Traumatic injuries of the distal femoral physis. Retrospective study on 151 cases

This is a retrospective study on a series of 151 injuries involving the distal femoral physis. The average age at the time of injury was 12.3 years. Patients were followed for an average of 8.2 years. The complications encountered were not insignificant and the satisfactory results were relatively low (64.9%). The juvenile age group was the most affected with complications. Salter-Harris type II injuries predominated (43.0%) and they did not have a good prognosis as previously suggested. Symptomatic knee ligamentous laxity was found in 12 patients (7.9%). Compartment syndrome is a devastating complication that occurred in 2 cases (1.3%). We stress the point that a child with a physeal injury of the distal femur should be followed for several years after injury and preferably until skeletal maturity. The surgeon must have high index of suspicious for compartment syndrome. Physeal injuries of the distal femur and in particular Salter and Harris type II should be reduced anatomically and fixed well. Whether this should be achieved by closed or opened means, requires a controlled prospective study to provide a confident answer.     

A single-centre long-term outcome analysis of artificial urinary sphincter placement in children

OBJECTIVE: To retrospectively evaluate the outcome of artificial urinary sphincter (AUS) placement in 79 children, with a mean follow-up of 12.5 years. PATIENTS AND METHODS: A total of 89 children had an AUS placed between 1977 and 1994; complete data were obtained for 79 (63 boys and 16 girls). The indication for AUS placement was urinary incontinence caused by sphincteric deficiency with a stable bladder. Before and after surgery, all patients underwent ultrasonography, voiding cysto-urethrography and urodynamics. Logistic regression was used to assess the factors influencing the outcome. RESULTS: The mean (range) age at surgery was 11.7 (3-18) years. The cause of incontinence was a neuropathic bladder in 74 patients and bladder exstrophy in five. At a mean (range) follow-up of 12.5 (5-22) years, 63 of 79 patients (80%) had an intact AUS. The AUS was removed in 16 patients (20%) because of erosion at a mean (range) of 5.6 (1-11) years after insertion; there were 0.035 revisions per patient-year. Of 63 patients with an AUS in place, 57 (90%) are completely dry and 36 (57%) are using clean intermittent catheterization. Thirteen patients (20%) developed bladder instability during the follow-up, which was managed by anticholinergics in eight, spinal cord de-tethering in three and enterocystoplasty in two. Hydronephrosis occurred in 12 of 126 renal units (10%) that improved after enterocystoplasty or anticholinergics. The overall 10-year survival of the AUS was 79% (78% for early models and 80% for the AMS800); the survival was not affected by age, sex, model, previous bladder neck surgery, augmentation cystoplasty or intermittent catheterization. Bladder exstrophy was associated with lower AUS survival, as four of the five patients affected had the AUS removed secondary to erosion (P = 0.014). CONCLUSION: In children the AUS has a 79% 10-year survival and gives a 90% continence rate. Bladder instability after AUS placement can be managed with anticholinergics or enterocystoplasty. The AUS is not a justifiable treatment option for patients with bladder exstrophy.     

Antenatal HIV testing in rural eastern Uganda in 2003: incomplete rollout of the prevention of mother-to-child transmission of HIV programme?

Background  

Uganda began to implement the prevention of mother-to-child transmission (PMTCT) of HIV programme in 2000, and by the end of 2003 it had expanded to cover 38 of the 56 districts including Mbale District. However, reports from Mbale Hospital showed that less than 10% of pregnant women accepted antenatal HIV testing. We therefore conducted a study to determine the proportion of pregnant women who tested for HIV and the gaps and barriers in PMTCT implementation.     

Tunica vaginalis for correcting penile chordee in a rabbit model: is there a difference in flap versus graft?

PURPOSE: We compared tunica vaginalis applied as a flap versus a graft for covering defects in the ventral tunica albuginea in a rabbit model. MATERIALS AND METHODS: We used 18 New Zealand White rabbits in the study. The urethra was mobilized off of the corpus cavernosum. A defect was created in the ventral aspect of the tunica albuginea by excising a 1 x 0.5 cm. rectangular area. The defect was covered by the testicular surface of tunica vaginalis as a vascularized flap in 9 animals and as a graft in 9. At 2, 6 and 12-week intervals 3 animals per group were sacrificed. Transverse sections of the penis at the repair site were stained with hematoxylin and eosin, and Masson's trichrome for microscopy. RESULTS: Autopsy revealed no contracture in any of the tunica vaginalis flaps. In contrast, the tunica vaginalis grafts had contracted by a mean of 22% (range 20% to 25%) at 2, 38% (range 30% to 44%) at 6 and 42% (range 38% to 48%) at 12 weeks. Microscopic examination of the tunica vaginalis flaps showed evidence of an intact blood supply and viable cremasteric muscle layer but no evidence of necrosis. Collagen remodeling and maturation was noted at 12 weeks. In tunica vaginalis grafts there was evidence of necrosis of all tunica vaginalis layers at 2 weeks with granulation tissue and active fibrosis at the periphery. At 6 and 12 weeks most necrotic tissue was replaced by fibrosis. Osseous metaplasia was identified in 1 graft at 12 weeks. CONCLUSIONS: The optimal use of tunica vaginalis for correction of chordee is as a flap rather than as a free graft. Grafts were associated with significant necrosis and contracture, of which neither was associated with flaps.     

Efficacy of endoscopic subureteral polydimethylsiloxane injection for treatment of vesicoureteral reflux in children: a North American clinical report

PURPOSE: Subureteral injection of bulking agents is an accepted surgical treatment of vesicoureteral reflux in children. Polydimethylsiloxane, a silicone elastomer, is an ideal agent because of bulky consistency, lack of migration, minimal local inflammatory reaction and is safe in laboratory animals. We record our experience with endoscopic subureteral polydimethylsiloxane injection in children for vesicoureteral reflux. MATERIALS AND METHODS: During a 2-year period 16 boys and 58 girls, with an average age of 8 years, with 112 refluxing ureters underwent endoscopic subureteral polydimethylsiloxane injection to treat vesicoureteral reflux. Vesicoureteral reflux was grade I in 8, II in 43, III in 50, IV in 10 and V in 1 ureter. Operative indications were breakthrough urinary tract infection in 29 children, nonresolution of reflux 38 and high grade reflux 7. All procedures were on an outpatient basis and performed with patient under general anesthesia. All children had a postoperative ultrasound and voiding cystourethrogram at 12 weeks. Followup was from 6 to 24 months. RESULTS: Overall, reflux was corrected in 90 (81%) ureters and 56 (76%) children after a single injection. With repeat injection reflux was corrected in 101 (90%) ureters and 63 (85%) children. Correction by grade was 85%, 84%, 80%, 45% and 0% for grades I to V, respectively. With repeat injection correction was 100%, 92%, 90% and 55% for grades I to IV, respectively. There were no surgical complications. De novo contralateral reflux developed in 2 (3%) children. There were 3 (4%) children who required open ureteral reimplantation for failed injection. Detection of the polydimethylsiloxane implant by followup ultrasound was 89% sensitive and 86% specific for the correction of reflux. CONCLUSIONS: Endoscopic subureteral polydimethylsiloxane injection is an effective treatment of vesicoureteral reflux in children. The procedure is safe with low associated morbidity. The presence of the polydimethylsiloxane implant can be documented accurately by ultrasound, and there is a strong correlation between implant stability and correction of reflux.     

Some epidemiological aspects of patients with end stage renal diseases

This study was carried out to describe End Stage Renal Disease (ESRD) among Egyptian patients and to identify the possible risk factors of their disease. A case-control study was conducted with 2 control groups (patient or hospital control group and normal community control group) compared with ESRD cases on haemodialysis. The study revealed that hypertension, followed by obstructive uropathy, are the leading causes of ESRD. Conducting the multiple logistic regression analysis, the following factors were found to act independently as risk factors for ESRD, in that order of importance: past history of hypertension, family history of renal failure, past history of renal pain, smoking, urban origin of birth, past history of renal or urinary stones, past history of schistosomiasis, the presence of a near-by residential factory and past history of frequent hospitalization. A quality of life score has been invented. Women experienced a bad quality of life in relation to men and the score correlated positively with age. A number of recommendations have been generated.     

Immunological factors in milk from Brazilian mothers delivering small-for-date term neonates

Breast milk samples from three groups of Brazilian women were evaluated: G1, mothers delivering term babies of low birth weight (n=16); G2, mothers delivering preterm babies of appropriate birth weight (n = 20); G3, mothers delivering term babies of appropriate birth weight ( n = 30). Milk samples were obtained at 48 h and on the 7th, 15th, 30th and 60th days after delivery and they were analyzed for lysozyme and total IgA levels and for the presence of specific antibodies against Poliovirus types I, II, III, Rotavirus, Herpes simplex virus, Varicella zoster and Cytomegalovirus. The groups were not statistically different in relation to mother's age, parity, type of delivery or socio-economic levels. IgA levels were higher in both low-birth-weight groups (G1 & G2) compared to the control group (G3) throughout the study period. Lysozyme levels decreased up to the 15th day, increasing thereafter up to the 60th day in all groups. Specific antibodies were detected throughout the study period, with no differences among groups. We conclude that breast milk composition of mothers delivering low-birth-weight babies (G1 & G2) was similar despite the different gestational ages.     

Features of transient hypogammaglobulinaemia in infants screened for immunological abnormalities

The incidence of transient hypogammaglobulinaemia of infancy (THI) detected in a major paediatric centre over a 10 year period was examined. A total of 2468 subjects less than 2 years of age had an IgG measurement taken between July 1979 and March 1990. Subjects with known immunodeficiencies were excluded. Fifteen patients were classified as having THI with an initial IgG level less than the fifth centile followed by a second measurement within the normal range. A further 24 patients were identified as having possible THI with a single low IgG concentration. There were 60,174 live births each year in Victoria in the years 1979-88. This gives an incidence of proved THI of 23 per 10(6) births, and including proved and probable THI an incidence of 61 per 10(6) live births. Of those patients with proved THI 12/15 had symptoms of either atopic disease or food allergy/intolerance and three had gastrointestinal symptoms without any evidence of atopic disease. At presentation 12/15 (80%) were IgA deficient and 9/15 had IgM concentrations less than the 20th centile for age. It is suggested that in view of the preponderance of atopic and food intolerant patients that subclinical protein loss from the bowel due to allergic inflammation may be a contributing factor to the development of THI in some patients.