Neurotrophin signaling in a genitofemoral nerve target organ during testicular descent in mice

BACKGROUND/AIM

It has been proposed that androgens control inguinoscrotal testicular descent via release of calcitonin gene-related peptide (CGRP) from a masculinised genitofemoral nerve (GFN). As there are androgen receptors in the inguinoscrotal fat pad (IFP) during the window of androgen sensitivity (E14-17 in mouse embryos), we tested the hypothesis that neurotrophins in the IFP may masculinise the sensory fibers of the GFN supplying the gubernaculum and IFP prior to gubernacular migration.

METHODS

Androgen-receptor knockout (ARKO) and wild-type (WT) mouse embryos were collected at E17, with ethical approval (AEC 734). Sagittal sections of IFP, mammary area and bulbocavernosus (BC) muscle were processed for standard histology and fluorescent immunohistochemistry for ciliary neurotrophic factor (CNTF), ciliary neurotrophic factor receptor (CNTFR) and cell nuclei (DAPI).

RESULTS

In the ARKO mouse CNTFR immunoreactivity (CNTFR-IR) was increased in the IFP but decreased in BC. Perinuclear staining of CNTF-IR was seen in mouse sciatic nerve but only weakly in IFP. In the mammary area, also supplied by GFN, there were no differences in IR staining.

CONCLUSION

This study found CNTFR-IR in the IFP was negatively regulated by androgen, suggesting that CNTF signaling may be suppressed in GFN sensory nerves to enable CGRP expression for regulating gubernacular migration in the male, but not the female. The indirect action of androgen via the GFN required for testicular descent may be one of the sites of anomalies in the putative multifactorial cause of cryptorchidism.

Nuclear transit study in children with chronic faecal soiling after Hirschsprung disease (HSCR) surgery has revealed a group with rapid proximal colonic treatment and possible adverse reactions to food

BACKGROUND/PURPOSE

Long-term problems with faecal incontinence occur in up to 50 % of patients after pull-through for Hirschsprung disease (HSCR). The cause often remains unknown, leading to empirical treatments. Using nuclear transit study, we found some patients surprisingly had rapid proximal colonic transit, suspicious of occult diarrhoea. We aimed to assess whether these patients had unrecognized adverse reactions to food.

METHODS

Patients (n = 10, all males, 9.6 year; 4.25-15.5 years) with persistent faecal incontinence following pull-through for HSCR referred to the senior author and after exclusion of anatomical defects, underwent nuclear transit studies. Most (8) subsequently underwent breath hydrogen tests for sugar malabsorption and were tested for adverse reactions to food. Exclusion diets for protein allergens, lactose or fructose were then trialed.

RESULTS

Of the 10 patients with rapid intestinal transit proven on nuclear transit study, breath hydrogen tests for fructose and/or lactose malabsorption were done in 8, and were positive in 7/8 patients. Exclusion diets contributed to either resolution or improvement in faecal incontinence in 9/10 patients.

CONCLUSIONS

Rapid transit in the proximal, ganglionated colon may be present in children with faecal incontinence following pull-through for HSCR, possibly secondary to adverse reactions to food. This study suggests that children with post-operative soiling may benefit from a transit study and hydrogen breath tests to diagnose adverse reactions to food caused by sugar malabsorption.

The effect of food withdrawal in children with rapid-transit constipation

BACKGROUND

Rapid proximal colonic transit with anorectal holdup is a subtype of chronic constipation linked to food intolerance. We aimed to determine the effectiveness of dietary exclusion as a treatment for constipated children with rapid-transit constipation by scintigraphy.

METHODS

Questionnaires on diet and symptoms were mailed out to 125 children with chronic constipation and rapid proximal colonic transit on nuclear transit study at our institute between 1998 and 2014 years. Patients were given instructions and encouraged to undertake a six-food elimination diet targeting common protein allergens (dairy, wheat, soy, eggs, nuts, seafood). Answers were completed by circling an option or on visual analogue scale. Results were evaluated statistically using GraphPad Prism 6 by a Wilcoxon matched-pairs rank test. P < 0.05 was considered significant.

RESULTS

We received 44/125 responses, 26 patients [mean age 11 years (5-21)] had attempted elimination diet and 18 had not. Dairy and wheat were the most common foods eliminated and symptomatic improvement was greater for patients who had completely eliminated foods. Constipation, abdominal pain and pain on defecation were reduced (p < 0.01). Laxative usage decreased, although this was not statistically significant. Families encountered problems with dietary exclusion, particularly expense. Assistance from a dietician or nutritionist was sought by >50 % of families.

CONCLUSION

Dietary exclusion is a promising strategy to treat constipation in children with rapid proximal colonic transit. However, it was hard for many families, demonstrating the need for identifying the cause more specifically and a better set of instructions for the family and/or dietitian to follow.

Is the ovary in an inguinal hernia 'descended' like a testis or not?

BACKGROUND/AIM

How testes descend through the inguinal canal is well described, but how the ovaries appear inside an inguinal hernia remains controversial. We reviewed the literature to determine whether ovarian 'descent' has been described.

METHODS

The English literature from 1950 to 2014 was reviewed via PubMed, Medline and Web of Science to identify papers describing an ovary in the hernia sac: reports were examined to find whether the ovary prolapsed or 'descended', and the anatomy of its supporting ligaments, cranial suspensory ligament (CSL) and round ligament (female gubernaculum, RL).

RESULTS

In forty reports of >7140 inguinal herniotomies and/or imaging studies in females the hernia contains an ovary in 15-20%, often with the ipsilateral fallopian tube. The RL and ovary were aligned along the same path as testicular descent only rarely in Müllerian anomalies with an isolated uterine horn preceding the ovary into the sac. The ligament usually found inside the hernia sac was the CSL, not the RL.

DISCUSSION

The high frequency of incarcerated ovary, along with the close proximity of the CSL to the internal ring in females is consistent with a sliding hernia pulling the CSL (and ovary) into the hernia sac, not ovarian 'descent' by traction on the RL.

Home Transcutaneous Electrical Stimulation Therapy to Treat Children With Anorectal Retention: A Pilot Study

AIM

As transcutaneous electrical stimulation (TES) increased defecation in children and adults with Slow-Transit Constipation (STC), we performed a pilot study to test if TES can improve symptoms (defecation and soiling) in children with chronic constipation without STC and transit delay in the anorectum.

METHODS

Children with treatment-resistant constipation presenting to a tertiary hospital had gastrointestinal nuclear transit study (NTS) showing normal proximal colonic transit and anorectal holdup of tracer. TES was administered at home (1 hour/day for 3 months) using a battery-powered interferential stimulator, with four adhesive electrodes (4 × 4 cm) connected so currents cross within the lower abdomen at the level of S2-S4. Stimulation was added to existing laxatives. Daily continence diary, and quality-of-life questionnaires (PedsQL4.0) were compared before and after TES.

RESULTS

Ten children (4 females: 5-10 years, mean 8 years) had holdup in the anorectum by NTS. Nine had <3 bowel motions (BM)/week. After three months TES, defecation frequency increased in 9/10 (mean 0.9-4.1 BM/week, p = 0.004), with 6/9 improved to ≥3 BM/week. Soiling reduced in 9/10 from 5.9 to 1.9 days/week with soiling, p = 0.004. Ten were on laxatives, and nine reduced/stopped laxative use. Quality-of-life improved to within the normal range.

CONCLUSION

TES improved symptoms of constipation in >50% of children with treatment-resistant constipation with isolated holdup in the anorectum. Further studies (RCTs) are warranted in these children.

Why do undescended testes and posterior urethral valve occur together?

BACKGROUND/AIM

Undescended testis (UDT) occurs in ~2 % of newborn males, and occasionally these infants also have posterior urethral valve (PUV). The cause of this relationship is uncertain. We aimed to review the literature to identify publications documenting co-occurrence of UDT and PUV, and to summarise the theories of co-occurrence.

METHODS

A search of the literature (Embase, Medline, Pubmed; 1947-2015) was undertaken to identify publications describing the link between UDT in PUV patients, as well as PUV in UDT patients. Ten publications in English were found with both UDT and PUV: 9 articles describing the frequency of UDT in patients with PUV, and 1 article examining the frequency of PUV in infants with UDT.

RESULTS

UDT occurred in 12-17 % of PUV compared with 1-2 % in the control population, consistent with a 10-fold increase. PUV occurred in 1.2 % of UDT patients compared with 0.01 % in the control population, consistent with a 100-fold increase.

DISCUSSION

PUV leads to a 10-fold increase in occurrence of UDT, while the presence of UDT causes a 100-fold increase in occurrence of PUV. Four main theories of causation have been proposed, each of which have some merit but little supporting evidence, leaving the cause of simultaneous occurrence of PUV and UDT uncertain.

The Sertoli cell hormones inhibin-B and anti Müllerian hormone have different patterns of secretion in prepubertal cryptorchid boys

OBJECTIVES AND HYPOTHESES

The Sertoli-cells produce inhibin-B and Anti-Müllerian-Hormone (AMH). Much is still unknown about these hormones in prepubertal cryptorchids. The Sertoli-cells are mandatory for germ cell development. The aim of the study was to investigate if there are differences in secretion pattern of Sertoli-cell hormones and their gonadotropin feed-back mechanisms.

METHODS

Included were 94 prepubertal cryptorchid boys 0.5-13.1years with measurements of serum-inhibin-B, Anti-Müllerian-Hormone (AMH), Luteinizing Hormone (LH) and Follicle Stimulation Hormone (FSH). The serum values were measured using commercially available kits. The hormonal values were related to age-matched normal values. Testicular biopsy was taken at orchiopexy.

RESULTS

Inhibin-B positively correlated to AMH for 1-13year-old patients (p<0.0001), but not for 0.5-1year-old patients (p=0.439). For 0.5-1year-old patients inhibin-B-values tended to decrease (p=0.055), in contrast to AMH-values (p=0.852). LH was elevated more often than FSH (p=0.014). FSH and LH were positively associated in patients both 0.5-1year (p=0.042) and 1-13years of age (p<0.0001). LH correlated positively to inhibin- B (p=0.001). In contrast, FSH did not correlate to inhibin-B or AMH (p=0.755 and p=0.528). The number of A-dark spermatogonia per tubular transverse section was positively correlated to inhibin-B serum level.

CONCLUSION

Our new finding of an association between LH and inhibin-B in infancy of cryptorchid boys may be essential for the transformation of gonocytes to A-dark spermatogonia. Previously, LH associated to inhibin-B was described in early puberty only. During the first year of life inhibin-B values decreased faster than AMH. The AMH-levels may just reflect the increased Sertoli cell number that occurs during the first 3months of life.

The relationship between the testis and tunica vaginalis changes with age

BACKGROUND/AIM

Anatomy of the testis and tunica vaginalis (TV) is taught to pediatric surgeons from adult postmortem material. Textbooks describe the testis as 'behind' the TV, but at pediatric orchidopexy it appears to be inside the TV. We aimed to study whether testis and TV anatomy changes with age.

METHODS

After ethical approval, postmortem photographs and measurements of testis length, width, and mesenteric attachment length (mm) in 37 adults (22-92years), one infant (4/12), and one fetus (19/52) were compared with intraoperative orchidopexies (x6) after opening TV (n=4; 7/12-14years). Testis length, area and perimeter and ratios for mesentery attachment were plotted against age.

RESULTS

The fetal and pediatric testes were intraperitoneal with a mesentery (mesorchium), but after 50years secondary adhesions between TV and testis obliterated the mesorchium, so in advanced age the testis appeared to be behind the TV.

DISCUSSION

These results show that in childhood testes were 'intraperitoneal', but after 50years of age the TV progressively shrinks and adheres to the testis, making it appear to be behind the TV. This difference between anatomical texts and childhood anatomy suggests that pediatric surgery may need anatomy texts that specifically highlight age differences.

Male gender identity in children with 46,XX DSD with congenital adrenal hyperplasia after delayed presentation in mid-childhood

BACKGROUND/AIM

Girls with congenital adrenal hyperplasia (CAH) diagnosed at birth have some masculine behaviors but rarely convert to male gender. In developing countries, however, diagnosis and treatment (with secondary androgen suppression) are delayed. We aimed to assess effect of delayed treatment of CAH on gender identity.

METHODS

As part of a cross-sectional, case-control study of children with disorders of sex development (DSD), there were 11 patients with CAH. Patients and caregivers answered a questionnaire about gender identity, and behavior was assessed by observing toy play. Patients were examined for Prader score and gender identity.

RESULTS

Of 11 CAH patients initially raised as girls, 3 (27%) had converted to male gender at presentation (5, 9, 9years) (Prader 3, 4, 4). Of the remaining 8 patients, one 4-year-old (Prader 2) had a male gender identity score. The remaining girls (2-13years, mean 8.1) (Prader 1-3) had gender identity scores in the female range.

CONCLUSIONS

One third (4/11) of CAH patients presenting in mid-childhood had male gender identity scores, and ¾ had assumed male gender role. Although social and cultural factors are important in developing countries, this result suggests that delayed treatment may trigger male gender identity, and delayed female genital surgery may be unwise.

Gene expression during gonocyte transformation into spermatogonial stem cells is not androgen dependent

BACKGROUND/AIMS

Early germ cell development is deranged in undescended testis, potentially leading to infertility and cancer. Androgens are proposed to regulate gonocyte transformation into stem cells during human 'minipuberty' at 3-12months. We studied genes expressed in germ cells, Sertoli cells, and other somatic cells to determine whether androgen mediates gonocyte transformation.

METHODS

Testes from androgen-receptor knockout (ARKO) and wild-type (WT) littermates were collected at postnatal day P0 (birth), P4, P8 for real-time PCR to measure gene expression of mouse VASA homolog (Mvh), anti-Mullerian hormone (Amh), kit oncogene (c-Kit), matrix metalloproteinase-1 (Mt1-mmp), zinc finger, and BTB domain-containing 16 (Plzf) and octamer-binding protein 4 (Oct4). Data were normalized to ribosomal protein L32 (Rpl32), and reproductive homeobox gene 5 (Rhox5) was a positive control for androgenic response. Changes in gene expression were calculated with GraphPad Prism 5.02.

RESULTS

There were no statistical differences (p>0.05) in Mvh, Oct4, c-Kit, Plzf, Amh and Mt1-mmp expression between WT and ARKO testes from P0 to P8.

CONCLUSION

These results show that androgen did not influence gene expression in postnatal mouse testis, which coincides with human 'minipuberty'. The results are consistent with gonocyte transformation being independent of androgens, and that nonandrogenic regulators need to be identified.

Disimpaction of children with severe constipation in 3-4 days in a suburban clinic using polyethylene glycol with electrolytes and sodium picosulphate

AIM

Constipation is a common cause of admission to hospital for disimpaction, as oral laxatives are often inadequate. High-dose oral laxative protocols are used for complete bowel clearance prior to colonoscopy, but have not been reported for treating faecal impaction. The aim of this study was to assess the effectiveness of a high-dose oral protocol using polyethylene glycol with electrolytes (PEG + E) (Movicol Rx) combined with sodium picosulphate (SP) (Dulcolax SP Rx) in faecal impaction in children presenting to a suburban clinic.

METHODS

Forty-four children presented with acute/chronic faecal impaction were given six to eight sachets of PEG + E were given on day 1, with decreasing doses on subsequent 3 days, while 15-20 SP drops were given on days 2 and 3. Compliance with medication was achieved using a simple method of motivation, with the child drinking the laxatives in a race. On day 4, PEG + E was reduced to one sachet and SP to 10 drops as an ongoing maintenance dose. Defecation, soiling, diet and water intake was monitored daily for 7 days in a diary.

RESULTS

Forty-four children (aged 2-17 years) seen over 8 months were reviewed retrospectively. Children began defecating within 10-12 h reaching a maximum volume of stool/day (four cups) on day 2. All patients were disimpacted successfully and in the week following disimpaction there was no reported faecal soiling or complications.

CONCLUSIONS

A high-dose oral protocol combining PEG + E sachets and SP drops successfully and safely disimpacted a cohort of children with acute/chronic constipation presenting to a suburban continence clinic. This protocol appears to be useful to control faecal disimpaction in an outpatient setting, thereby avoiding hospital admission.

Oct4-GFP expression during transformation of gonocytes into spermatogonial stem cells in the perinatal mouse testis

BACKGROUND/AIM

In cryptorchidism perinatal failure to switch off Oct4, a germ cell (GC) marker, may lead to carcinoma in situ. We aimed to analyze Oct4 expression during mouse gonocyte transformation into spermatogonial stem cells (SSC).

MATERIALS AND METHODS

Testes from OG2 (Oct4-promoter driven eGFP) mice at embryonic day (E) 17 and postnatal day P0-10 underwent immunohistochemistry and immunoblotting. Antibodies against MVH, AMH, Ki67, and c-Kit were visualized by confocal microscopy. Numbers of Oct4-GFP(+) GC and Oct4-GFP(-) GC/tubule were counted using ImageJ. Data were analyzed using nonparametric one-way ANOVA.

RESULTS

GC from E17-P4 were Oct4-GFP(+). Numbers of Oct4-GFP(-) GC/tubule increased from P6-10, whereas Oct4-GFP(+) GC/tubule numbers remained similar between P6 and P10. Sertoli cells proliferated from E17-P10, whereas GC only proliferated from P2. Gonocytes (Oct4-GFP(+)/c-Kit(-)) central in tubules migrated to the basement membrane to become prospermatogonia (Oct4-GFP(+)/c-Kit(-)) and then SSC (Oct4-GFP(+)/c-Kit(+)) from day 4 and further developed into Oct4-GFP(-)/c-Kit(+) at P6.

CONCLUSION

In Oct4-GFP mice both centrally located gonocytes and prospermatogonia located at the tubular basement membrane were Oct4-GFP(+)/c-Kit(-) before further developing into SSC (Oct4-GFP(+)/c-Kit(+)). This indicates that Oct4 is important in gonocyte transformation into SSC. Understanding this process will aid GC tumor diagnostics and fertility potential in boys with UDT undergoing orchidopexy.

Enteric Neural Cells From Hirschsprung Disease Patients Form Ganglia in Autologous Aneuronal Colon

BACKGROUND & AIMS

Hirschsprung disease (HSCR) is caused by failure of cells derived from the neural crest (NC) to colonize the distal bowel in early embryogenesis, resulting in absence of the enteric nervous system (ENS) and failure of intestinal transit postnatally. Treatment is by distal bowel resection, but neural cell replacement may be an alternative. We tested whether aneuronal (aganglionic) colon tissue from patients may be colonized by autologous ENS-derived cells.

METHODS

Cells were obtained and cryopreserved from 31 HSCR patients from the proximal resection margin of colon, and ENS cells were isolated using flow cytometry for the NC marker p75 (nine patients). Aneuronal colon tissue was obtained from the distal resection margin (23 patients). ENS cells were assessed for NC markers immunohistologically and by quantitative reverse-transcription polymerase chain reaction, and mitosis was detected by ethynyl-2'-deoxyuridine labeling. The ability of human HSCR postnatal ENS-derived cells to colonize the embryonic intestine was demonstrated by organ coculture with avian embryo gut, and the ability of human postnatal HSCR aneuronal colon muscle to support ENS formation was tested by organ coculture with embryonic mouse ENS cells. Finally, the ability of HSCR patient ENS cells to colonize autologous aneuronal colon muscle tissue was assessed.

RESULTS

ENS-derived p75-sorted cells from patients expressed multiple NC progenitor and differentiation markers and proliferated in culture under conditions simulating Wnt signaling. In organ culture, patient ENS cells migrated appropriately in aneural quail embryo gut, and mouse embryo ENS cells rapidly spread, differentiated, and extended axons in patient aneuronal colon muscle tissue. Postnatal ENS cells derived from HSCR patients colonized autologous aneuronal colon tissue in cocultures, proliferating and differentiating as neurons and glia.

CONCLUSIONS

NC-lineage cells can be obtained from HSCR patient colon and can form ENS-like structures in aneuronal colonic muscle from the same patient.

Transabdominal electrical stimulation (TES) for the treatment of slow-transit constipation (STC)

Slow-transit constipation (STC) is a newly described subtype of intractable constipation in children which we originally identified with deficiency of substance P in axons supplying the proximal colonic muscle. When nuclear transit studies became available, the patients were found to have slow proximal colonic transit, and responded to antegrade enemas. Using the appendicostomy, we found that there was reduced frequency in propagating sequences throughout the colon. We began testing whether transcutaneous electrical stimulation (TES) could improve motility and symptoms, and over several trials have now shown that TES is remarkably effective in treating children with STC, with long-lasting effects. TES holds promise for treating STC, as well as a range of gastrointestinal motility disorders.

The syndrome of Spigelian hernia and cryptorchidism: a review of paediatric literature

BACKGROUND/PURPOSE

The purpose of this study is to present a summary of paediatric Spigelian hernia (SH) reported to date, and discuss possible aetiology of SH associated with ipsilateral ectopic testis (SH-ET).

METHODS

Search of PubMed, Medline, Embase, and CINAHL was performed using keywords "Spigelian hernia". The following were extracted from articles describing paediatric SH: demographics, site and contents of SH, comorbidities, proposed aetiology, presence of ipsilateral inguinal canal (IC) and gubernaculum (G).

RESULTS

There were 78 patients with 88 hernias (69 male, 19 female), including 55 male (19 left, 22 right, 7 bilateral) and 16 female (5 left, 5 right, 3 bilateral) nontraumatic SHs. In nontraumatic male SH, 29 hernias contained testis (10 left, 11 right, 4 bilateral), 15 did not, 10 had no data. Of 29 SH-EH, 15 were lacking IC and G, 3 were missing IC (no G data) and 2 had absent G (no IC data). The combination of SH and cryptorchidism is increasingly recognised as a distinct syndrome. However, there is controversy as to the pathogenic mechanism of this association. We hypothesise SH-ET develops because the G, and therefore IC and line of descent, become cranially 'mislocated' along the mammary line, which overlies the Spigelian fascia.

CONCLUSION

SH is rare in children. SH-ET may result by testicular descent to an ectopic site along the embryological mammary line.

Factors relating to hospitalisation and economic burden of paediatric constipation in the state of Victoria, Australia, 2002-2009

AIM

Constipation is common, with severe symptoms requiring hospitalisation. Constipation can be a primary (present at admission and requires treatment or investigation) or principal (first listed) diagnosis for hospitalisation. In the USA, constipation is the second most common ambulatory care digestive diagnosis with total costs >US$1.7 billion/year. Incidence of hospitalisation for constipation in children peaks at toilet-training age. This study determined the burden of paediatric constipation to hospital care in Victoria, Australia.

METHOD

The Victorian Admitted Episodes Dataset was analysed retrospectively, examining hospital admissions with a primary diagnosis of constipation in the 7-year period 2002/2003 to 2008/2009.

RESULTS

For children, constipation was recorded as a primary diagnosis in 8688 admissions (3.6/1000 of population). In-hospital prevalence was ∼1.0%. Mean length of stay was 4.4 days (median 1.0, range 0-993, standard deviation 16.7). There were 1121 readmissions in 668 children. Average treatment cost was A$4235/admission (median A$1461, range A$0-$278 816), with annual costs of ∼A$5 505 500. Children in the highest socio-economic area had ∼50% fewer admissions (P < 0.0001). Predictors of readmission included age 10-18, male gender, rural residence, severe socio-economic disadvantage, public hospital, planned admission, longer length of stay and association with other medical conditions.

CONCLUSIONS

This study identified that constipation in children is a significant cost burden in Victoria (costing public hospitals ∼A$5.5 million/year). Hospitalisation in Victoria is 10-fold higher than in the USA with 10% readmissions within a month. We conclude that strategies aimed at reducing hospitalisation for constipation could result in significant savings for the paediatric public health system in Victoria, Australia.

Long-gap oesophageal atresia: comparison of delayed primary anastomosis and oesophageal replacement with gastric tube

BACKGROUND

Long-gap oesophageal atresia (LGOA) causes significant early and long-term morbidity. We conducted a retrospective 25-year review comparing outcomes of delayed primary anastomosis versus oesophageal replacement with greater curvature gastric tube.

METHODS

Records of 44 consecutive patients undergoing LGOA repair (1986-2010) were obtained from OA database with ethics approval and were analysed for complication and long-term outcomes. Analysis was conducted using Student's t-test for quantitative and Fisher exact test for qualitative data.

RESULTS

Thirty (68%) patients underwent delayed primary anastomosis and 14 (32%) had oesophageal replacement. Oesophageal replacement patients had longer gaps (mean 5.5 vertebrae, range 4-9) compared to delayed primary anastomosis (mean 3.9, range 2-6) (p=0.004), but no difference in perioperative complications (p=0.2) (Table 1). Oesophageal replacement had more long-term complications (86%) compared to delayed primary anastomosis (30%) (p=0.005). Almost all patients (>90%) experienced gastro-oesophageal reflux and 21 delayed primary anastomosis patients (70%) underwent fundoplication. 60% of delayed primary anastomosis and 64.3% of oesophageal replacement patients had continued gastrointestinal symptoms years after repair.

CONCLUSIONS

Our experience indicates that LGOA can be repaired safely using both methods, with no deaths and similar perioperative risk, but high long-term morbidity mandates long-term follow-up of these patients. Delayed primary anastomosis has a better long-term outcome compared to oesophageal replacement with gastric tube.

Malformation syndromes associated with disorders of sex development

When embryological development of the internal and/or external genitalia is disrupted, the patient presents with a disorder of sex development (DSD) in the neonatal period or sometime later in life. Some of these patients have other, nongenital malformations, which makes their overall management more complex than if they just had a DSD. This Review summarises these malformation syndromes and discusses the recent research into their aetiology. The genetic causes of these malformation syndromes, when they are known, will also be described. Many specific genetic mutations are now known in malformation syndromes with a defect in hormonal function. By contrast, the genetic causes remain unknown in many nonhormonal morphological anomalies that affect the genitalia.

Potentially avoidable hospitalisation for constipation in Victoria, Australia in 2010-11

BACKGROUND

When primary care of constipation fails, the patient may need emergency hospitalisation for disimpaction. This study aimed to provide population-based data on the number of unplanned admissions and the cost to the healthcare system for constipation in Victoria, Australia in financial year 2010-11.

METHODS

The Victorian Admitted Episodes Dataset was examined to find the number of emergency hospital separations coded as constipation (ICD-10-AM Code K390). An estimate of costs was determined from the number of weighted inlier equivalent separations (WIES) multiplied by the WEIS price, used by the Victorian Government for funding purposes.

RESULTS

There were 3978 emergency separations for constipation in Victoria in 2010-2011, 92% in public hospitals. Fifty-five percent were female and 38% > 75 years old. One third stayed overnight and 1/3 more than 1 day. The emergency bed day rate was 7.1 per 10,000 of population. The estimate of cost, based on WEIS, was approximately $8.3 million. Potential savings could be made by reducing the number of separations in 6 Local Government Areas (LGAs).

CONCLUSIONS

This study shows that the burden (in number of admissions, emergency bed days and overall direct costs) in managing emergency admissions for constipation in Victoria, Australia, is very significant and likely to be similar in other developed countries. Improved primary healthcare and alternative ways to achieve faecal disimpaction without emergency admission could save the public health system a proportion of this $8.3 million.

Genetic and environmental origins of hypospadias

PURPOSE OF REVIEW

The purpose of this study was to review and comment on recent original presentations dealing with genetic and environmental factors in the cause of hypospadias.

RECENT FINDINGS

The heritability is definitely high and having an affected family member is the highest identified risk factor so far. Many candidate genes and polymorphisms have been suggested for hypospadias. Some associations with hypospadias were found, and many of these were replicated inconsistently as would be expected in a complex disorder affected by both genes and environment. The consistent association of hypospadias with low birth weight, maternal hypertension, and preeclampsia suggests that placental insufficiency is a major risk factor. Maternal exposure to chemical pollutants or endocrine disruptors in high concentrations related to selected occupations or geographic areas may be additional risk factors for hypospadias, especially in genetically predisposed individuals. So far, however, no environmental chemical pollutants or endocrine disruptor with a general common impact on the risk for hypospadias in most societies has been demonstrated.

SUMMARY

A major point that should be considered regarding the action of environmental toxicants in inducing hypospadias is the cumulative effects of multiple low-dose exposures. Furthermore, interactions between genetic and environmental factors may help to explain nonreplication in genetic studies of hypospadias.