Somatostatin infusion withdrawal in the diagnosis of childhood growth hormone deficiency

OBJECTIVE: An evaluation of growth hormone (GH) testing for GH deficiency (GHD) in childhood is confounded by the lack of a world-wide consensus on the definition of GHD. Although a single GH test remains the most powerful biochemical tool in the evaluation of a child with growth failure, the test remains far from ideal. Withdrawal of somatostatin (SS) infusion is followed by a rebound rise of GH thought to be mediated by endogenous GH-releasing hormone (GHRH) function. This study was designed to compare the GH response to 90 min SS infusion in children with normal GH secretion versus children with GH deficiency. METHODS: Ten children with GHD and 10 healthy controls (NC) have been evaluated for GH response to somatostatin infusion withdrawal (SSIW) and compared with response of two provocative tests, glucagon plus propranolol test and L-Dopa test. All children received constant infusion of somatostatin for 90 min (3 microg/kg per h, Stilamin, Serono, Aubonne, Switzerland). In order to determine GH, blood samples were obtained 90 min before the SS infusion and 0, 15, 30, 45, 60, 75, and 90 min after the cessation of infusion. RESULTS: Growth hormone peak levels with SSIW were significantly lower in GH deficient children than in healthy children (2.5 +/- 1.2 ng/dL, vs 21.9 +/- 5.3 ng/dL, respectively, P < 0.01). No adverse effects were observed during or after somatostatin infusion. CONCLUSION: In the present study, SSIW elicited a significant GH rise in healthy children but not in children with GH deficiency. Although further controlled studies using more data are necessary to expand these findings, the results suggested that children with GH deficiency can be reliably discriminated from healthy children by SSIW.     

Role of early EEG and neuroimaging in determination of prognosis in children with complex febrile seizure

BACKGROUND: The present study investigates the role of early use of EEG in children with no known neuropathology prior to the first CFS, and the contribution made by computed tomography (CT) and magnetic resonance imaging (MRI) to treatment and prognosis. METHODS: Over a period of 7 years, the authors evaluated 159 children (age range: 2 months-5 years) who were being treated for CFS at Haydarpasa Numune Training and Research Hospital, Pediatrics Clinic, Istanbul, Turkey, and who had no previously known neurological disorder. Patients who presented with febrile seizure were determined to have CFS if they fulfilled the following criteria: <3 months of age when seizure occurred, duration of seizure >/=15 min, more than one seizure occurred during a single episode of illness, or focal seizures and postictal neurological deficit was found. EEG was performed on all patients. CT was performed on the patients who had postictal neurologic deficit or focal seizures. Cranial MRI was performed on patients who had focal findings in their EEGs. RESULTS: Electroencephalogram abnormality was found in 71 cases; 51 of these were diagnosed with epilepsy during follow up. Six of the 16 cases whose EEGs were abnormal between days 2 and 6 were diagnosed with epilepsy. Twenty of the 30 cases whose EEGs were abnormal between days 7 and 10 were diagnosed with epilepsy. All 25 cases who had abnormal EEGs after day 11 were diagnosed with epilepsy. CT was performed for 36 patients, of which five were found to have pathological changes. Pathological changes were detected in two of the nine patients who had cranial MRI. Patients who received CT or MRI were all diagnosed with epilepsy during follow up. CONCLUSION: The results suggest that if neurological examination of CFS patients are normal after their clinical status has stabilised, EEG should be performed after 7 days at the earliest, however for the most accurate diagnosis EEG should be performed 10 days after CFS. The most important predictor for neuroimaging was found to be detection of postictal neurologic deficit. MRI had no advantages over CT in first treating CFS in the emergency unit.     

Technological Advances in Penile Implant Surgery

BackgroundDuring the last century, surgical management of erectile dysfunction has evolved from an experimental concept to a core treatment modality with widespread use among the men's health community. Over time, innovations in materials, mechanical design elements, device coatings, and surgical technique have provided patients with low-risk, reliable, and reproducible erectile function with high satisfaction rates.AimTo provide a foundation for future innovation by improving understanding of historical penile prosthetics and the rationale behind incremental technological improvements for the contemporary Men's Health physician.MethodsLiterature review was conducted to generate a comprehensive review of historical technological innovations in penile implant surgery. Companies with FDA approved penile prosthetics in use in the United States were contacted for information regarding technological innovations in the past and future devices in development. A separate literature review was performed to identify any significant future device design elements being tested, even in the ex vivo setting, which may have future clinical applications.OutcomesTechnological innovations in penile implant surgery were described.ResultsCurrent options for the prosthetic surgeon include malleable penile prostheses (MPP), self-contained (2-piece) inflatable penile prostheses, and multicomponent (3-piece) inflatable penile prostheses. Current MPPs consist of a synthetic coated solid core which allow for manipulation of the penis for concealability while maintaining sufficient axial rigidity to achieve penetration when desired. Multi-component (3-Piece) IPPs currently include the Coloplast Titan and Boston Scientific/AMS 700 which consist of a fluid reservoir, intrascrotal pump, and intracavernosal cylinders. The devices have undergone numerous design updates to the cylinders, pump, reservoir, tubing, and external coatings to increase reliability and decrease short- and long-term complications.Clinical ImplicationsFuture innovations in penile prosthetic surgery seek to broaden the indications and applicability to the transgender community and improve both safety and functionality for patient and partner.Strengths & LimitationsThe review is limited primarily to penile prosthetics approved for current or historical clinical use in the United States and may not be representative of the global prosthetic environment. Additionally, the research and development of future innovations, particularly those provided by device manufacturers, is likely limited by non-disclosure to maintain a competitive advantage.ConclusionsPenile prosthetic surgery will undoubtedly remain integral to the treatment of erectile dysfunction, and education regarding the current state of technological innovation will empower the prosthetic surgeon and biomedical engineering community to improve contemporary patient care and drive the development of the next generation of implantable penile prosthetics.Barnard JT, Cakir OO, Ralph D, et al. Technological Advances in Penile Implant Surgery. J Sex Med 2021;18:1158–1166.     

Spinal Cord Injury: How Could Acupuncture Help?

Spinal cord injury (SCI) is one of the most common causes of death and disability worldwide, and it can result in both permanent disability and serial complications in patients. Research shows that patients with SCI complications are often interested in acupuncture for symptomatic relief. Therefore, the issue of physicians advising their patients regarding the use of acupuncture to alleviate SCI complications becomes pertinent. We review and summarize two types of relevant publications: (1) literature concerning acupuncture for SCI and its complications and (2) underlying mechanisms of acupuncture therapy for SCI. Clinical trials and reviews have suggested that acupuncture effectively manages a range of post-SCI complications, including motor and sensory dysfunction, pain, neurogenic bowel and bladder, pressure ulcers, spasticity, and osteoporosis. The effect of acupuncture on post-SCI orthostatic hypotension and sexual dysfunction remains unclear. Decreased oxidative stress, inhibition of inflammation and neuronal apoptosis, regulation of the expression and activity of endogenous biological mediators, and increased regenerative stem cell production are the possible mechanisms of acupuncture therapy for SCI. Although many limitations have been reported in previous studies, given the evidence for the efficacy of acupuncture, we recommend that physicians should support the use of acupuncture therapy for SCI complications.     

Contrast‐Enhanced Echocardiographic Evaluation of a Giant Saphenous Vein Graft Aneurysm

A 61‐year‐old man presented with unstable angina 16 years after undergoing coronary artery bypass grafting with a left internal mammary artery graft to the left anterior descending coronary artery and a sequential saphenous vein graft (SVG) to the right coronary artery and an obtuse marginal branch. Transthoracic echocardiography (TTE) with a Philips iE33 machine and an S5 transducer revealed a 5.3 cm × 4.6 cm mass with a central echolucent area, surrounded by a peripheral zone of increased echodensity adjacent to, and partially compressing, the right atrium. Contrast echocardiography following an intravenous bolus injection of Definity revealed late appearance of contrast within the mass consistent with a giant SVG aneurysm. Coronary artery bypass graft angiography revealed a giant aneurysm in the SVG proximal to the RCA anastomosis; the distal limb of the graft to the obtuse marginal branch was occluded. Under intravascular ultrasound guidance, a 7‐mm spider filter was placed in the distal graft; then, a 6 mm × 10 cm Viabahn self‐expanding nitinol polyethylene terephthalate‐covered stent was deployed in the SVG with good seal zones proximally and distally. A follow‐up contrast‐enhanced transthoracic echocardiogram 1 day postprocedure revealed partial thrombosis of the aneurysm cavity. Ultrasound contrast did not appear in the aneurysm following intravenous injection, consistent with complete exclusion from the systemic circulation. This is the first report demonstrating feasibility of contrast‐enhanced transthoracic echocardiography for the diagnosis of SVG aneurysm and confirming procedural success by documenting exclusion from the systemic circulation following intervention.     

Comparison of Ho:YAG laser and pneumatic lithotripsy in the treatment of impacted ureteral stones: An analysis of risk factors

The aim was to compare pneumatic and holmium:yttrium-aluminum-garnet laser in the treatment of impacted ureteral stones with different locations and to identify the risk factors for complications. Between March 2005 and November 2012, a total of 230 patients underwent ureteroscopic lithotripsy for impacted stones. Of the patients, 117 had pneumatic and 113 had laser lithotripsy for the fragmentation of the stones. Treatment outcomes based on evidence of being stone free were evaluated. Preoperative, operative, and postoperative follow-up findings were analyzed and compared. There was a difference between the two groups according to overall stone clearance rate (93.8% vs. 80.3%, p = 0.002). There was no statistically significant difference for distal location between the laser and pneumatic groups (96.8% vs. 91.7%, p = 0.288). For 10 patients with intrarenally migrated stones who were managed with flexible ureterorenoscopy in the same session, laser lithotripsy was more successful than pneumatic for proximal ureteral stone (94.4% vs. 67.9%, p = 0.007). The overall complication rate was 26.1%. There was no statistically significant difference between the two groups (29% vs. 23%, p = 0.296). Multivariate logistic regression analysis revealed that the proximal location was a statistically significant parameter for the occurrence of complications in both groups (p = 0.001 for PL, p = 0.004 for laser). The pneumatic and holmium:yttrium-aluminum-garnet laser lithotripsy are effective in the treatment of distal impacted stones. Both treatments with semirigid ureteroscopy are acceptable for proximal impacted ureteral stones, but holmium laser lithotripsy has an advantage of use with flexible ureteroscope for intrarenally migrated stone.