Controversies in the diagnosis and management of urinary tract infections in children

Urinary tract infection (UTI) is one of the most common childhood bacterial infections, after upper respiratory tract and middle ear infections. The current goal of management is to prevent detrimental effects of UTI by early detection and treatment. Recommendations for the imaging of children depend upon age at presentation and sex. All children aged <5 years who have had a febrile UTI require a radiologic evaluation to identify any underlying genitourinary pathology. Older children can undergo a more tailored work-up depending on whether there is a febrile UTI or cystitis-type symptoms. Dysfunctional voiding and urge syndrome significantly increase the risk of developing UTIs in children. Vesicoureteral reflux can increase the risk of pyelonephritis and renal scarring in children with UTIs. For the most part, pyelonephritis can be diagnosed on clinical grounds in the majority of patients and a subsequent (99m)Tc-dimercaptosuccinic acid scan can be reserved to identify post-nephritic renal scarring. When renal scarring is identified, the child and parents need to be educated regarding the possibility of hypertension, proteinuria, progressive nephropathy, and the risk of complications in future pregnancies. Treatment of UTI is started in the unwell child before the culture results are available and subsequently changed to culture-specific antimicrobial therapy. A short course of treatment is required for acute uncomplicated UTIs. A child with acute pyelonephritis requires 10-14 days of antibacterial treatment. The oral route in young children often causes vomiting, which implies therapeutic delay, a well known risk factor for scarring.     

Food insecurity affects school children's academic performance, weight gain, and social skills

Food insecurity has been associated with diverse developmental consequences for U.S. children primarily from cross-sectional studies. We used longitudinal data to investigate how food insecurity over time related to changes in reading and mathematics test performance, weight and BMI, and social skills in children. Data were from the Early Childhood Longitudinal Study-Kindergarten Cohort, a prospective sample of approximately 21,000 nationally representative children entering kindergarten in 1998 and followed through 3rd grade. Food insecurity was measured by parent interview using a modification of the USDA module in which households were classified as food insecure if they reported > or =1 affirmative response in the past year. Households were grouped into 4 categories based on the temporal occurrence of food insecurity in kindergarten and 3rd grade. Children's academic performance, height, and weight were assessed directly. Children's social skills were reported by teachers. Analyses examined the effects of modified food insecurity on changes in child outcomes using lagged, dynamic, and difference (i.e., fixed-effects) models and controlling for child and household contextual variables. In lagged models, food insecurity was predictive of poor developmental trajectories in children before controlling for other variables. Food insecurity thus serves as an important marker for identifying children who fare worse in terms of subsequent development. In all models with controls, food insecurity was associated with outcomes, and associations differed by gender. This study provides the strongest empirical evidence to date that food insecurity is linked to specific developmental consequences for children, and that these consequences may be both nutritional and nonnutritional.     

Catastrophic antiphospholipid antibody syndrome

Antiphospholipid antibody syndrome (APS) is characterized by recurrent thrombosis with the presence of circulating antiphospholipid antibodies. A diagnosis of APS requires the presence of at least one clinical and one laboratory criteria (detection of aCL IgG or IgM antibodies or the presence of lupus anticoagulant on two or more consecutive occasions 6 weeks apart). A severe, rapidly progressive form characterized by clinical involvement of at least three different organ systems with histopathological evidence of small and large vessel occlusion is termed catastrophic antiphospholipid syndrome. Early recognition of APS is crucial since aggressive management can result in a favorable outcome. We present the case of a 12-year-old boy who presented with a devastating illness with multiple thrombotic episodes and rapidly progressive renal failure.     

QSAR study on carbonic anhydrase inhibitors: water-soluble sulfonamides incorporating beta-alanyl moieties, possessing long lasting-intra ocular pressure lowering properties--a molecular connectivity approach

A QSAR study on a series of carbonic anhydrase (CA, EC 4.2.1.1) inhibitors, and more precisely on water-soluble sulfonamides incorporating beta-alanyl moieties, possessing long lasting intra-ocular pressure lowering properties, was carried out using a series of distance-based topological indices. The regression analysis has shown that out of the pool of topological indices used, the 1chi (first-order Randic connectivity index) is the best one for modeling CA inhibitory properties against all three investigated isozymes, the cytosolic CA I, CA II and the membrane-bound CA IV, and that excellent results are obtained in multiparametric regressions. The results are critically discussed on the basis of statistical parameters.     

Does β-amyloid plaque formation cause structural injury to neuronal processes?

The precise role of beta-amyloid plaque formation in the cascade of brain cell changes that lead to neurodegeneration and dementia in Alzheimer's disease has been unclear. Studies have indicated that neuronal processes surrounding and within plaques undergo a series of biochemical and morphological alterations. Morphological alterations include reactive, degenerative and sprouting-related 'dystrophic' neuritic structures, derived principally from axons, which involve specific changes in cytoskeletal proteins such as tau and NF triplet proteins. More compact and fibrous plaques are associated with more extensive neuritic pathology than non-fibrillar, diffuse beta-amyloid deposits. Cortical apical dendritic processes are either 'clipped' by plaque formation or are bent around more compact plaques. Examination of cases of 'pathological' brain ageing, which may represent a preclinical form of Alzheimer's disease, demonstrated that the earliest neuritic pathology associated with plaques was similar to the reactive changes that follow structural injury to axons. In vivo and in vitro experimental models of structural injury to axons produce identical reactive changes that subsequently lead to an attempt at regenerative sprouting by damaged axons. Thus, beta-amyloid plaque formation may cause structural injury to axons that is subsequently followed by an aberrant sprouting response that presages neurodegeneration and dementia. Identification of the key neuronal alterations underlying the pathology of Alzheimer's disease may provide new avenues for therapeutic intervention.     

Parkinsonism and recovery in central and extrapontine myelinolysis

Central pontine myelinolysis is a demyelinating affection of central pons diagnosed on the basis of characteristic MRI finding in an appropriate clinical setting. The condition has been described as universally fatal; however, recent reports of recovery have been documented. We report a case of central pontine and extra pontine myelinolysis, which presented with parkinsonian features apart from bulbar symptoms and made a remarkable recovery. A short review of the literature follows.     

Pseudohypoparathyroidism presenting with bony deformities resembling rickets

Pseudohypoparathyroidism (PHP), characterized by hypocalcemia, hyperphosphatemia and elevated parathormone level, may rarely be associated with bony deformities resembling rickets. The authors report two siblings with clinical and radiological features suggestive of rickets unresponsive to treatment with vitamin D. Low serum calcium, elevated serum phosphate, normal renal functions, raised tubular maximum of phosphate and high serum parathormone were suggestive of PHP. Treatment with 1-hydroxyvitamin D and calcium carbonate led to decrease in bone pain, increase in height and weight and resolution of radiological features. PHP should be suspected in patients with bony deformities, hypocalcemia, elevated blood phosphate levels and normal renal functions.     

Recruitment in urology: a national survey in the UK

PURPOSE: Urology is one of the most common specialties chosen by surgical trainees. This study set out to determine what factors influence the decision in pursuing a career in urology as opposed to other surgical specialties. MATERIALS AND METHODS: A questionnaire was mailed to 844 urologists of various career levels within the UK. Subjects were asked to document the top three factors that influenced their choice of urology as a career. Specifically, they were asked whether their undergraduate teaching was an influence. RESULTS: Completed surveys were received from 362 respondents. Less than one-third of the respondents were influenced by their undergraduate urology exposure. The top five reasons cited for pursing a career in urology were: (i) a positive role model; (ii) postgraduate urology experience; (iii) the wide variety of procedures encompassing open and endoscopic work; (iv) the lifestyle; and (v) the pleasant personalities of urologists when compared with other specialties. CONCLUSIONS: This is the first study if its kind to establish the factors influencing career choices. As urology continues to be eroded from undergraduate curricula, the data support the view that undergraduate urology exposure is not the most influential factor.     

Nerve-sparing retroperitoneal lymphadenectomy using hydro-jet dissection: initial experience

BACKGROUND AND PURPOSE: Nerve-sparing retroperitoneal lymphadenectomy (RPL) is performed in a significant number of patients to preserve ejaculation after treatment for testicular cancer. Identification and preservation of the sympathetic nerves may be challenging. Hydro-Jet technology has been utilized for various surgical applications. A small high-pressure stream of water is used to delineate surgical planes, with preservation of vascular and neural structures. We have examined the utility of this technology for RPL in a porcine model and in human subjects. MATERIALS AND METHOD: A Helix Hydro-Jet device (Erbe, USA) was used for all procedures. A high-pressure water-jet stream is directed through a small nozzle with a 120-microm inner radius for soft-tissue dissection. The upper pressure limit (range 0-2175 psi) is set using a digital monitor. The jet is initiated using a foot pedal, and the actual pressure is monitored. A pressure of 360 to 400 psi was used for experimental studies, which was decreased to 255 to 300 psi for human use. Three pigs underwent RPL using this technique. Subsequently, RPL was performed in five men with testicular cancer, being primary in two and postchemotherapy in three. The primary diagnosis was seminoma in one and non-seminomatous cancer in four. The patient with seminoma had a residual mass after chemotherapy. RESULTS: The procedures were completed successfully in all subjects. There were no intraoperative or postoperative complications. Hydro-Jet dissection permitted tissue selectivity, with preservation of vascular structures and sympathetic nerves. The soft tissue and lymphatics were removed with the high-pressure water stream assisted by blunt dissection. The nerve fibers were grossly resistant to the pressure used and were isolated individually. Dissection around the great vessels appeared to be safe, and no injury was observed with direct application of the jet. Lumbar arteries and veins and accessory vessels could be isolated safely. The estimated blood loss was minimal in animals and 300 to 800 mL in humans. CONCLUSIONS: Hydro-Jet dissection demonstrated tissue selectivity using a pressure range of 255 to 300 psi in humans. The vascular structures and sympathetic nerves were preserved. Our initial experience with this device for nerve-sparing RPL is encouraging.