of follow-up was 49.6 ± 27 months. Fourteen patients (70%) had complete remission, three (15%) had partial remission, one (5%) continued to have active disease, and two (10%) progressed to end-stage renal disease. Nine of the patients (45%) with complete remission had received AZA, and switching to MMF increased complete remission rate (additional five patients; 25%). In conclusion, short-term (6-month) IV bolus CYC treatment followed by AZA is a safe and effective treatment in children with severe lupus nephritis, and using MMF increases remission rate in resistant cases.     

The correlation between metabolic syndrome and prostatic growth in patients with benign prostatic hyperplasia

OBJECTIVES: To evaluate the relationship between metabolic syndrome and annual prostatic growth rates in benign prostatic hyperplasia (BPH) patients. METHODS: The 78 BPH patients with lower urinary tract symptoms included in this prospective study were divided into two groups according to whether they had a diagnosis of metabolic syndrome. This diagnosis was made according to the most recent consensus report of the National Cholesterol Education Program's Third Adult Treatment Panel. Blood pressure, body weight, body height, and waist and hip circumferences were measured. The body mass index (BMI) and waist-to-hip ratio (WHR) were calculated. Biochemical analyses including serum glucose, total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), insulin, and prostate-specific antigen (PSA) were performed. Total prostate (TP) volume and transitional zone (TZ) volume were measured by transrectal ultrasound. Annual TP and TZ growth rates were calculated. RESULTS: BPH patients with metabolic syndrome (first group) had significantly higher median body weight, BMI, serum glucose, serum triglyceride, and PSA levels but lower serum HDL-C level, compared with BPH patients without metabolic syndrome (second group, p<0.05). Median annual TP growth rate (1.0 ml/yr) and median annual TZ growth rate (1.25 ml/yr) were significantly higher in the first group versus the second group (0.64 ml/yr and 0.93 ml/yr, respectively, p<0.05). CONCLUSIONS: The present study demonstrates a further increase in prostate growth in BPH patients with metabolic syndrome. Future studies are needed to confirm our results and to explain underlying mechanisms.     

Predictors of marijuana use in adolescents before and after licit drug use: examination of the gateway hypothesis

OBJECTIVE: The authors investigated whether the transition from licit drug use to marijuana use is determined by particular risk factors, as specified by the gateway hypothesis. They also evaluated the accuracy of the "gateway sequence" (illicit drug use following licit drugs) for predicting a diagnosis of substance use disorder. METHOD: Boys who consumed licit drugs only (N=99), boys who consumed licit drugs and then transitioned to marijuana use (gateway sequence) (N=97), and boys who used marijuana before using licit substances (alternative sequence) (N=28) were prospectively studied from ages 10-12 years through 22 years to determine whether specific factors were associated with each drug use pattern. The groups were compared on 35 variables measuring psychological, family, peer, school, and neighborhood characteristics. In addition, the utility of the gateway and alternative sequences in predicting substance use disorder was compared to assess their clinical informativeness. RESULTS: Twenty-eight (22.4%) of the participants who used marijuana did not exhibit the gateway sequence, thereby demonstrating that this pattern is not invariant in drug-using youths. Among youths who did exhibit the gateway pattern, only delinquency was more strongly related to marijuana use than licit drug use. Specific risk factors associated with transition from licit to illicit drugs were not revealed. The alternative sequence had the same accuracy for predicting substance use disorder as the gateway sequence. CONCLUSIONS: Proneness to deviancy and drug availability in the neighborhood promote marijuana use. These findings support the common liability model of substance use behavior and substance use disorder.     

Second-Look Operation for Unresectable Pancreatic Ductal Adenocarcinoma at a High-Volume Center

Background The value of re-exploration for pancreatic ductal adenocarcinoma after the initial diagnosis of unresectability is unclear. Methods In this study, we analyzed 33 patients who were re-explored after an initial diagnosis of unresectability. Results At the time of reoperation, a resectable tumor was found in 18 patients: therefore, 15 pancreaticoduodenectomies, two total pancreatectomies and one left resection were performed with three vascular resections. Morbidity and mortality rates for the cohort were 6/33 and 1/33, without significant differences between resectable and nonresectable patients. Length of stay, duration of operation, and blood loss were significantly increased in the resection group. Kaplan–Meier survival analysis demonstrated increased median survival for resected patients (1078 days after the initial operation versus 547 days in the group of unresectable patients; p = 0.018). Analysis of the reasons against initial resection showed that, if the patients had been sent to a tertiary referral center for pancreatic surgery, a different decision in favor of resection would probably have been made in 14 out of 33 patients. A review of 10 published reports on reoperation for pancreatic cancer revealed results comparable to our study in terms of low morbidity and mortality as well as a survival benefit. Conclusions Reoperation for pancreatic ductal adenocarcinoma that is initially deemed unresectable can be safely performed in a selected group of patients by experienced surgeons, supporting the concept of patient centralization in pancreatic surgery. Resection at the second operation may confer a survival benefit even when the initial findings preclude a potentially curative approach.     

Does stone dimension affect the effectiveness of ureteroscopic lithotripsy in distal ureteral stones?

Objective To investigate whether stone dimension is a restrictive factor for ureterorenoscopic procedures. Materials and methods A group of 416 patients who had undergone ureterorenoscopic pneumatic lithotripsy (URS-PL) for lower ureteral stones between January 1999 and June 2006 in our clinic had been evaluated retrospectively. Two hundred and seventy (270, 64.9%) patients were men and 146 (35.1%) were women. The mean age of the patients was 36.61 (±12.43) years. Patients were grouped according to stone dimension; 193 patients with stones smaller than 1 cm being group 1 and 223 patients with stones ≥1 cm in dimension being group 2. Stone-free rate, operative time and rate of complications of the groups were compared. Pearson’s correlation test, χ² test, Fischer’s exact test and Student’s t-test were used for the statistical analysis. The p value was accepted as being meaningful if p < 0.05. Results For group 1, the mean operative time was 39.19 (±18.33) min. Proximal stone migration in five and false passage formation in three patients was observed. Three patients were stone-free after a second session of URS-PL. The cumulative stone-free rate was 97.4% (188/193). For group 2, the mean operative time was 48.5 (±11.31) min. About 208 (93.27%) patients were stone-free after the first session and an additional eight patients became stone-free after the second session of URS-PL. False passage, ureteral perforation, ureteral avulsion and stricture were observed in four, six, one and one patients, respectively. No proximal stone migration was observed. The cumulative stone-free rate was 96.86% (216/223). Conclusions The effectiveness of ureterorenoscopy (URS) in the treatment of distal ureteral stones was independent of stone dimension. However, the operative time was longer and the rate of perforation was higher in stones with a diameter ≥1 cm. On the other hand, the migration rate was higher in stones <1 cm in diameter. Generally speaking, there was no meaningful effect of stone dimension on complication rates.     

Treatment of humeral shaft non-unions by the Ilizarov method

Thirty-five humeral shaft non-unions treated by the Ilizarov external fixator were studied after an average of 39 months. Bone union was achieved in all but one. The mean time to union was 5.5 months (range: 3-10 months). Major pin tract problems leading to removal of the Schanz screws occurred in three patients. A radial nerve palsy developed in three patients, two recovered spontaneously and one was treated with a triple tendon transfer.     

Anterior urethral valve as a cause of end-stage renal disease

Although posterior urethral valves are predominant as a cause of obstructive uropathy in children, anterior urethral valves may also appear as the underlying etiologic factor in end-stage renal disease that results from obstruction. Two cases are presented of anterior urethral valve patients that were admitted with end-stage renal disease. The first case was successfully treated with diverticulectomy and urethral reconstruction in preparation for renal transplantation. The second case, however, had been on cystostomy drainage for 6 years and also had a contracted bladder. A more extensive lower urinary tract reconstruction was delayed. Children with poor stream and recurrent infections should be evaluated carefully and anterior urethral valve or diverticula should be considered in differential diagnosis of obstructive lesions.