31 PORCINE SKIN-DERIVED STEM CELLS MAY BE A SUPERIOR SOURCE OF DONOR NUCLEI FOR EFFICIENT GENETIC MODIFICATION OF CLONED EMBRYOS

Somatic cell nuclear transfer (SCNT) in pigs relies primarily on the utilization of fetal-derived fibroblast cells, and the resultant clones tend to exhibit a significant level of phenotypic instability, which may be due to epigenetic reprogramming and/or genomic damage in the donor cells. In addition to the compromised phenotypic stability, production of transgenic clones through SCNT is inefficient, because the restricted lifespan of somatic donor cells in culture can be limiting when the genetic modification requires selection. In contrast, stem cells proliferate rapidly and do not undergo senescence at a high rate, so the selection process can be extended. Since there is no report of an embryonic stem cell line derived in the pig that could contribute to the germ line, we decided to investigate the utility of porcine skin-derived stem cells (SSCs). Porcine SSCs were isolated from the skin on the back of day 35 to 50 Yorkshire fetuses. The SSCs were cultured continually in SSCs medium (DMEM/F12 containing B-27, 20 ng mL–1 of epidermal growth factor, and 40 ng mL–1 of basic fibroblast growth factor) at 37.8°C, 5% CO2, 95% air. The SSCs expressed the neural progenitor marker nestin, as well as genes that are critical for pluripotency, such as Oct4 and Stat3. The SSCs proliferated actively in vitro and retained a normal karyotype after long-term culture. Electron microscopy revealed 2 distinct cell types within the spheres; elongated cells at the sphere periphery had invaginated nuclear envelopes and prominent nucleoli, and these cells displayed few, but large elongated mitochondria with transversal cristae as well as large cisternae of rough endoplasmic reticulum. In contrast, the cells in the center of the spheres were predominantly round-shaped, with a large round nucleus or cuboidal. The SSCs can be genetically modified with long-term positive selection, and 50 μg mL–1 G418 appeared to be an appropriate dose of G418 for selection of the transfected SSCs. Finally, NT embryos reconstructed with SSCs showed high rates of pre- and post-implantation development.The cell number in the blastocyst stage embryos derived from cloning with the SSC was significantly higher than those of the blastocysts derived from IVF (28.5 ± 1.9, 16.8 ± 4.0, respectively, P < 0.05), although there was no significant difference in blastocyst formation rates between these groups (21 to 25%). Three of the animals became pregnant in 4 surrogate gilts which received cloned embryos and reached to term. Two healthy male cloned piglets and 1 healthy female cloned piglet are genetically identical to the SSCs. Funding for this study was provided by the National Institutes of Health.

33 PRE-AND POST-IMPLANTATION DEVELOPMENT OF EMBRYOS CLONED FROM PORCINE SKIN-DERIVED SPHERE STEM CELLS

Although transgenic animals have been successfully cloned, the process is still inefficient. One of the limitations is the use of somatic donor cells that have a limited lifespan. If a genetic modification is made, the selection process must be initiated and completed rapidly or the cells will undergo senescence. Identification of a stem cell that would proliferate rapidly and not undergo senescence would prove to be very valuable. Here we report attempts at cloning by using porcine skin-derived sphere stem cells to determine if they are a suitable donor cell type. Skin-derived stem cells were isolated from fetal skin and express the neural progenitor marker NES, as well as genes that may be critical for pluripotency such as POU5F1 and STAT3. The skin-derived stem cells proliferate rapidly in vitro and retain a normal karyotype after long-term culture. In the present study, skin-derived stem cells were cultured and frozen in liquid nitrogen from passage 1 to passage 8. To investigate the developmental potential of the skin-derived stem cells, we performed nuclear transfer (NT) and compared their preimplantation developmental efficiency to that of the embryos derived from in vitro fertilization (IVF). Cumulus–oocyte complexes (COCs) were aspirated from antral follicles of ovaries from prepubertal gilts. Approximately, groups of 50-70 COCs were matured in vitro in 500 µL TCM-199 per culture well for 40–44 h at 38.5�C, in a humidified atmosphere of 5% CO2 in air. The donor cells were thawed and cultured one day before NT; skin-derived stem cells were pipetted vigorously in PBS-EDTA to isolate individual cells. For IVF, cryopreserved ejaculated spermatozoa were thawed and washed and then resuspended with fertilization medium (mTBM). The MII oocytes were co-incubated with sperm for 6 h, and then transferred to PZM3 and cultured. For NT and IVF, respectively, the percent cleavage at 48 h in PZM3 was 64.9 � 8.2% (169/208) and 62.1 � 3.1% (94/184) (P > 0.05), the percent blastocysts after 6 days was 21.5 � 5.8% (53/208) and 25.2 � 3.4% (46/184) (P > 0.05), and the number of nuclei per blastocyst was 28.5 � 1.9 (NT, maximum was 58) and 16.8 � 4.0 (IVF, maximum was 31) (P < 0.05). To determine development post-implantation, some cloned embryos were cultured in PZM3 for 15.5 h and an average of 112 cloned embryos were transferred to the oviducts of four naturally cycling gilts on Day 0–1 of standing estrus. Three of the animals were pregnant: one of them farrowed two male piglets on August 14th, with the other two due on September 8th and 9th. Future studies will involve performing NT and ET on skin-derived stem cells from a higher passage number to determine if they would be suitable for genetic modification prior to NT.

Awareness of HIV post-exposure prophylaxis after sexual exposure and emergency hormonal contraception in HIV-positive women

Women attending a dedicated medical gynaecology and family planning referral clinic for women with HIV were surveyed using a standard questionnaire about their knowledge and attitudes to post-exposure prophylaxis after sexual exposure (PEPSE) and emergency hormonal contraception (EHC). Eighty percent of them had not heard of PEPSE, but once informed about it, 86% said they would inform a partner about it. Less than 10% had any idea of the duration of effectiveness. Seventy-three percent of the women knew about EC and 45% of them had used it previously. Ninety-eight percent of them would use it in the future if necessary. Eighty percent of them knew its period of effectiveness. There is a clear need for information about PEPSE, which needs to be delivered around the time of HIV diagnosis and reinforced later. Some women will need help in discussing it with HIV-negative partners.

Oxytocin agonists for preventing postpartum haemorrhage

BACKGROUND

Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side-effects. Carbetocin, a long-acting oxytocin agonist appears to be a promising agent for the prevention of PPH.

OBJECTIVES

To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 2), MEDLINE (1966 to June 2006) and EMBASE (1974 to June 2006). We checked references of articles and communicated with authors and pharmaceutical industry.

SELECTION CRITERIA

Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

Four studies (1037 women) were included in the review (three studies on caesarean delivery and one on vaginal delivery). The risk of PPH was similar in both oxytocin and carbetocin arms for participants who underwent caesarean delivery as well as participants, with risk factor(s) for PPH, who underwent vaginal delivery. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonic agent (relative risk (RR) 0.44, 95% confidence interval (CI) 0.25 to 0.78) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Carbetocin is also associated with a reduced need for uterine massage in both caesarean and vaginal deliveries (RR 0.38, 95% CI 0.18 to 0.80; RR 0.70, 95% CI 0.51 to 0.94) respectively. However, this outcome measure was only documented in one study on caesarean delivery and in the only study on vaginal delivery. Pooled data from the trials did not reveal any statistically significant differences in terms of the adverse effects between carbetocin and oxytocin.

AUTHORS' CONCLUSIONS

There is insufficient evidence that 100 micrograms of intravenous carbetocin is as effective as oxytocin to prevent PPH. In comparison to oxytocin, carbetocin was associated with reduced need for additional uterotonic agents, and uterine massage. There was limited comparative evidence on adverse events.

Vaccines for preventing Japanese encephalitis

BACKGROUND

Vaccination is recognized as the only practical measure for preventing Japanese encephalitis. Production shortage, costs, and issues of licensure impair vaccination programmes in many affected countries. Concerns over vaccine effectiveness and safety also have a negative impact on acceptance and uptake.

OBJECTIVES

To evaluate vaccines for preventing Japanese encephalitis in terms of effectiveness, adverse events, and immunogenicity.

SEARCH STRATEGY

In March 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 1), MEDLINE, EMBASE, LILACS, BIOSIS, and reference lists. We also attempted to contact corresponding authors and vaccine companies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), including cluster-RCTs, comparing Japanese encephalitis vaccines with placebo (inert agent or unrelated vaccine), no intervention, or alternative Japanese encephalitis vaccine.

DATA COLLECTION AND ANALYSIS

Authors independently extracted data and assessed methodological quality. Dichotomous data were compared with relative risks and a 95% confidence interval (CI), and converted into percentage vaccine efficacy.

MAIN RESULTS

Eight RCTs involving 358,750 participants were included. These trials investigated two available and three pre-licensure vaccines. Two RCTs assessing efficacy of the commercially available inactivated Nakayama vaccine were identified. A two-dose schedule of the licensed vaccine provided significant protection of 95% (95% CI 10% to 100%) for one year only, while two doses of an unpurified precursor vaccine protected children by 81% (95% CI 45% to 94%) in year one and by 59% (95% CI 2% to 83%) in year two. Serious adverse events were not observed. Mild and moderate episodes of injection site soreness, fever, headache, and nausea were reported in less than 6% of children receiving inactivated vaccine compared to 0.6% of unvaccinated controls. One cluster-RCT compared the live-attenuated SA14-14-2 vaccine (widely used in China) with no intervention measuring adverse events. Fever was reported in 2.7% of vaccinees compared to 3.1% of controls, while 0.1% of both groups suffered diarrhoea or seizures. Four small pre-licensure RCTs assessing a genetically engineered vaccine and two cell culture-derived inactivated vaccines revealed high immunogenicity and relative safety.

AUTHORS' CONCLUSIONS

Only one of the three currently used vaccines has been assessed for efficacy in a RCT. Other RCTs have assessed their safety, however, and they appear to cause only occasional mild or moderate adverse events. Further trials of effectiveness and safety are needed for the currently used vaccines, especially concerning dose levels and schedules. Trials investigating several new vaccines are planned or in progress.

A hat trick of ulcerating pathogens in a single genital lesion

We report on a patient from a London clinic, (a Jamaican heterosexual man known to have herpes) who has donovanosis and syphilis in a single genital ulcer. The case highlights the importance of careful clinical examination of genital ulcers.

A meta-analysis of local anesthesia for transrectal ultrasound-guided biopsy of the prostate

This meta-analysis evaluated the efficacy and safety of periprostatic nerve block (PPNB) and intrarectal local anesthestic (IRLA) gel in alleviating pain during prostate biopsy. Electronic databases MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE were searched to identify all randomized controlled trials comparing PPNB with periprostatic placebo injection, no injection or with IRLA. Studies for inclusion were identified and extracted by two authors independently. The main outcome measure was patients' assessment of mean pain scores on a 10-point scale at the end of the biopsy procedure. Secondary outcomes were complications and adverse events. Continuous data from the trials were combined by calculating the weighted mean difference (WMD) with its 95% confidence interval. In total, 25 studies met the inclusion criteria. Twenty studies involving 1685 patients compared PPNB with either no anesthesia or with placebo injection controls, showing a significant reduction in pain score in the anesthetic group (WMD -2.09, 95% CI -2.44 to -1.75, P<0.00001). Five studies with 466 patients compared IRLA and control. Although IRLA was associated with pain reduction, the effect size was not statistically significant (WMD -0.22, 95% CI -0.56 to 0.12). Six studies with 872 patients compared PPNB with IRLA, showing a significant pain reduction in the former group (WMD -1.53, 95% CI -2.67 to -0.39, P=0.008). No trials reported an increase in complications in the treatment arms. In conclusion, the evidence from randomized controlled trials shows that local anesthetic given as a PPNB, but not as an intrarectal instillation, is effective and safe in alleviating pain from transrectal ultrasound biopsy of the prostate.

Production of endothelial nitric oxide synthase (eNOS) over-expressing piglets

Vascular function, vascular structure, and homeostasis are thought to be regulated in part by nitric oxide (NO) released by endothelial cell nitric oxide synthase (eNOS), and NO released by eNOS plays an important role in modulating metabolism of skeletal and cardiac muscle in health and disease. The pig is an optimal model for human diseases because of the large number of important similarities between the genomic, metabolic and cardiovascular systems of pigs and humans. To gain a better understanding of cardiovascular regulation by eNOS we produced pigs carrying an endogenous eNOS gene driven by a Tie-2 promoter and tagged with a V5 His tag. Nuclear transfer was conducted to create these animals and the effects of two different oocyte activation treatments and two different culture systems were examined. Donor cells were electrically fused to the recipient oocytes. Electrical fusion/activation (1 mM calcium in mannitol: Treatment 1) and electrical fusion (0.1 mM calcium in mannitol)/chemical activation (200 microM Thimerosal for 10 min followed by 8 mM DTT for 30 min: Treatment 2) were used. Embryos were surgically transferred to the oviducts of gilts that exhibited estrus on the day of fusion or the day of transfer. Two cloned transgenic piglets were born from Treatment 1 and low oxygen, and another two from Treatment 2 and normal oxygen. PCR, RT-PCR, Western blotting and immunohistochemistry confirmed that the pigs were transgenic, made message, made the fusion protein and that the fusion protein localized to the endothelial cells of placental vasculature from the conceptuses as did the endogenous eNOS. Thus both activation conditions and culture systems are compatible with development to term. These pigs will serve as the founders for a colony of miniature pigs that will help to elucidate the function of eNOS in regulating muscle metabolism and the cardiorespiratory system.

Meta-analysis of randomized clinical trials comparing drainage alone vs primary sphincter-cutting procedures for anorectal abscess-fistula

BACKGROUND AND AIM

Concurrent definitive treatment of underlying fistulas from infected anal glands at the time when the anorectal abscesses are drained is controversial as this is associated with a higher incidence of faecal incontinence, failure and recurrence. This meta-analysis was conducted to determine the merits of drainage alone vs primary sphincter-cutting procedures (which includes fistulotomy and fistulectomy) for anorectal abscess-fistula.

METHODS

Medline, Embase and Cochrane Central Register of Controlled Trials database searches identified all randomized controlled trials using the keywords: anorectal abscess, anal sepsis, drainage, fistulotomy, fistulectomy or surgery from 1966 to 2004. The outcome variables analysed were recurrence, faecal continence and wound-healing times.

RESULTS

Five trials were considered suitable for the meta-analysis, with a total of 405 patients. Sphincter-cutting procedures for anorectal abscesses resulted in 83% reduction in recurrence rate [relative risk (RR) 0.17, 95% confidence interval (CI) 0.09-0.32, p<0.001]. However, there was a tendency to a higher risk of faecal incontinence to flatus and soiling when primary sphincter-cutting procedure was performed (RR 2.46, 95% CI 0.75-8.06, p=0.140).

CONCLUSION

There is no conclusive evidence if simple drainage or sphincter-cutting procedure is better in the treatment of anorectal abscess-fistula.

Does gastroschisis reduction require general anesthesia? A comparative analysis

BACKGROUND

Outcome after gastroschisis repair without general anesthesia is controversial, and published conclusions are variable with no comparative studies.

AIM

The aim of this study was to present a comparative study evaluating outcome after gastroschisis repair with and without general anesthesia.

METHODS

An ambispective nonrandomized study of a cohort of 51 neonates born with gastroschisis between July 1998 and December 2003 was performed. Twenty-four neonates (group 1) had conventional reduction under general anesthesia, and 27 (group 2) cotside minimal intervention reductions were without general anesthesia.

RESULTS

Groups were comparable regarding gestational age, birth weight, and quality of eviscerated bowel. Statistical significance (P < .05) was seen between groups 1 and 2 with regard to age at reduction of gastroschisis (5.6 +/- 2.5 vs 3 +/- 1 hours) and time taken for completion of gastroschisis reduction (58.1 +/- 15 vs 49 +/- 14 minutes). No statistical significance (P > .05) was seen with respect to start of feeds (10.4 +/- 3.6 vs 10.9 +/- 4.1 days), duration of total parenteral nutrition (21.5 +/- 7.3 vs 22.4 +/- 6.8 days), and total hospital (stay 29 +/- 10 vs 30 +/- 13 days). Admission to the intensive care unit was required in 92% in group 1 for 1 to 6 days vs 7% in group 2 for 3 to 6 days. There was 1 death in group 1 (4%). Total hospital cost in group 1 was 12,283 pounds sterling +/- 2438 pounds sterling vs 6208 pounds sterling +/- 2120 pounds sterling in group 2 (P = .013).

CONCLUSIONS

Neonates with gastroschisis, whose bowel was reduced without general anesthesia, have similar outcomes to those whose bowel was reduced under general anesthesia. Both approaches appear to be safe and effective, but reduction without general anesthesia was cost-effective.

Congenital alveolar capillary dysplasia and associated gastrointestinal anomalies

Congenital alveolar capillary dysplasia is a rare cause of irreversible pulmonary hypertension with 100% mortality. We present three cases of congenital alveolar capillary dysplasia with associated gastrointestinal abnormalities. Three full-term neonates presented with pulmonary hypertension needing ventilatory support by oscillation. Of the three, two neonates subsequently needed extracorporeal membrane oxygenation. Abdominal distension associated with bilious aspirates was the gastrointestinal manifestation. One child had duodenal atresia and anorectal anomaly, one with intestinal malrotation and the other with a rare combination of intestinal malrotaion and total colonic Hirschsprung's disease. All three infants succumbed to pulmonary hypertension at mean age 34 days. The etiopathogenesis and pathology of this condition are discussed with a comprehensive review of the literature.

1 ABERRANT DNA METHYLATION IN PORCINE IN VITRO-, PARTHENOGENETIC-, AND NUCLEAR TRANSFER-PRODUCED BLASTOCYSTS

Aberrant DNA methylation of in vitro-, parthenogenetic-, and nuclear transfer-derived embryos has been implicated in the low developmental competence of early embryos. Demethylation of the genome occurs immediately after fertilization and continues through the blastocyst stage. Remethylation or reprogramming of the genome occurs around the time of implantation and is maintained in somatic tissues. The aim of this study was to analyze DNA methylation in porcine gametes and blastocysts. Differential DNA methylation hybridization was conducted to analyze the methylation status of the Bstu I site (CGCG) in the gamete and blastocyst epigenomes. Germinal vesicle oocytes were aspirated from ovaries collected at an abattoir, sperm was isolated from a fresh ejaculate, and blastocysts were derived and collected from in vivo, in vitro, nuclear transfer, and parthenogenetic sources. Genomic clones were selected from a porcine CpG Island library based on the presence of a Bstu I site. The inserts from these clones were PCR amplified and spotted on glass slides. DNA was digested with Mse I, ligated to linkers, and digested with Bstu I. Fragments with methylated Bstu I sites remained intact whereas fragments with unmethylated Bstu I sites were cut. Intact fragments were amplified by PCR and labeled with amino allyl-dUTP. Liver DNA served as the reference and was labeled with Cy5; the other samples were labeled with Cy3. An Axon Genepix 4000B scanner (Axon Instruments, Inc., Union City, CA, USA) was used to scan the slides. Initial analysis of the microarray image was performed with GenePix Pro 4.0 software. Additional analysis, performed by using Genespring 7.0 ANOVA (P < 0.05), identified 221 clones as being significantly different in at least one of the biological conditions of the gametes or the blastocysts. Forty-six clones were sequenced and BLAST analysis identified 18 clones that were unique, 16 clones that had no similarity, and 12 clones that had similarity to multiple genes. Ribosomal (RPS20, RPL18) and protoporphyrinogen oxidase (PPOX) genes were identified in several clones. Components of the immune system (CCRs, TLRs), a transcription factor (ATF2), and an embryo-specific gene (WNT8B) were also identified. A condition tree was created according to the standard correlation similarity measure for the spots identified as significantly different. The condition tree shows that the methylation profiles are most similar in the germinal vesicle oocyte, parthenogenetic blastocyst, nuclear transfer blastocyst, in vitro-produced blastocyst, and sperm. In vivo-produced blastocysts grouped separately from the other samples. These results are consistent with previous studies that have shown that gametes undergo demethylation after fertilization on through the blastocyst stage when the genome is remethylated. Additionally, these results suggest that the reprogramming events that occur during the development of the in vivo-produced blastocysts are less likely to occur in in vitro-, nuclear transfer-, and parthenogenetic-produced blastocysts. This work was funded by a grant from the NIH (RR13438) and Food for the 21st Century.

374 PRODUCTION OF TRANSGENIC CLONED PIGLETS BY USING PORCINE FETAL FIBROBLASTS OVEREXPRESSING ENDOTHELIAL NITRIC OXIDE SYNTHASE

Vascular function, vascular structure, and homeostasis are thought to be regulated in part by endothelial nitric oxide synthase (eNOS). In addition, eNOS plays an important role in modulating metabolism of skeletal and cardiac muscle in health and disease. The pig is an optimal model for human diseases because of the large number of important similarities between the genomic, metabolism, and cardiovascular systems of pigs and humans. The main goal of this study was to produce pigs that carry an endogenous eNOS gene driven by a Tie-2 promoter and tagged with a V5 His tag so that a better understanding of cardiovascular regulation by eNOS can be gained. Nuclear transfer was conducted to create these animals, and the effects of two different oocyte activation treatments and two different culture systems were examined. Mature oocytes were purchased from BoMed, Inc. (Maidson, WI, USA) and enucleated by micromanipulation. Donor cells were injected into the perivitelline space and electrically fused to the recipient oocyte. Treatment 1 consisted of electrical fusion/activation in 1 mM calcium in mannitol; Treatment 2 consisted of electrical fusion in 0.1 mM calcium in mannitol, followed by chemical activation in 200 �M thimerosal for 10 min followed by 8 mM DTT for 30 min. The fusion rate (71% vs. 82%) was lower (P < 0.0001) in Treatment 2 than in Treatment 1. For those oocytes that fused, the cleavage rates (5.9% vs. 0.4%) at 14-18 h were higher (P < 0.0001) for Treatment 2. Fused oocytes were cultured for 12-18 h in 5% O2, 5% CO2, 90% N2 (low oxygen) or 5% CO2 in air (normal oxygen), and were then surgically transferred to the oviducts of gilts that exhibited estrus on the day of fusion or the day of transfer. In February four cloned transgenic piglets were born (birth weights were 495, 595, 965, and 685 g). Two were from Treatment 1 and low oxygen, and the other two were from Treatment 2 and normal oxygen, and all are currently healthy. PCR, RT-PCR, and Western blotting analysis confirmed that the pigs were transgenic, made message, and made the fusion protein. Immunohistochemistry confirmed that the fusion protein localized in the endothelial cells of the placental vasculature from the conceptuses as did the endogenous eNOS. In addition to the transgenic males, four wild-type females were born (birth weights were 585 (this one died on Day 4) 445, 930, and 585 g). All four were from Treatment 2 and low oxygen, and three are healthy. In conclusion, viable piglets were produced from both Treatments 1 and 2, as well as in both high and low oxygen conditions. Thus, both activation conditions and culture systems are compatible with development to term. These pigs will serve as the founders for a colony of miniature pigs that will help to elucidate the function of eNOS in regulating muscle metabolism and the cardiorespiratory system. This work was funded by a grant from the NIH RR18276 and Food for the 21st Century.

381 PRODUCTION OF A TRANSGENIC PIGLET BY A NEW SPERM INJECTION TECHNIQUE

The technique for intracytoplasmic sperm injection (ICSI) has, until now, focused on scoring the tail of the sperm prior to catching and aspiration into the injection pipette. This is in spite of the fact that damage to the head would more closely simulate what occurs during normal fertilization. In addition, to aid in visualizing the injection process so that a reduced volume can be injected, the oocyte is generally centrifuged to clear a portion of the cytoplasm. Thus, with conventional ICSI, the sperm are immobilized with polyvinylpyrrolidone, repeatedly frozen and thawed, treated with DTT or Triton X-100, and severed between the head and tail; the oocyte is centrifuged or activated. All of the above treatments are designed to compensate for the intrinsic defects in conventional ICSI. Our objective was to use a modified ICSI procedure whereby aggressively motile sperm were captured onto the broken tip of an injection pipette and then injected into noncentrifuged oocytes. Damage to the head of the sperm occurred on the pipette or while pushed through the zona pellucida. These procedures are based on the work of Yong et al. 2003 Hum. Reprod. 18, 2390, where they achieved an improvement in development in vitro as compared to conventional methods. Ovaries were collected from prepubertal gilts, and oocytes were aspirated and matured in vitro. Sperm were collected from a transgenic boar carrying the green fluorescent protein (GFP) and frozen. After thawing, aggressively motile sperm were captured and injected through the zona pellucida and into the cytoplasm of the in vitro-matured oocytes. A total of 452 injected oocytes (43-171 oocytes per recipient) were surgically transferred into the oviduct of six surrogate gilts. Two gilts (33%) became pregnant. One gave birth to a healthy male piglet. GFP expression was observed in the nose and hooves by direct epifluorescent examination of the newborn piglet. This pattern of GFP expression is identical to that in non-ICSI-derived GFP pigs in this line. This result showed for the first time that this new sperm injection technique could be used for production of a viable transgenic piglet using in vitro-matured oocytes and frozen-thawed sperm.

Short-pouch and low-anastomosis Duhamel procedure results in better fecal control and normal defecation pattern

PURPOSE

The purpose of this study was to analyze the long-term outcome of the short-pouch and low-anastomosis Duhamel procedure and to evaluate the quality of life after pull-through. We also tried to answer the questions: Does the modified Duhamel procedure produce fecal continence? Is the quality of life correlated to normal bowel function (1-3 per day) without the use of laxatives?

MATERIALS AND METHODS

Between January 1993 and January 2002, 53 patients, 44 (83 percent) males and 9 (17 percent) females, who underwent a Duhamel procedure were assessed retrospectively. Of the 53 children, 36 (67.9 percent) underwent a primary Duhamel procedure at our institute (Group A). Seventeen (32.1 percent) patients had a primary Duhamel pull-through and subsequently a stoma before a redo modified Duhamel procedure (Group B). The technical modification was creation of a short rectal pouch of 35 mm, achieving a low colorectal anastomosis 0.5 cm from or on the dentate line. All 53 patients were assessed prospectively by a disease-specific questionnaire. The total score provided a single index of the quality of life associated with fecal continence.

RESULTS

For Group A (n = 36), the mean period of follow-up was 71.4 +/- 29 months. Constipation was seen in four (11.1 percent) patients. In two (5.6 percent) patients there was a mild degree of soiling. Sensation and urge to defecate was intact in 34 (94.4 percent) children who could wait to go to the toilet until it was socially convenient. For Group B (n = 17), the mean period of follow-up was 73.9 +/- 31.2 months. Constipation occurred in 17 (100 percent), encopresis in 14 (82.4 percent), and enterocolitis in 15 (88.2 percent) after the primary Duhamel procedure. In comparison, there was complete absence of constipation (100 percent), encopresis (100 percent), and complete resolution of enterocolitis (100 percent) after the redo modified Duhamel (P = 0.001). Continence to solid stools after primary Duhamel was seen in 5 (29.4 percent) vs. 17 (100 percent) after redo modified Duhamel. After the redo modified Duhamel all 17 (100 percent) patients have retained the sensation and urge to defecate and 15 (88.2 percent) can wait to get to the toilet until it is socially convenient. In all 53 patients, the quality of life was good in 86.8 percent (46/53) and correlated directly with fecal continence (r = 0.977). There was no correlation between age of patient and fecal continence (r = 0.597) and rate of fecal incontinence did not decrease with age. Direct correlation was seen with the presence of constipation and the incidence of late onset enterocolitis (r = 0.942).

CONCLUSIONS

Short-pouch, low-anastomosis Duhamel pull-through procedure results in fecal continence and complete emptying. The above procedure has a positive impact on the quality of life in these children.

Herniation through the foramen of Winslow presenting as obstructive jaundice

Herniation through the foramen of Winslow is a rare variety of paraduodenal hernia. We report a 19-month-old child with obstructive jaundice due to midgut herniation through the foramen of Winslow with associated volvulus. The herniation and volvulus were precipitated by intestinal malrotation. The patient underwent extraamniotic silo repair of exomphalos major in the neonatal period. Investigation for malrotation is recommended after extraamniotic closure of exomphalos.

Fludarabine in comparison to alkylator-based regimen as induction therapy for chronic lymphocytic leukemia: a systematic review and meta-analysis

The superiority of Fludarabine over conventional therapy as primary induction therapy for patients with chronic lymphocytic leukemia (CLL) has been shown in several studies but no studies have yet reported a pooled estimate of the treatment effect. We performed a systematic review of evidence from 5 randomized controlled trials involving approximately 1300 patients with CLL, comparing Fludarabine with several alkylator-based combination regimens in the primary treatment of CLL. Complete response rate was significantly higher for Fludarabine compared to alkylator-based chemotherapy (RR 1.87, 95% CI 1.10-3.19, P=0.02), while overall response, though superior, did not reach statistical significance (RR 1.22, 95% CI=0.88-1.69, P=0.24). Overall survival was similar for Fludarabine and alkylator-based therapy (the pooled log hazard ratio of death, HR=-0.05, 95% CI=-0.36-0.26, P=0.75). Infection rate was significantly higher (RR 1.58, 95% CI=1.10-2.27, P=0.01), but there was no significant difference in the incidence of thrombocytopenia, neutropenia and anemia. Therefore, this meta-analysis supports the findings that Fludarabine as an induction agent for patients with CLL yields a better clinical response with acceptable toxicity when compared with alkylator-based combination therapy, but without a survival benefit by 5-6 years of follow up.

A forgotten old disease: mediastinal tuberculous lymphadenitis in children

OBJECTIVE

The purpose of the study was two-fold: (1) to highlight the varied presentation of mediastinal tuberculous lymphadenitis (MTL) in children and (2) to identify parameters, that may help in the early diagnosis of this condition.

METHODS

Between January 1995 and December 2002, 13 children with histological diagnosis of MTL were retrospectively assessed for age at presentation, history of exposure to TB, presenting symptoms, investigations, initial diagnosis, surgical treatment and outcome. Stepwise multiple linear regression analysis was used to determine potential risk factors for early diagnosis of MTL.

RESULTS

Thirteen children presented with: (a) fever, night sweats and weight loss (4); (b) acute respiratory distress (2); (c) cough and shortness of breath (SOB) (5); (d) stridor (1); and (e) chest pain (1). TB was suspected only in 6 children (46%) at presentation. In the other 7 cases (54%) the presumed diagnoses were: neuroblastoma (n=1), metastatic malignancy (n=1), bronchial polyp (n=1), bronchogenic cyst (n=2), and presumed foreign body (n=2). Bronchoscopy was diagnostic in identifying cheesy material within the bronchus and organisms on lavage in 4 (30%) and in identifying external compression in 2 (15%). Thoracotomy and excision of the lymph node mass was necessary to treat the mediastinal compression and to ascertain the diagnosis of TB in 3 children (23%). All 13 children had complete resolution of tuberculous lymphadenitis following anti-tuberculous treatment. The diagnostic clues in this cohort of patients were cough and SOB with history of exposure to tuberculosis (P=0.0001) and bronchoscopy and lavage with positive staining for acid-fast bacilli (P=0.0001).

CONCLUSIONS

Tuberculosis was not suspected in 54% of children with MTL, and they posed diagnostic dilemma on admission. Bronchoscopy must be used as a diagnostic tool in children where tuberculosis cannot be excluded by radiology or specific skin tests. Thoracotomy and excision may be necessary to treat the obstructive symptoms.

Interventions for photodamaged skin

BACKGROUND

Photodamage describes skin changes such as fine and coarse wrinkles, roughness, freckles and pigmentation changes that occur as a result of prolonged exposure to the sun. Many treatments are available to reverse the damage, but it is unclear which work and at what cost in terms of unwanted side effects.

OBJECTIVES

To assess the effects of topically applied treatments, tablet treatments, laser and surgical procedures for photodamaged skin.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Issue 1 2002, MEDLINE (1966-June 2002), EMBASE (1974-June 2002), Health Periodicals (1976-June 2002). We checked references of articles and communicated with authors and the pharmaceutical industry.

SELECTION CRITERIA

Randomised controlled trials which compared drug or surgical interventions with no treatment, placebo or another drug, in adults with mild, moderate or severe photodamage of the face or forearms.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Thirty studies of variable quality were included. Eight trials showed that topical tretinoin cream, in concentrations of 0.02% or higher, was superior to placebo for participants with mild to severe photodamage on the face and forearms (although losses to follow-up were relatively high in most studies). For example, the relative risk of improvement for 0.05% tretinoin cream, compared to placebo (three studies), at 24 weeks, was 1.73 (95% confidence interval 1.39 to 2.14). This effect was not seen for 0.001% topical tretinoin (one study) or 0.01% (three studies). A dose-response relationship was evident for both effectiveness and skin irritation. One small within-patient study showed benefit from topical ascorbic acid compared with placebo. Tazarotene (0.01% to 0.1%) and isotretinoin (0.1%) both showed significant improvement over placebo for moderate photodamage (one study each). There is limited evidence (one trial), to show that the effectiveness of 0.05% tretinoin, is equivalent to the effects of 0.05% and 0.1% tazarotene. One small study showed greater improvement in upper lip wrinkles with CO2 laser technique compared to Baker's phenol chemical peel, at 6 months. Three small RCTs comparing CO2 laser with dermabrasion found no difference in wrinkle score at 4 to 6 months, suggesting that both methods are equally efficacious, but more erythema was reported with the laser. The effectiveness of other interventions such as hydroxy acids and natural polysaccharides was not clear.

AUTHORS' CONCLUSIONS

There is conclusive evidence that topical tretinoin improves the appearance of mild to moderate photodamage on the face and forearms, in the short term. However erythema, scaling/dryness, burning/stinging and irritation may be experienced initially. There is limited evidence that tazarotene and isotretinoin benefit patients with moderate photodamage on the face: both are associated with skin irritation and erythema. The effectiveness of other interventions remains uncertain.

Spontaneous postnatal involution of intraabdominal pulmonary sequestration

Prenatal ultrasonography in 2 pregnant women identified a suprarenal echogenic mass. The lesions were treated conservatively and involuted with time. These masses were consistent with a suprarenal pulmonary sequestration.

Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review

BACKGROUND

The initial treatment of a primary spontaneous pneumothorax (PSP) is controversial. Guidelines of the British Thoracic Society recommend simple aspiration for all PSP requiring intervention. The placement of chest tubes is only advocated for patients who fail simple aspiration. However, the American College of Chest Physicians Delphi Consensus Statement found simple aspiration to be rarely appropriate in the management of PSP.

AIMS

To compare simple aspiration with chest-tube drainage in the initial management of PSP.

METHODS

Meta-analysis of randomized controlled trials (RCTs).

OUTCOME MEASURES

Reductions in duration of hospital stay, recurrence rate and pain or dyspnoea score were classified as benefits, whereas reductions in successful events were classified as risks.

DATA COLLECTION AND ANALYSIS

For dichotomous data, the relative risk (RR) and 95% confidence intervals were calculated. For continuous data, weighted mean differences (WMD) were used.

RESULTS

Three RCTs were identified with a combined total of 194 patients. Simple aspiration was associated with shorter hospitalization (WMD -1.30 days [-2.20 to -0.39]). The results for success rate could not be combined because of differences in outcome definitions. However, a pooled result for "success at 1 week or more" showed no significant difference between either intervention (RR 0.86 [0.67, 1.11]). Results of recurrence at 1 year were also not significantly different (RR 0.73 [0.39-1.38]). Different reporting systems for pain scores meant that data could not be pooled. Only one trial reported dyspnoea scores.

CONCLUSION

RCT evidence in this field is limited, and the total sample size is too small to make any firm conclusion. On the basis of current available evidence, simple aspiration is advantageous in the initial management of PSP because of shorter hospitalization. There is no significant difference in recurrence at 1 year using either modality, and the efficacy data are inconclusive.

IS SPINA BIFIDA OCCULTA ASSOCIATED WITH LOWER URINARY TRACT DYSFUNCTION IN CHILDREN?

PURPOSE

Of congenital malformations of the central nervous system 46% are abnormalities of the spinal cord, which includes spina bifida occulta. The occurrence and significance of spina bifida occulta in children with lower urinary tract and bowel dysfunction were evaluated prospectively.

MATERIALS AND METHODS

Between January 1999 and February 2001, 158 consecutive children presenting with lower urinary tract and bowel dysfunction were prospectively evaluated for associated spinal abnormalities. Plain abdominal x-ray showed either the presence or absence of fusion of the posterior elements of the lumbar and/or sacral spinous processes. Of the 158 patients 57 (36%) had spina bifida occulta (group 1) and 101 (64%) did not (group 2).

RESULTS

There was no correlation between clinical outcome in group 1 with spina bifida occulta and lower urinary tract dysfunction and the pattern of spina bifida occulta. Significant correlation was present between lower urinary tract dysfunction and the presence of spina bifida occulta on plain abdominal x-ray. No significant correlation was found between the presence of spina bifida occulta and spinal cord abnormalities by magnetic resonance imaging scan. There was no direct causal relation between the radiological finding and lower urinary tract dysfunction.

CONCLUSIONS

Children presenting with spina bifida occulta, and lower urinary tract and bowel dysfunction have normal genitourinary tracts and absent spinal cord abnormalities. Spina bifida occulta is probably a coincidental finding and its true significance in this cohort was not established.

318EFFECT OF PIG FOLLICLE FLUID AND FETAL CALF SERUM ON PORCINE OOCYTE MATURATION AND SUBSEQUENT DEVELOPMENT AFTER ACTIVATION AND SOMATIC CELL NUCLEAR TRANSFER

In vitro maturation of porcine oocytes is very important for understanding porcine somatic cell nuclear transfer (SCNT). In order to develop an in vitro maturation system that can provide more high quality oocytes, the effect of porcine follicle fluid (pFF) (gathered from 3–5-mm porcine follicles) and fetal calf serum (FCS: Sigma, St. Louis, MO, USA), as an important additional component of a chemically-defined medium was studied. Cumulus-oocyte complexes (COC) derived from follicles 3–5mm in diameter were cultured in three different media: a chemically-defined medium (CDM: TCM-199 with 0.1mgmL−1 cysteine, 10ngmL−1 EGF, 0.5μgmL−1 LH and 0.5μgmL−1 FSH); CDM with 10% pFF (CDM+p); and CDM with 10% FCS (CDM+F). After 42–44h of maturation, oocytes with a clear polar body were classified as matured oocytes. Matured oocytes stimulated by electric pulse (120v, 30μs, 2 pulse), or enucleated and fused with fibroblasts to construct SCNT embryos by using the same electrical parameters. All of these parthenogenetic and SCNT embryos were cultured in Porcine Zygote Medium-3. The blastocyst rate was assessed under a stereomicroscope on Day 6, and the number of nuclei in the blastocysts was counted under a fluorescent microscope after staining with 5μgmL−1 of Hoechst 33342. All data were subjected to a Generalized Linear Model Procedure (PROC-GLM) of Statistical Analysis System (SAS). The maturation rates of porcine oocytes in CDM and CDM+p were 53.2±3.8% (539/1050) and 69.7±3.8% (587/847), respectively;; in CDM and CDM+F, 61.1±3.1% (471/776) and 70.2±3.7% (577/844), respectively. Oocytes matured in CDM+p and CDM+F showed a higher (P&lt;0.05) maturation rate than those in CDM. The percentages of parthenogenetic blastocysts of oocytes matured in CDM and CDM+p were 13.9±2.1% (35/250) and 20.2±5.3% (64/300), and the numbers of nuclei in these blastocysts were 25.8±2.3 and 25.8±1.4, respectively. The blastocyst rate from CDM- and CDM+F-matured oocytes were 20.1±2.0% (53/272) and 22.2±4.7%(71/298), and the numbers of nuclei in these blastocysts were 24.7±1.5 and 25.3±1.5, respectively. There were no significant (P&gt;0.05) differences in the percentages of parthenogenetic blastocysts and nuclei numbers between CDM and CDM+p, or CDM and CDM+F. The percentages of blastocysts in SCNT embryos derived from CDM and CDM+p were 8.1±1.5% (14/192) and 12.3±1.9% (24/192), while the nuclei numbers in these blastocysts were 26.6±1.2 and 34.5±2.2, respectively. The percentages of blastocysts after SCNT from oocytes matured in CDM and CDM+F were 24.3±4.9% (35/139) and 27.1±5.5% (45/176), while the numbers of nuclei were 29.8±2.5 and 32.2±1.9, respectively. There were no significant (P&gt;0.05) differences between CDM and CDM+p, or CDM and CDM+F in SCNT embryo blastocyst rate, but the SCNT embryos derived from CDM+p showed a higher (P&lt;0.05) nuclear number. In conclusion, these results indicate that 10% pFF or FCS in CDM can promote a higher maturation rate of porcine oocytes. As recipient cytoplasm for SCNT, oocytes matured in CDM+p can support development of blastocysts that contain more nuclei than those matured in CDM alone. Supported in part by Food for the 21st Century and RR13438.

Tubularized incised-plate urethroplasty for distal and proximal hypospadias

OBJECTIVE

To describe the tubularized incised-plate (TIP) urethroplasty for distal and proximal hypospadias.

PATIENTS AND METHODS

TIP urethroplasty was undertaken in 83 consecutive boys (mean age 14.1 months, sd 7.8) within the past 3 years; 65 (78%) had distal and 18 (22%) proximal penile hypospadias. This was the primary attempt at hypospadias repair in all children.

RESULTS

All patients were assessed 7 days after surgery at the time of dressing and catheter removal, and subsequently at a median of 4 months in the clinic, before being discharged. The overall late complication rate was 12% and 10% required a second operation. There was a urethrocutaneous fistula in three (5%) of those with distal and in one of the 18 with proximal penile hypospadias (P = 0.56). Glans dehiscence in distal hypospadias occurred in one (1%) and three, respectively (P = 0.01). Secondary surgery for fistula repair and glans closure was successful in all patients. All children void with a single straight urinary stream in a forward direction, and have a normally situated vertical slit-like glanular meatus.

CONCLUSIONS

TIP urethroplasty is a versatile, simple operation with good cosmetic results, which uses the urethral plate to its maximum potential.

Management of urinary extravasation in 18 boys with posterior urethral valves

PURPOSE

Urinary extravasation with associated posterior urethral valves is uncommon and published articles are restricted to case reports. We propose a management algorithm on the basis of presentation of 18 boys with this condition.

MATERIALS AND METHODS

In this retrospective review we analyze the clinical features, diagnostic radiological imaging (voiding cystourethrogram and (99m)technetium mercaptoacetyltriglycine scan) and measured glomerular filtration rate (GFR) for assessment of renal function in boys presenting with posterior urethral valves and urinary extravasation. Indications for surgical intervention and long-term outcome were evaluated. Results are presented as mean +/- SD.

RESULTS

Patient age at presentation was 4 days (range 1 to 28). Salient features at presentation were abdominal distention in 55.5% of cases, flank mass in 55.5%, respiratory distress in 16.6% and septicemia in 22.2%. Patients were categorized into group 1 with ascites (6 boys) and group 2 without ascites (12). Followup was 70.8 +/- 5.6 months. In group 1 the 3 boys with ascites alone had a followup GFR of 29 versus 74 ml. per minute per 1.73 m.2 in 3 with urinoma plus ascites (p = 0.001) at 64 +/- 4.9 months. In group 2 the GFR in 3 boys with bilateral urinoma was 104.7 +/- 30.4 versus 54.3 +/- 29.4 ml. per minute per 1.73 m.2 in the other 9 with unilateral urinoma (p = 0.001) at 36 +/- 4.2 and 81.3 +/- 4.7 months, respectively. The ipsilateral kidney showed reduced function in 6 of 12 boys with unilateral urinoma from both groups.

CONCLUSIONS

Renal function on the side of the urinoma is impaired, and the majority of patients have impaired global renal function. A management algorithm is proposed.

Distal hypospadias: which repair?

OBJECTIVE

To compare the function, complications and cosmesis after a modified Thiersch-Duplay and Mathieu unstented urethroplasty.

PATIENTS AND METHODS

Over a 5-year period 381 consecutive patients (not randomized) with distal hypospadias were evaluated. A modified Thiersch-Duplay with dorsal incised urethral plate tubularization (group A) was undertaken in 170 (45%) and a parameatal based flip-flap Mathieu hypospadias repair (group B) in 211 (55%). No urinary diversion or stent was used in any of the 381 patients.

RESULTS

In both groups the mean (sd) follow-up was 3.1 (1.4) years. All 381 patients voided spontaneously after surgery and none developed urinary retention needing catheterization. In groups A and B, respectively, the overall late complications were 12 (7.1%) and 32 (15.2%) (P=0.001), with urethrocutaneous fistula in six (3.5%) and 26 (12.3%; P=0.001); secondary surgery for fistula repair was successful in all boys in A and 89% in B. The glanular meatus was a vertical slit in all in group A and 86% in B (P=0.02). In both groups, 71% of the children who are now toilet-trained and standing to void have a good calibre, single and straight urinary stream in a forward direction.

CONCLUSIONS

Stenting or urinary diversion is unnecessary after distal hypospadias surgery. The functional results were good in those standing to void. A more natural vertical slit-like glanular meatus was easily created using the modified Thiersch-Duplay urethroplasty, with a lower fistula rate.

Prospective evaluation of nonsurgical versus surgical management of appendiceal mass

PURPOSE

Prospective evaluation was undertaken of surgical findings, complications, morbidity, and hospital stay between initial nonsurgical management versus early surgical intervention of an appendicular mass.

METHODS

A prospective, nonrandomized study was conducted of 82 consecutive patients (mean age, 6.9 +/- 3.3 years) presenting with an appendicular mass over a 5-year period. They were categorized as group 1, 58.5% (48 of 82) nonsurgically managed and an interval appendectomy performed at a mean period of 8.6 +/- 4.6 weeks and group 2, 41.5% (34 of 82) appendectomy at presentation.

RESULTS

An appendix was identified in all 82 patients in both groups at operation. In-group 1, recurrent episodes of abdominal pain necessitated interval appendectomy in 39.6% (19 of 48) patients at a mean 4.3 +/- 0.8 versus 11.5 +/- 3.7 weeks in 60.4% (29 of 48) who underwent scheduled interval appendectomy. Periappendiceal abscesses present at interval appendectomy in group 1 was (38 of 48) 79.2% versus 100% (34 of 34) at appendectomy in group 2. Adhesions at interval appendectomy in group 1 was 81.3% (39 of 48) versus 100% (34 of 34) at appendectomy in group 2. In-group 1, superficial wound infection was observed in 0 versus 4 wound infections in group 2. Overall morbidity rate between group 1 and group 2 was statistically significant (P <.05). Total mean hospital stay in group 1 was 13.2 +/- 1.5 versus 4.8 +/- 0.4 days in group 2. Of the 48-interval appendectomy specimens, 37 of 48 (77%) appendices had a patent lumen, and 11 of 48 (23%) showed fibrosis and obliteration of appendicular lumen. There was no correlation (r = 0.22) between the histopathologic findings and the interval between abscess treatment and interval appendectomy.

CONCLUSIONS

Early surgical intervention was beneficial over nonoperative management in this cohort of patients. Interval appendectomy is recommended after nonsurgical management of an appendicular mass.

Quantitative and qualitative analysis of gastroesophageal reflux after percutaneous endoscopic gastrostomy

BACKGROUND/PURPOSE

Percutaneous endoscopic gastrostomy (PEG) is of great benefit to a defined population of children, but gastrostomy has been implicated in causation or exacerbation of gastroesophageal reflux (GER). The aim of this study was to quantitatively and qualitatively analyze the effect of PEG on GER.

METHODS AND MATERIAL

Sixty-four children mean age 6.7 +/- 4.2 years, most of whom were impaired neurologically were evaluated for GER after PEG between 1998 and 2000. Twenty-four-hour pH monitoring was used for quantitative assessment. Qualitative analysis was by interview to record the following: vomiting, choking, chest infection, and weight gain.

RESULTS

Twenty-four hour pH monitoring was performed 9.4 +/- 1.2 weeks after PEG. Patients underwent follow-up for 18 +/- 6 months. Seventy-two percent who did not have reflux before PEG remained reflux free. Fourteen percent who had GER before PEG continued to have reflux (P <.05). Only 5% of patients without GER before PEG had reflux afterward, and 3% of patients with preexisting GER deteriorated (P >.05). Six percent of patients with preexisting GER improved post-PEG. Of the 14 patients (22%) who had or continued to have reflux after PEG, 11 of 14 (79%) underwent antireflux surgery, and 21% were managed successfully by intensive medical treatment and change of feeding regimen. Only 6% experienced difficulties and complications with the device. Forty-eight percent of patients did not vomit pre- or postoperation. In 16%, vomiting improved post-PEG, whereas 14% experienced minor deterioration (1 to 2 vomits per month). Major deterioration was experienced by 22%. Weight gain occurred in 77%, and in 23% there was no loss of weight. There was an overall improvement in quality of life in 88% after PEG. Overall improvement in quality of life post-PEG, post-antireflux surgery and post-intensive medical management for pathologic GER was 94%.

CONCLUSIONS

(1) PEG did not precipitate or exacerbate GER quantitatively or qualitatively in the majority of children. (2) A normal 24-hour pH study predicted a favourable outcome after PEG. (3) An abnormal preoperation pH study predicted persistence or worsening reflux after PEG, but not all of these patients required an antireflux procedure. (4) GER is not a contraindication to PEG, the overall benefits of which outweigh the risks.

Prospective to a randomized double-blind controlled trial to assess efficacy of double caudal analgesia in hypospadias repair

BACKGROUND/PURPOSE

A prospective, randomised, double-blind, controlled trial to evaluate efficacy of double-caudal versus single-caudal injection for postoperative analgesia in hypospadias repair was performed.

METHODS

Between October 1998 and September 2000, 160 boys underwent distal hypospadias repair. The first 80 boys were analyzed prospectively for postoperative analgesia after double-caudal bupivacaine, which involves the administration of a second bupivacaine injection into the caudal extradural space at the end of surgery. Pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The study groups were: group 1, unstented Thiersch-Duplay urethroplasty (50); and group 2, stented Mathieu type repair (30). Results of this cohort formed the basis for a prospective, randomised, double-blind control trial comparing double-caudal against a single injection before operation. The further 80 patients were allocated randomly: group 3, single caudal injection of 1 mL kg(-1) of 0.25% plain bupivacaine at the start of surgery with unstented Thiersh-Duplay repair (25); group 4, similar single caudal injection but stented Mattieu type operation (15); group 5, second caudal and at end of operation (0.5 mL kg(-1) on each occasion) with unstented Thiersh-Duplay repair (25); and group 6, similar to group 5 but with stented Mattieu type repair (15).

RESULTS

Patient demographics (age and weight) and mean duration of operative time were similar for all groups. There was no significant difference in early pain scores at 0 to 2 hours with a good correlation coefficient (r = 0.88). At 4, 6, and 8 hours there was a significant difference in pain scores between double and single caudals (P <.05). There was a significant difference in mean duration of caudal analgesia and need for oral analgesia between single caudal 3.45 versus 7.85 hours for double caudal (P <.001). Mean duration of caudal analgesia and requirement for oral analgesia after single caudal in group 3 (unstented) was 3.5 versus 3.4 hours in group 4 (stented). In double caudals this lengthened to 9.4 hours in group 5 (unstented) versus 6.3 hours in group 6 (stented; P <.05). This also was significant when operation time was excluded.

CONCLUSIONS

A prospective study of double caudal analgesia showed good postoperative pain control after hypospadias surgery. This was followed by a prospective, randomised, double-blind controlled trial that has confirmed that double caudal injection of bupivacaine prolonged the duration of pain relief after hypospadias repair. The second or top-up caudal did not increase the total dose but supplemented and prolonged postoperative analgesia.

Staged proximal hypospadias repair: Modified thiersch duplay with midline incision in urethral plate followed by Mathieu urethroplasty

PURPOSE

Functional results, complications, cosmesis, operating time, and hospital stay were analyzed after staged urethroplasty for proximal hypospadias.

METHODS

Seventeen consecutive boys, mean age 17.7 +/- 1.6 months underwent a staged urethroplasty in the past 5 years. Urethral plate was tubularized and proximal hypospadias converted to distal. Hooded dorsal prepuce was buttonholed and transposed ventrally to cover the neo-urethra. Subsequently, a parameatal based flip flap urethroplasty completed the urethral reconstruction at mean age of 26.7 +/- 4.1 months.

RESULTS

Mean follow-up time was 2.8 +/- 1.7 years. Eighty-eight percent of boys who are now toilet trained and standing to void have a good caliber straight single stream of urine in a forward direction. Urethrocutaneous fistula was seen in 1 child (6%), and a simple fistulectomy with double layered closure was successful at first attempt of fistula closure. Cosmetic appearance of a natural vertical slit glanular meatus situated at normal position on the glans was achieved in all patients. Total mean operating time was 193.5 +/- 42.9 minutes and total mean duration of hospital stay was 3.4 +/- 0.6 days.

CONCLUSION

Staged urethroplasty for proximal hypospadias results in a normal penis with good function, minimal complications, and excellent cosmesis.

Molecular species composition of rat liver phospholipids by ESI-MS/MS: the effect of chromatography

Using electrospray ionization tandem mass spectrometry (ESI-MS/MS) this study shows that the loss of glycerophospholipid (GPL) after chromatography was unevenly distributed across the GPL molecular species. Both TLC and HPLC caused a preferential loss of GPL with 0 to 3 double bonds: 20% and 7.2% for choline glycerophosphates (PC) and 19.7% and 7.5% for ethanolamine glycerophosphates (PE), respectively. A consequence of these losses was that GPLs containing fatty acids with four or more double bonds had a greater contribution to the total after chromatography. ESI-MS/MS analysis also showed that PC molecular species with four or more double bonds migrated at the front of the TLC band of PCs. GPLs extracted from TLC plates occasionally contained PCs that were smaller than those in the original extract. These low molecular mass PCs were easily reduced to alcohols and formed derivatives with 2,4-dinitrophenylhydrazine, suggesting that aldehydes were generated by the oxidation of unsaturated fatty acids. Directly analyzing lipid extracts by ESI-MS/MS without preliminary chromatographic separation gives an accurate distribution of GPL molecular species in lipid mixtures. However, the ionization of the phospholipids in the electrospray jet maximized at relatively low concentrations of GPL. There was a linear response between phospholipid mass and ion intensity for concentrations around 1-2 nmol/ml for both PC and PE. The total ion intensity continued to increase with concentrations above 1-2 nmol/ml, but the response was non-linear.

Preparation and incorporation of probe-labeled apoA-I for fluorescence resonance energy transfer studies of rHDL

Apolipoprotein A-I (apoA-I), the major constituent of HDL, plays an essential role in regulating cholesterol metabolism, acting as the physiological activator of lecithin: cholesterol acyltransferase, which converts cholesterol to cholesterol ester. Thiol-reactive fluorescent probes attached to cysteine-containing apoA-I mutants are currently being used to investigate the "LCAT active" conformation of lipid-bound apoA-I. Herein, we report new methodologies allowing rapid expression, fluorescent labeling, and recombinant HDL (rHDL) preparation for use in apoA-I in fluorescence resonance energy transfer (FRET) studies. Cysteine-containing mutant forms of human apoA-I were cloned into the pTYB12 vector containing a T7 promoter, a modified self-splicing protein element (intein), and a small affinity tag [chitin binding domain (CBD)]. The fusion proteins were expressed in Escherichia coli, isolated from cell lysates, and bound to a chitin-affinity column. Release of mature human apoA-I was initiated by the addition of DTT, which induced self-cleavage at the COOH terminus of the intein - CBD fusion protein. ApoA-I was further purified by Q-sepharose and then used for fluorescent probe labeling. Discoidal rHDL were then prepared with donor and/or acceptor labeled apoA-I and characterized with respect to their size, composition and ability to activate LCAT.

Production of nuclear transfer-derived swine that express the enhanced green fluorescent protein

The ability to add or delete specific genes in swine will likely provide considerable benefits not just to agriculture but also to medicine, where pigs have potential as models for human disease and as organ donors. Here we have transferred nuclei from a genetically modified fibroblast cell line to porcine oocytes, matured in vitro under defined culture conditions, to create piglets expressing enhanced green fluorescent protein. The nuclear transfer-derived piglets were of normal size, although some mild symptoms of "large offspring syndrome" were evident. These experiments represent a next step towards creating swine with more useful genetic modifications.

Sodium channel gene mutations in hypokalemic periodic paralysis: an uncommon cause in the UK

Eleven of 36 families with hypokalemic periodic paralysis (hypoPP) harbored mutations in the skeletal muscle calcium channel gene (CACNA1S). The authors screened the skeletal muscle sodium channel gene (SCN4A) in the remainder. One family harbored a new heterozygous point mutation C2014A in exon 12 (R672S) of SCN4A. The authors identified the genetic defect underlying hypoPP in 33% of individuals tested. The authors conclude that SCN4A mutations are an uncommon cause of hypoPP in this UK population.

Proximal hypospadias. Comparative evaluation of staged urethroplasty (modified Thiersch Duplay followed by Mathieu) and single stage on-lay island flap repair

OBJECTIVES

Comparative analysis of functional results, complications, cosmesis, operative time and hospital stay between staged urethroplasty and single-stage on-lay island flap for proximal hypospadias.

MATERIALS AND METHODS

Non-randomised single observer study of two groups of patients over a 5-year period with proximal hypospadias. Group 1 had 17 patients (mean age 17.7+/-1.6 months) who underwent a staged urethroplasty. Urethral plate was tubularised and proximal hypospadias converted to a distal hypospadias. Hooded dorsal prepuce was buttonholed and transposed ventrally to cover the neo-urethra. Subsequently a parameatal based flip flap urethroplasty completed urethral reconstruction. Group 2 had 17 patients (mean age 18.2+/-2.2 months) with a single stage inner preputial on-lay island flap based on superficial dorsal vessels.

RESULTS

Mean period of follow-up has been 2.8+/-1.7 years in group 1 vs. 3.2+/-1.6 years in group 2 (p = 0.2). In both groups (34), 79% of the children who are now toilet trained and standing to void have a good calibre straight single stream of urine in a forward direction (p = 1.00). Main complication seen in both groups was urethrocutaneous fistulae: 6% (1/17) in group 1 vs. 59% (10/17) in group 2 (p = 0.0002). In both groups (34) cosmetic appearance of a natural vertical slit glanular meatus situated at the normal position on the glans was achieved (p = 1.00). Total mean duration of operative time in group 1 was 193.5+/-42.9 vs. 203+/-27.6 min in group 2 (p = 0.24). Total mean duration of hospital stay in group 1 was 3.4+/-0.6 vs. 9.2+/-2.9 days in group 2 (p = 0.0001). Total mean cost of the procedure in group 1 was 2,347.3 pounds +/- 220 vs. 3,753.5 pounds +/- 75 in group 2 (p = 0.002).

CONCLUSION

Staged urethroplasty for proximal hypospadias results in a normal penis with good function, minimal complications and excellent cosmesis. Hospital stay was shorter and overall cost lower than a single stage on-lay island flap urethroplasty.

What happens to the bladder at night? Overnight urodynamic monitoring in children with neurogenic vesical dysfunction

PURPOSE

We assess night and day function of the neuropathic bladder in children with neurogenic vesical dysfunction by overnight urodynamic monitoring and conventional static cystometrogram. Overnight urodynamics as a diagnostic tool was evaluated and its reproducibility analyzed.

MATERIALS AND METHODS

In 18 months 3 boys and 3 girls 6 to 14 years old (mean age plus or minus standard deviation 10.3 +/- 3.3) were studied prospectively. Each child was evaluated on 4 separate occasions with 2-daytime cystometrograms at a standard fill rate of 10 ml. per minute and 2 overnight urodynamic studies for 8 hours using a Urolog Recorder. All 6 children were interviewed regarding the acceptability, repeatability and compliance to overnight urodynamics.

RESULTS

Bladder capacity was not significantly different during each episode for either of the 2 tests. Mean bladder pressures in 2 children showed stable detrusor activity on cystometry (2 +/- 1.4 cm. H2O) and overnight urodynamics (0.4 +/- 0.5, r = 0.9). Detrusor compliance was not impaired in these 2 children. Four patients had frank detrusor instability with a mean bladder pressure of 50.6 +/- 17.4 cm. H2O on cystometry versus 35.9 +/- 5.2 on overnight urodynamics (r = 0.9). Bladder compliance was severely impaired in these 4 patients. Compliance at potential bladder capacity for patient age was 6.6 +/- 2.1 ml./cm. H2O for cystometry versus 9.2 +/- 3.4 for overnight urodynamics (p = 0.26, r = 0.9). Compliance at actual bladder capacity was 3.4 +/- 1.2 ml./cm. H2O for cystometry versus 3.8 +/- 0.8 for overnight urodynamics (p = 0.28, r = 0.9). There was good correlation between daytime cystometry and overnight urodynamics (p <0.001, Pearson's coefficient correlation 0.92, 95% confidence interval 0.90 to 0.94). A kappa statistical analysis showed good agreement between cystometry and overnight urodynamics for stable bladder and frank detrusor instability (kappa = 0.9). Replicated measurements of the same patient by the same observer had an error of variance of 1.7 cm. H2O with a narrow confidence interval, indicating the measurement error was small and that overnight urodynamics can be reproduced with relative accuracy within an individual. All 6 children preferred overnight urodynamics to cystometry.

CONCLUSIONS

There was good correlation between bladder behavior day and night. Overnight urodynamics were accurate in predicting detrusor activity, and well tolerated and less embarrassing for a child with neurogenic vesical dysfunction.

Xanthogranulomatous pyelonephritis in childhood

PURPOSE

Demographic data, clinical presentation, associated abnormalities, and radiologic findings were evaluated to outline diagnostic criteria that may lead to the diagnosis of xanthogranulomatous pyelonephritis in children.

METHODS

Eleven boys and 8 girls with a mean age of 3.4 +/- 1.7 years were classified into obstructive xanthogranulomatous pyelonephritis (n = 13), which was associated with nephrolithiasis and nonobstructive (n = 6), which mimicked Wilms' tumor.

RESULTS

Twelve children with obstructive diffuse involvement of the renal parenchyma, 1 with left-sided obstructive focal involvement in a horseshoe kidney (group 1), and 6 with nonobstructive diffuse xanthogranulomatous pyelonephritis (group 2) showed a male to female ratio of 1.2:1 and 2:1, respectively. Mean age was 4.1 +/- 1.2 years in group 1 versus 1.8 +/- 1.5 years in group 2; P =.001. The common features were renal mass, hematuria, and anemia (100%; P =.07) and leucocytosis (77% v 83%; P =.097). Main differences between the 2 groups were acute inflammatory syndrome (0 v 33%; P =.01), recurrent urinary infection (54% v 17%; P =.05), isolation of Proteus mirabilis as a pathogen (69% v 0; P =.001), and renal stones (100% v 0; P =.001). Preoperative diagnosis was accurate in all 13 (100%) children with obstructive xanthogranulomatous pyelonephritis. Radiologic features that were not consistent with Wilms' tumor in group 2 were absence of sharp definition and encapsulation of the mass, ill-defined margins with inflammatory infiltration of the perinephric fat and focal inflammatory tissue destruction. Nephrectomy was technically difficult because of extensive adhesions to the retroperitoneum, psoas muscle, and surrounding structures in both groups.

CONCLUSIONS

Xanthogranulomatous pyelonephritis must be considered in the differential diagnosis of a child presenting with a renal mass, anemia, and elevated inflammatory markers. Treatment by nephrectomy is curative. J Pediatr Surg 36:598-601.

Motor imagery in normal subjects and Parkinson's disease patients: an H215O PET study

Motor imagery paradigms can be used to investigate motor preparation. We used positron emission tomography to compare regional cerebral blood flow (rCBF) in patients with Parkinson's disease and normal controls under three conditions: rest, motor imagery and motor execution. In controls, imagery activated bilateral dorsolateral and mesial frontal cortex, inferior parietal cortex and precuneus. Motor execution additionally activated primary motor cortex (p < 0.001). Between-group, for imagery there was relative reduction in dorsolateral and mesial frontal activation in the patient group (p<0.01). For execution, there was impaired activation of right dorsolateral frontal cortex and basal ganglia (p<0.01). Our results support the notion that underfunctioning of mesial frontal and dorsolateral prefrontal cortex may underlie motor preparation in Parkinson's disease but also suggest that akinesia may occur in the absence of impaired mesial frontal cortex activation.

The effects of surgical treatment of Parkinson's disease on brain function: PET findings

Positron emission tomography allows a quantitative assessment of the impact of functional neurosurgery in Parkinson's disease (PD) by measuring regional cerebral flow and glucose and oxygen consumption as indicators of metabolic activity of specific brain regions. PET can also be used to study the dopaminergic nigrostriatal system, and therefore serves as a surrogate marker of the evolution of striatal grafts for PD. Pallidotomy has been associated with increased activation of premotor areas (supplementary motor area and dorsolateral prefrontal cortex) and reduced hyperactivity of the lentiform nucleus (augmented preoperatively). Pallidal (GPi) and subthalamic (STN) stimulation also increase activation of premotor areas but decrease activation of primary motor area. Suppression of unilateral tremor with thalamic stimulation is associated with a reduction in cerebellar blood flow. These main findings are in keeping with the general notion that increased activity in the STN GPi projection is directly implicated in the pathophysiology of PD. Surgical blockage of these output nuclei leads to partial restoration of cortical physiology.

Gastric tube graft interposition as an oesophageal substitute

BACKGROUND

Use and techniques of oesophageal replacement for long gap oesophageal atresia are still evolving. Gastric tube graft interposition as an oesophageal substitute was evaluated on an animal model.

METHODS

Twenty-three postweaned, 28-day-old-piglets were used as the experimental animals. Isoperistaltic gastric tube interposition based on the right gastroepiploic vessels was performed at 28 days of life. Postoperative evaluation included weekly measurement of weight, clinical assessment for gastrointestinal and respiratory complications and deglutition difficulties. Haemoglobin, serum ferritin, albumin, globulins, total proteins and red cell folate were assayed. Pigs were killed and analysed histopathologically following a maximum observation period of 149 days.

RESULTS

Growth of the pigs was normal. Deglutition was not impaired in 16 pigs (89%). Minor leak was diagnosed in three pigs (17%), which was successfully managed conservatively. Anastomotic stricture was seen in two pigs (11%). Graft necrosis was not seen. Gross histology showed the absence of hypertrophy, redundancy and kinking of the interposed gastric tube graft. Microscopically non-erosive oesophagitis was seen in three pigs (17%), ulcerative oesophagitis was seen in two pigs (11%) and submucosal fibrosis was seen in seven pigs (39%). Dysplasia or Barrett's oesophagitis was not observed at the end of animal growth.

CONCLUSIONS

Gastric tube graft interposition is an immediate ideal oesophageal substitute due to fewer complications, probable absence of gastro-oesophageal reflux in the majority by histology, and absence of dilatation and redundancy of the interpose tube. The oesophageal substitute adequately met the nutritional needs for growth and development in the animal model.

Interventions for treating melioidosis

BACKGROUND

Melioidosis is an infectious disease caused by a bacterium (Burkholderia pseudomallei) found particularly in some areas in the tropics. It is a serious condition which can be fatal. Beta lactam antibiotics have dramatically reduced the risk of death, but mortality still remains high.

OBJECTIVES

To summarise evidence from randomised trials on the effects of treatment regimens on death and relapse.

SEARCH STRATEGY

Cochrane Controlled Trials Register, MEDLINE, EMBASE, BIOSIS from 1966 to September 2000 using MeSH terms "pseudomallei", "melioidosis" together with the terms "randomized-controlled-trial", "random allocation"; reference lists in articles on melioidosis; contact with trialists.

SELECTION CRITERIA

Randomised and quasi-randomised trials assessing treatments in patients with melioidosis.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality was assessed by two reviewers independently.

MAIN RESULTS

For intravenous therapy in the acute phase, we identified five trials with a total of 519 patients. Chloramphenicol, doxycycline, and co-trimoxazole (trimethoprim-sulphamethoxazole) combination regimens were associated with a mortality of 50% or more (two studies). Patients randomised to regimens that included ceftazidime were more likely to survive (relative risk [RR] 0.46, 95% confidence interval [CI] 0.30 to 0.71). When ceftazidime-containing regimens were compared with beta lactam or alternative beta lactamase inhibitor regimens such as co-amoxiclav (amoxycillin-clavulanic acid) and cefoperazone-sulbactam, mortality rates were similar (RR 1.10, 95% CI 0.83 to 1.46), as was the case in one trial of imipenem. For oral therapy in the maintenance phase, we found two trials of 188 participants. Results showed that treatment with the conventional regimen (chloramphenicol, doxycycline, and trimethoprim-sulphamethoxazole) resulted in fewer fatalities in patients compared to a regimen of amoxycillin-clavulanic acid and doxycycline alone.

REVIEWER'S CONCLUSIONS

Regimens for the acute phase of illness should contain ceftazidime or imipenem. It is not yet clear if combinations of treatments in the early phase reduce relapse. For oral therapy after the acute phase of treatment, trials suggest that conventional four drug regimens can be used for treatment.

Currarino triad--diagnostic dilemma and a combined surgical approach

PURPOSE

The authors present 2 families with 3 cases of Currarino triad, diagnostic difficulties, their familial occurrence, and genetic mapping, with emphasis on a combined pediatric surgical and pediatric neurosurgical approach in managing these children.

RESULTS

The main presentation was intractable constipation. In the first family there was a 4-generation pedigree with recurrence of Currarino triad. The mother and the child have the condition. Family 2 screening showed a 3-generation pedigree with presence of Currarino triad in 3 members. Patients 2 and 3 are cousins whose fathers are affected by spina bifida occulta and Currarino triad, respectively. In patient 1, the diagnosis was made after inadvertent rupture of an anterior meningocele during posterior myectomy. In patient 2, the presacral mass was found on examination under anesthesia, and the planned anorectal myectomy for intractable constipation was abandoned. Patient 3 was a cousin of patient 2, and the diagnosis was considered when she presented with intractable constipation at the age of 7 months. Magnetic resonance scan was useful in showing the presence of presacral mass, spinal abnormalities, and tethered cord. A combined pediatric and neurosurgical approach optimized the extirpation of the presacral mass with minimal complications. Surgical treatment was individualized according to the estimation of the operative risk factors. All patients have a normal bladder function. Patient 1 has required laxatives and enemas for intermittent constipation. She has associated learning difficulties but is otherwise well. Patient 2 and 3, aged 10 and 2 years, respectively, are awaiting closure of colostomy. They are thriving and well.

CONCLUSIONS

The authors recommend a combined pediatric and neurosurgical assessment and management for all cases of Currarino triad. Family screening is obligatory. The authors suggest the use of a magnetic resonance scan or computerized axial tomography myelogram to define the presence of anosacral and spinal cord anomalies in patients with intractable constipation.