Long-term outcome of severe hypospadias

OBJECTIVE

To evaluate, from the patient's point of view, long-term urinary and sexual outcome of surgery for severe hypospadias.

PATIENTS AND METHOD

Patients treated for severe posterior hypospadias during childhood and now aged 20-35 years were included. Outcome was evaluated using the Hypospadias Objective Scoring Evaluation and our own quality of life questionnaire.

RESULTS

Of 48 patients, 13 were lost to follow up. The questionnaire was thus sent to 35 patients of whom 27 agreed to answer (77% response rate). Fifteen presented proximal and 12 scrotal hypospadias. Average age at surgery was 3.3 years and the children underwent an average of 3.7 procedures. There were 40% early complications, and 59% late complications, including 33% fistulae and 26% stenosis. At present, 70% of patients have an apical meatus, 82% have a straight penis, 37% present difficulty initiating voiding, and one patient has a persistent fistula; 74% say their penis looks abnormal, either because of the absence of foreskin, penis size or scarring. Sexual and global satisfaction rates, determined using a visual analogue scale, are respectively 68% and 63%. Satisfaction is statistically correlated to the presence of early complications or stenosis, but not fistula. It decreases if the patient thinks his penis is not normal, even if the anatomical result is good.

CONCLUSION

Urinary and sexual outcome is good for most patients though the results are variable. Satisfaction seems more affected by subjective feelings than the anatomical result.

Should we perform orchidopexy for cryptorchidism in children with severe encephalopathy?

OBJECTIVE

To conduct a survey of practices in France concerning cryptorchidism in patients presenting with severe encephalopathy.

MATERIAL AND METHOD

We conducted an e-mail survey of current practices in 27 pediatric surgery departments in 27 French university or general hospitals. The study concerned children with severe mental deficiency.

RESULTS

The survey showed a disparity in attitudes towards cryptorchidism in patients with severe encephalopathy, ranging from no treatment to orchidopexy in all cases. In most cases, the indication for surgery was the psychological aspect for the parents or accessibility to clinical examination.

CONCLUSIONS

This survey illustrates the unease concerning the pertinence of performing orchidopexy in these children. As improved fertility is not really an issue in children with severe encephalopathy, psychological aspects apply only to the family, and, as the benefit of orchidopexy for prevention or early diagnosis of testicular cancer is marginal, the risk/benefit ratio of orchidopexy for children with severe encephalopathy and cryptorchidism is unclear.

One-step management of apple-peel atresia

PURPOSE

Apple-peel atresia is a rare form of bowel atresia associating proximal jejunal atresia with a typical coil-shaped distal small bowel. Many of the children suffering from this condition are still managed with initial enterostomy followed by delayed anastomosis.

PATIENTS AND METHOD

Between 2000 and 2007, we managed four patients with apple-peel atresia. Three by primary anastomosis and one by initial enterostomy with delayed anastomosis.

RESULTS

Total duration of total parenteral nutrition (TPN) was an average 109 days. Survival rate was 100% with an average follow-up of 4.3 years.

CONCLUSION

Nowadays, the prognosis of apple-peel atresia depends mainly on prolonged TPN-related morbidity rather than immediate postoperative complications. We therefore recommend that those infants affected be managed by primary anastomosis in order to reduce the duration of parenteral nutrition, followed by careful nutrition by teams experienced in neonatal TPN and short bowel syndrome.

Multipotent CD15+ cancer stem cells in patched-1-deficient mouse medulloblastoma

Subpopulations of tumorigenic cells have been identified in many human tumors, although these cells may not be very rare in some types of cancer. Here, we report that medulloblastomas arising from Patched-1-deficient mice contain a subpopulation of cells that show a neural precursor phenotype, clonogenic and multilineage differentiation capacity, activated Hedgehog signaling, wild-type Patched-1 expression, and the ability to initiate tumors following allogeneic orthotopic transplantation. The normal neural stem cell surface antigen CD15 enriches for the in vitro proliferative and in vivo tumorigenic potential from uncultured medulloblastomas, supporting the existence of a cancer stem cell hierarchy in this clinically relevant mouse model of cancer.

Pulmonary infection in Wegener granulomatosis and idiopathic pulmonary fibrosis

RATIONALE

Wegener granulomatosis (WG) has previously been associated with increased nasal carriage of Staphylococcus aureus, but no studies have investigated the occurrence of pathogen growth in the lower airways.

OBJECTIVES

To culture bronchoalveolar lavage fluid (BALF) from patients with WG, patients with idiopathic pulmonary fibrosis (IPF) and normal controls.

METHODS

33 patients with WG, 22 with IPF and 8 normal controls underwent bronchoscopy and bronchoalveolar lavage. Quantitative culture established bacterial levels in the lower airways. Culture experiments were designed to investigate whether BALF is a supportive environment for S aureus growth. BALF cytokines were measured by ELISA.

RESULTS

Pathogens were commonly grown from BALF of patients with WG and those with IPF. S aureus was particularly associated with patients with WG both in relapse and in remission. BALF levels of interleukin 1 receptor antagonist (IL1ra) were statistically significantly elevated in those patients who grew a pathogen from lavage fluid. BALF from patients with WG and IPF stimulated S aureus growth compared with normal lavage fluid.

CONCLUSIONS

Pathogens are more commonly isolated from BALF from patients with WG than from that of patients with IPF or normal controls, and with a different culture profile. IL1ra was associated with pathogen growth in WG and IPF. WG BALF is a trophic environment for S aureus growth. Pulmonologists treating patients with acute or relapsing WG should consider bronchoscopic microbiological sampling and consider antibiotics with antistaphylococcal activity.

Soluble endostatin is a novel inhibitor of epithelial repair in idiopathic pulmonary fibrosis

BACKGROUND AND AIM

Aberrant angiogenesis and defective epithelial repair are key features of idiopathic pulmonary fibrosis (IPF). Endostatin is an antiangiogenic peptide with known effects on endothelial cells. This study aimed to establish the levels of endostatin in the bronchoalveolar lavage fluid (BALF) in IPF and to investigate its actions on distal lung epithelial cells (DLEC) and primary type II cells.

METHODS

20 patients with IPF and 10 controls underwent BAL. Endostatin was measured by ELISA. BALF cytokines and matrix metalloproteinase (MMP)-3 were measured by Luminex array. Primary DLEC monolayers were wounded and treated with endostatin. Apoptosis and cell viability were assessed.

RESULTS

Endostatin was elevated in the BALF and plasma of patients with IPF compared with normal controls. There was a negative correlation between endostatin, forced vital capacity and gas transfer. Endostatin correlated with a number of proinflammatory cytokines and MMP3. Physiological endostatin doses inhibited DLEC wound repair by 44% in an effect that was partially FasL and caspase dependent. Endostatin increased apoptosis rates by 8% and reduced their viability by 34%. Similar effects of endostatin were seen in primary type II cells in terms of inhibition of wound repair and proliferation.

CONCLUSIONS

Elevated BALF endostatin levels correlated with a number of elevated cytokines, MMP3 and lung function in IPF. Endostatin is a novel inhibitor of DLEC wound repair, inducing apoptosis and reducing cell viability in a FasL and caspase dependent manner. Endostatin may play a role in aberrant epithelial repair in IPF.

Surgical management of neuroblastoma-related hepatomegaly: do material and method really count?

The authors report 2 cases of neuroblastoma-associated hepatomegaly, which were treated using a Silastic patch, and discuss in the light of recent reports, the technical aspects and outcome of these children. They were satisfied by the decompression achieved with the patch and believe there is no increased risk in using Silastic rather than other types of material. The outcome for these children depends more on the evolution of the underlying disease than the technical aspects of the abdominal decompression.

The in vitro behaviour and patterns of colony formation of murine epithelial stem cells

OBJECTIVE

The mechanisms of renewal of skin and mucosal epithelia in vivo are associated with hierarchies of stem and amplifying cells organized in distinct spatial patterns. Stem and amplifying characteristics persist after isolation and growth of human keratinocytes in vitro but the pattern for murine keratinocytes has been less clear.

MATERIALS AND METHODS

Murine keratinocytes were grown in low calcium media and examined for their patterns of colony morphologies.

RESULTS

We consistently identified three types of colonies, one of which contains concentric zones of amplifying and differentiated cells surrounding a central zone of cells that have patterns of expression and behavioural characteristic of stem cells. This zonal organization facilitated analysis of stem cell formation and loss. Cells in the central stem cell zone undergo rapid symmetric divisions but expansion of this population is partially limited by their peripheral transition into amplifying cells. A striking feature of central zone cells is their enhanced apoptotic susceptibility and stem cell expansion limited by consistently high background rates of apoptosis. This occasionally reaches catastrophic levels with elimination of the entire central zone.

CONCLUSION

In vitro amplification of stem cells for the generation of engineered tissue has tended to focus on control of asymmetric division but these findings suggest that development of mechanisms protecting stem cells from apoptotic changes are also likely to be of particular value.

Intravesical instillation of ropivacaine reduces bladder spasms following paediatric ureteroneocystostomy

OBJECTIVE

Bladder spasms are a common cause of pain after surgical procedures that call for postoperative catheter drainage. Several therapeutic methods have been used to lessen these spasms but none have received widespread success.

PATIENTS AND METHODS

Twenty-six children were included in a prospective randomized trial to evaluate the safety and efficacy of daily intravesical instillation of ropivacaine as prophylactic treatment for bladder spasms following ureteroneocystostomy.

RESULTS

Although six patients experienced mild transient pain during instillation, there was no systemic toxicity attributable to the ropivacaine. The average number of spasms per day fell by half in the instillation group (p<0.01).

CONCLUSION

Intravesical instillation of ropivacaine is a feasible alternative prophylactic treatment for postoperative bladder spasms.

Lamivudine/abacavir maintains virological superiority over zidovudine/lamivudine and zidovudine/abacavir beyond 5 years in children

OBJECTIVE

To describe the long-term efficacy over 5 years of regimens including combinations of abacavir, lamivudine and/or zidovudine in previously untreated children in the PENTA 5 trial.

DESIGN

PENTA 5 was a 48-week randomised controlled trial comparing three dual nucleoside reverse transcriptase inhibitor (NRTI) combinations as part of first triple antiretroviral therapy (ART).

METHODS

128 ART-naïve children were randomised to zidovudine\lamivudine (n = 36), zidovudine\abacavir (45) or lamivudine\abacavir (47). Asymptomatic children (n = 55) were also randomised to nelfinavir or placebo; all other children received open-label nelfinavir. Analyses are intent-to-treat and adjusted for minor baseline imbalances and receipt of nelfinavir/placebo.

RESULTS

Median follow-up was 5.8 years. By 5 years, 17 (47%), 28 (64%) and 18 (39%) children had changed their randomised NRTIs in the zidovudine\lamivudine, zidovudine\abacavir and lamivudine\abacavir groups respectively, but 18%, 50% and 50% of these changes were either early single drug substitutions for toxicity or switches with viral suppression (HIV-1 RNA < 400 copies/ml; e.g. to simplify regimen delivery). At 5 years, 55%/32% zidovudine\lamivudine, 50%/25% zidovudine\abacavir and 79%/63% lamivudine\abacavir had HIV-1 RNA < 400/< 50 copies/ml respectively (p = 0.03/p = 0.003). Mean increase in height-for-age 0.42, 0.68, 1.05 (p = 0.02); weight-for-age 0.03, 0.13, 0.75 (p = 0.02). Reverse transcriptase resistance mutations emerging on therapy differed between the groups: zidovudine\lamivudine (M41L, D67N, K70R, M184V, L210W, T215Y); zidovudine\abacavir (M41L, D67N, K70R, L210W, T215F/Y, K219Q); lamivudine\abacavir (K65R, L74V, Y115F, M184V).

CONCLUSIONS

Five year data demonstrate that lamivudine\abacavir is more effective in terms of HIV-1 RNA suppression and growth changes, with lower rates of switching with detectable HIV-1 RNA than zidovudine\lamivudine or zidovudine\abacavir, and should be preferred as first-line NRTI backbone.