The appendix as ureteral substitute: a report of 10 cases

BackgroundUreteric replacement in part or in total is rarely needed in children. We present our experience in using the appendix to replace the ureter.MethodsA retrospective case note review was carried out at Sheffield Children's Hospital (UK), Ekta Institute of Child Health (Raipur, Chhattisgarh, India) and Christian Medical College Hospital (Vellore, India) of all cases of ureteric substitution using the appendix.ResultsTen patients were identified, operated in 2002–2007: seven males and three females with a median age of 2.5 years (range 2.5 months to 12 years). The reasons for ureteric replacement were traumatic ureteric avulsion (n = 1), congenital ureteric stenosis (n = 5), non-drainage following previous pyeloplasty for pelvi-ureteric junction obstruction (n = 3) and ureteric stricture following reimplantation for vesico-ureteric reflux (n = 1). The appendix was used in an anti-peristaltic manner in all cases, and in one case a transureteroureterostomy was performed. At a median follow up of 16 months (1–72 months), all the patients were well except one whose kidney function had deteriorated.ConclusionsTotal or partial replacement of the ureter using the appendix, even in the first year of life, preserved renal function in nine cases. Ureteric continuity can be successfully restored in children using the appendix.     

Insulin lispro low mixture twice daily versus basal insulin glargine once daily and prandial insulin lispro once daily in patients with type 2 diabetes mellitus requiring insulin intensification—a randomized phase IV trial: Indian subpopulation analyses

The aim of this study was to describe the efficacy and safety of two insulin intensification strategies in patients recruited in India with type 2 diabetes mellitus inadequately controlled on basal insulin glargine with metformin and/or pioglitazone. This multinational, open-label, randomized, parallel-arm, noninferiority, phase IV clinical trial evaluated insulin lispro low mixture (LM25) and basal insulin glargine administered with prandial insulin lispro (IGL) for 24 weeks. Patients were male and female, aged ≥18 to ≤75 years, with screening glycosylated hemoglobin (HbA_1c) concentration ≥7.5 to ≤10.5 % and fasting plasma glucose ≤121 mg/dL. The primary efficacy end point was change in HbA_1c from baseline to 24 weeks of treatment. Secondary efficacy end points included change in HbA_1c from baseline to 12 weeks and change in fasting blood glucose (FBG) from baseline to 12 and 24 weeks. Safety and tolerability were measured by treatment-emergent adverse events and the incidence, rate, and severity of hypoglycemic episodes. Of 81 patients randomized to LM25 (n?=?40) or IGL (n?=?41), 80 patients completed the trial and one patient discontinued due to subject decision. Mean (SD) change in HbA_1c from baseline to week 24 was ?1.2 % (1.11) for the LM25 group and ?1.0 % (1.18) for the IGL group. Safety profile, mean (FBG), glycemic variability, hypoglycemic episodes per patient-year, and health outcome measures were numerically similar between the two groups. The results of this post hoc analysis in an Indian subpopulation were consistent with results reported for the trial-level population and provide information to the consideration of LM25 as treatment option for intensification.     

Percutaneous MR imaging-guided transvascular access of mesenteric venous system: study in swine model

PURPOSE: To determine if, with use of magnetic resonance (MR) imaging guidance alone, transcaval puncture of the superior mesenteric vein (SMV) and/or portal vein is feasible with a percutaneous femoral vein approach. MATERIALS AND METHODS: The Institutional Animal Care and Use Committee approved the animal studies. Ten inferior vena cava (IVC)-SMV punctures were performed in six pigs. An active MR intravascular needle system was used for all transvascular punctures, and all procedures were performed with a 1.5-T MR unit. The needle was introduced via a 12-F femoral vein sheath and advanced into the IVC by using a real-time gradient-recalled-echo sequence (3.4/1.2 [repetition time msec/echo time msec], 45 degrees flip angle, and six to eight frames per second). Fast transverse spoiled gradient-recalled acquisition in the steady state (SPGR) (6.0/1.5, 60 degrees flip angle, one frame per second) was performed to confirm needle trajectory. The needle system was advanced under real-time MR imaging to puncture the SMV. The location of the needle tip was confirmed with a fast spin-echo sequence (1904/4.5, 36-cm field of view). A direct MR portogram was obtained after the administration of gadopentetate dimeglumine at a concentration of 25% with fast SPGR (6/1.3, 90 degrees flip angle, no section selection, three frames per second). Success was defined as entry into the mesenteric venous system without traversal of any retroperitoneal organs or adjacent vasculature. RESULTS: Successful MR imaging-guided IVC-SMV punctures were performed in all 10 procedures (100%). The needle was fully visualized as it traversed the retroperitoneum and entered the SMV. MR portograms were successfully obtained following all punctures through the needle. Conventional transverse MR imaging helped confirm that the needle did not traverse any retroperitoneal organs or vessels. CONCLUSION: With use of only MR imaging guidance and an active MR imaging intravascular needle system, the authors were able to successfully puncture the SMV from the IVC with direct visualization of the needle and all retroperitoneal structures.     

Sonographic findings of uterine rupture with expulsion of the fetus into broad ligament

We report the sonographic findings of a rare case of uterine rupture with extrusion of the fetus into the broad ligament during a second-trimester abortion. Sonography revealed the empty uterus with an indistinct defect on the side wall and the dead fetus lying outside, surrounded by a thin membrane. At surgery, the uterine rupture was confirmed with the fetus lying in the broad ligament. This study shows the importance of timely sonography in second-trimester abortion, enabling immediate management and preventing further complications.     

Intravitreal bevacizumab (Avastin) for post laser anterior segment ischemia in aggressive posterior retinopathy of prematurity

Aggressive posterior retinopathy of prematurity (formerly known as fulminate/type II/rush disease) occurs in zone 1 or posterior zone 2. Treatment involves extensive near confluent laser ablation of a large area of avascular retina. Anterior segment ischemia is a rare complication that can occur due to injury to the long posterior ciliary arteries in the horizontal meridians during aggressive posterior laser treatment. The outcome of this rare complication is very poor. This case describes a favorable outcome of intravitreal injection of bevacizumab (Avastin) in a case of anterior segment ischemia.     

Neurobehavioral disorders in children, adolescents, and young adults with Down syndrome

The term dual-diagnosis refers to a person with mental retardation and a psychiatric disorder. Most children with Down syndrome (DS) do not have a psychiatric or neurobehavioral disorder. Current prevalence estimates of neurobehavioral and psychiatric co-morbidity in children with DS range from 18% to 38%. We have found it useful to distinguish conditions with a pre-pubertal onset from those presenting in the post-pubertal period, as these are biologically distinct periods each with a unique vulnerability to specific psychiatric disorders. Due to the increased recognition that psychiatric symptoms may co-occur with mental retardation, and are not inextricably linked to cognitive impairment, these conditions are considered treatable, in part, under a medical model. Improvement in physiologic regulation, emotional stability, and neurocognitive processing is one of the most elusive but fundamental goals of pharmacologic intervention in these disorders.