Identification of genetic variants associated with anterior cruciate ligament rupture and AKC standard coat color in the Labrador Retriever

Canine anterior cruciate ligament (ACL) rupture is a common complex disease. Prevalence of ACL rupture is breed dependent. In an epidemiological study, yellow coat color was associated with increased risk of ACL rupture in the Labrador Retriever. ACL rupture risk variants may be linked to coat color through genetic selection or through linkage with coat color genes. To investigate these associations, Labrador Retrievers were phenotyped as ACL rupture case or controls and for coat color and were single nucleotide polymorphism (SNP) genotyped. After filtering, ~ 697 K SNPs were analyzed using GEMMA and mvBIMBAM for multivariate association. Functional annotation clustering analysis with DAVID was performed on candidate genes. A large 8 Mb region on chromosome 5 that included ACSF3, as well as 32 additional SNPs, met genome-wide significance at P < 6.07E-7 or Log10(BF) = 3.0 for GEMMA and mvBIMBAM, respectively. On chromosome 23, SNPs were located within or near PCCB and MSL2. On chromosome 30, a SNP was located within IGDCC3. SNPs associated with coat color were also located within ADAM9, FAM109B, SULT1C4, RTDR1, BCR, and RGS7. DZIP1L was associated with ACL rupture. Several significant SNPs on chromosomes 2, 3, 7, 24, and 26 were located within uncharacterized regions or long non-coding RNA sequences. This study validates associations with the previous ACL rupture candidate genes ACSF3 and DZIP1L and identifies novel candidate genes. These variants could act as targets for treatment or as factors in disease prediction modeling. The study highlighted the importance of regulatory SNPs in the disease, as several significant SNPs were located within non-coding regions.

Abstract 4042: Genomic and pharmaco-genomic profiling of pancreatic cancer using patient-derived organoids

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal common malignancies, with little improvement in patient outcomes over the past decades. We have developed a novel methodology to culture organoids from both human healthy pancreatic ductal epithelial tissues and PDAC. A collection of patient-derived organoids (PDO), grown using this protocol, numbers over 100 models to date. The 100% neoplastic purity of the organoid cultures facilitates molecular characterization that has been traditionally challenging in the pauci-cellular state of primary pancreatic tumors. These PDO open new opportunities for deep genomic and transcriptomic studies of the disease, and for individualized drug screens. Here we demonstrate that accurate predictive models of response to pharmacological treatments of PDAC can be developed using data from such screens alongside molecular profiles of the PDO.

Methods: Molecular analysis of the PDO library yielded genomic and transcriptional profiles of the cultures, including those of copy number variation (CNV), mutations in the exome and mRNA expression. From these, we drew features for prediction of drug responses. Using molecular features drawn from these profiles, we developed a panel of predictive models for response to standard-of-care cytotoxic agents and a number of targeted treatments. We employed Random Forest (RF) regression as a machine-learning tool for this purpose.

Results: PDO are faithful models of PDAC, whose molecular features closely resemble those of PDAC tumor specimens. Using a subset of these features, we were able to accurately learn PDO responses to cytotoxic agents: for each of the five agents considered, the predicted drug response correlated strongly (p &lt; 10-7) with the observed value. A similar accuracy of prediction was achieved for a number of targeted agents.

Conclusion: PDOs are a valuable resource for molecular and pharmacological characterization of PDAC, with a potential to guide clinical decisions with regard to treatment.

Citation Format: Astrid Deschênes, Pascal Belleau, Dennis Plenker, Amber Habowski, Hardik Patel, Youngkyu Park, Hervé Tiriac, Lindsey A. Baker, Alexander Krasnitz, David A. Tuveson. Genomic and pharmaco-genomic profiling of pancreatic cancer using patient-derived organoids [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4042.

Intraductal Transplantation Models of Human Pancreatic Ductal Adenocarcinoma Reveal Progressive Transition of Molecular Subtypes

Pancreatic ductal adenocarcinoma (PDAC) is the most lethal common malignancy, with little improvement in patient outcomes over the past decades. Recently, subtypes of pancreatic cancer with different prognoses have been elaborated; however, the inability to model these subtypes has precluded mechanistic investigation of their origins. Here, we present a xenotransplantation model of PDAC in which neoplasms originate from patient-derived organoids injected directly into murine pancreatic ducts. Our model enables distinction of the two main PDAC subtypes: intraepithelial neoplasms from this model progress in an indolent or invasive manner representing the classical or basal-like subtypes of PDAC, respectively. Parameters that influence PDAC subtype specification in this intraductal model include cell plasticity and hyperactivation of the RAS pathway. Finally, through intratumoral dissection and the direct manipulation of RAS gene dosage, we identify a suite of RAS-regulated secreted and membrane-bound proteins that may represent potential candidates for therapeutic intervention in patients with PDAC. SIGNIFICANCE: Accurate modeling of the molecular subtypes of pancreatic cancer is crucial to facilitate the generation of effective therapies. We report the development of an intraductal organoid transplantation model of pancreatic cancer that models the progressive switching of subtypes, and identify stochastic and RAS-driven mechanisms that determine subtype specification.See related commentary by Pickering and Morton, p. 1448.This article is highlighted in the In This Issue feature, p. 1426.

SOAT1 promotes mevalonate pathway dependency in pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, and new therapies are needed. Altered metabolism is a cancer vulnerability, and several metabolic pathways have been shown to promote PDAC. However, the changes in cholesterol metabolism and their role during PDAC progression remain largely unknown. Here we used organoid and mouse models to determine the drivers of altered cholesterol metabolism in PDAC and the consequences of its disruption on tumor progression. We identified sterol O-acyltransferase 1 (SOAT1) as a key player in sustaining the mevalonate pathway by converting cholesterol to inert cholesterol esters, thereby preventing the negative feedback elicited by unesterified cholesterol. Genetic targeting of Soat1 impairs cell proliferation in vitro and tumor progression in vivo and reveals a mevalonate pathway dependency in p53 mutant PDAC cells that have undergone p53 loss of heterozygosity (LOH). In contrast, pancreatic organoids lacking p53 mutation and p53 LOH are insensitive to SOAT1 loss, indicating a potential therapeutic window for inhibiting SOAT1 in PDAC.

Identification of Resistance Pathways Specific to Malignancy Using Organoid Models of Pancreatic Cancer

PURPOSE

KRAS is mutated in the majority of pancreatic ductal adenocarcinoma. MAPK and PI3K-AKT are primary KRAS effector pathways, but combined MAPK and PI3K inhibition has not been demonstrated to be clinically effective to date. We explore the resistance mechanisms uniquely employed by malignant cells.

EXPERIMENTAL DESIGN

We evaluated the expression and activation of receptor tyrosine kinases in response to combined MEK and AKT inhibition in KPC mice and pancreatic ductal organoids. In addition, we sought to determine the therapeutic efficacy of targeting resistance pathways induced by MEK and AKT inhibition in order to identify malignant-specific vulnerabilities.

RESULTS

Combined MEK and AKT inhibition modestly extended the survival of KPC mice and increased Egfr and ErbB2 phosphorylation levels. Tumor organoids, but not their normal counterparts, exhibited elevated phosphorylation of ERBB2 and ERBB3 after MEK and AKT blockade. A pan-ERBB inhibitor synergized with MEK and AKT blockade in human PDA organoids, whereas this was not observed for the EGFR inhibitor erlotinib. Combined MEK and ERBB inhibitor treatment of human organoid orthotopic xenografts was sufficient to cause tumor regression in short-term intervention studies.

CONCLUSIONS

Analyses of normal and tumor pancreatic organoids revealed the importance of ERBB activation during MEK and AKT blockade primarily in the malignant cultures. The lack of ERBB hyperactivation in normal organoids suggests a larger therapeutic index. In our models, pan-ERBB inhibition was synergistic with dual inhibition of MEK and AKT, and the combination of a pan-ERBB inhibitor with MEK antagonists showed the highest activity both in vitro and in vivo.

Organoid models for translational pancreatic cancer research

Despite recent advances in the treatment of cancer, pancreatic ductal adenocarcinoma (PDAC) still retains the worst survival rate of common malignancies. Late diagnosis and lack of curative therapeutic options are the most pressing clinical problems for this disease. Therefore, there is a need for patient models and biomarkers that can be applied in the clinic to identify the most effective therapy for a patient. Pancreatic ductal organoids are ex-vivo models of PDAC that can be established from very small biopsies, enabling the study of localized, advanced, and metastatic patients. Organoids models have been applied to pancreatic cancer research and offer a promising platform for precision medicine approaches.

Phenotypic severity scoring system and categorisation for prune belly syndrome: application to a pilot cohort of 50 living patients

OBJECTIVE

To design a novel system of scoring prune belly syndrome (PBS) phenotypic severity at any presenting age and apply it to a large pilot cohort.

PATIENTS AND METHODS

From 2000 to 2017, patients with PBS were recruited to our prospective PBS study and medical records were cross-sectionally analysed, generating individualised RUBACE scores. We designed the pragmatic RUBACE-scoring system based on six sub-scores (R: renal, U: ureter, B: bladder/outlet, A: abdominal wall, C: cryptorchidism, E: extra-genitourinary, generating the acronym RUBACE), yielding a potential summed score of 0-31. The 'E' score was used to segregate syndromic PBS and PBS-plus variants. The cohort was scored per classic Woodard criteria and RUBACE scores compared to Woodard category.

RESULTS

In all, 48 males and two females had a mean (range) RUBACE score of 13.8 (8-25) at a mean age of 7.3 years. Segregated by phenotypic categories, there were 39 isolated PBS (76%), six syndromic PBS (12%) and five PBS-plus (10%) cases. The mean RUBACE scores for Woodard categories 1, 2, and 3 were 20.5 (eight patients), 13.8 (25), and 10.6 (17), respectively (P < 0.001).

CONCLUSIONS

RUBACE is a practical, organ/system level, phenotyping tool designed to grade PBS severity and categorise patients into isolated PBS, syndromic PBS, and PBS-plus groups. This standardised system will facilitate genotype-phenotype correlations and future prospective multicentre studies assessing medical and surgical treatment outcomes.

Generation and Culture of Tumor and Metastatic Organoids from Murine Models of Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDA) is a lethal malignancy that is refractory to all current therapies. Research into the mechanisms driving this cancer is the key to developing better diagnostic and treatment options which are urgently needed in the clinic. Genetically engineered mouse models of PDA have been valuable research tools, enabling studies of all stages of PDA progression. However, these models are difficult and time-consuming to breed, and engineering further mutations into these models requires additional time. Recently, organoid cultures of PDA have emerged as alternative models for this disease. Organoids can be rapidly generated from mouse models of PDA and enable genetic and biochemical perturbation of all stages of PDA progression. Here, we describe the generation and propagation of organoid models from PDA tumors and metastases harvested from genetically engineered mouse models.

Testing Susceptibility of Patient-Derived Organoid Cultures to Therapies: Pharmacotyping

Increasingly, patient models of disease are being utilized to facilitate precision medicine approaches through molecular characterization or direct chemotherapeutic testing. Organoids, 3-dimensional (3D) cultures of neoplastic cells derived from primary tumor specimens, represent an ideal platform for these types of studies because benchtop protocols previously developed for 2-dimensional cell lines can be adapted for use. These protocols include directly testing the survival of these organoid cultures when exposed to clinically relevant chemotherapeutic agents, a process we have called pharmacotyping. In this protocol, established tumor-derived organoid cultures are dissociated into single cells, plated in a 3D gel matrix, and exposed to pharmacologic agents. While our protocol has been developed for use with patient-derived pancreatic ductal adenocarcinoma organoids, with minor modifications to the dissociation and medium conditions, this protocol could be adapted for use with a wide range of organoid cultures. We further describe our standard ATP-based assay to determine cellular survival. This protocol can be scaled for use in high-throughput assays.

Distinct populations of inflammatory fibroblasts and myofibroblasts in pancreatic cancer

Pancreatic stellate cells (PSCs) differentiate into cancer-associated fibroblasts (CAFs) that produce desmoplastic stroma, thereby modulating disease progression and therapeutic response in pancreatic ductal adenocarcinoma (PDA). However, it is unknown whether CAFs uniformly carry out these tasks or if subtypes of CAFs with distinct phenotypes in PDA exist. We identified a CAF subpopulation with elevated expression of α-smooth muscle actin (αSMA) located immediately adjacent to neoplastic cells in mouse and human PDA tissue. We recapitulated this finding in co-cultures of murine PSCs and PDA organoids, and demonstrated that organoid-activated CAFs produced desmoplastic stroma. The co-cultures showed cooperative interactions and revealed another distinct subpopulation of CAFs, located more distantly from neoplastic cells, which lacked elevated αSMA expression and instead secreted IL6 and additional inflammatory mediators. These findings were corroborated in mouse and human PDA tissue, providing direct evidence for CAF heterogeneity in PDA tumor biology with implications for disease etiology and therapeutic development.

Utility of retrograde ureterocelogram in management of complex ureterocele

INTRODUCTION

Symptomatic pediatric ureterocele has diverse manifestations, making evidence-based management impractical. Thus, detailed visualization of ureterocele anatomy prior to first surgical incision is invaluable. Retrograde ureterocelogram (RUC) is a simple, underutilized radiologic technique that can be performed during cystoscopy. This study sought to determine whether RUC changes surgical management by more accurately depicting the complex ureteral and ureterocele anatomy, compared with renal ultrasound (US) and voiding cystourethrography (VCUG).

METHODS

Patients who underwent surgical management of ureterocele from 2003 to 2015 were identified; those who received concomitant fluoroscopic RUC were selected for the case series. Data collected included: demographics, pre-operative evaluation, surgical interventions, and outcomes. The RUC images were individually examined, and the anatomic impression compared with previous renal US and VCUG. Novel RUC findings not previously appreciated by the pre-operative evaluation were noted. The RUC was performed by cystoscopically inserting a needle into the ureterocele and injecting contrast retrograde. If indicated, simultaneous PIC (Positioning the Instillation of Contrast) cystography was performed.

RESULTS

Of the 43 patients that underwent surgery for suspected ureterocele, 28 underwent cystoscopy + RUC (10 M: 18 F) at a median age of 4.6 months and median follow-up of 37.0 months. All patients had prior US, 25 had prior VCUG, and 20 had prior radionuclide studies. Ureteroceles were either duplex system (n = 21) or single system (n = 7); 17 were ectopic into the bladder neck or urethra; seven were intravesical; and four were pseudoureteroceles. Fourteen patients underwent concomitant transurethral incision of the ureterocele (TUIU); two were deferred for surgery; and 11 received concomitant definitive surgery (e.g., nephrectomy). The RUC illuminated novel aspects of the anatomy in 20 of the 28 patients. No adverse events occurred. Notably, in nine of the 28 children, significant observations from RUC prompted change to the pre-operative surgical plan.

DISCUSSION

Retrograde ureterocelogram clearly revealed ureterocele ectopy, pseudoureterocele, ureterocele disproportion, and unsuspected duplex systems, making it a useful adjunct to standard US and VCUG studies. Retrograde ureterocelogram can also be used to fluoroscopically verify decompression of the ureterocele post incision, document severity of ureteral dilation, and teach residents about the great damage generated by ureterocele variations. Limitations of RUC included increasing radiation dose and overall cost. The study design was limited by its small size, retrospective approach, selection bias, and availability of RUC images.

CONCLUSIONS

While not indicated in routine ureterocele management, intraoperative RUC further defined ureterocele anatomy in nearly all cases and yielded changes to the original surgical plan frequently enough to merit greater use in complex patients.

Clitoral hoodplasty in females with disorders of sex development

INTRODUCTION

The surgical management of girls with masculinized genitalia is gradually changing towards a more conservative approach. Reports on loss of clitoral sensitivity and related impairment of sexual function in women after feminizing genital surgery in childhood have been pivotal in this evolution. An exposed clitoral glans is occasionally seen at follow-up, and while patients may complain of aesthetics, no clitoral discomfort secondary to glans exposure has been reported. A technique has been developed to reconstruct the clitoral hood and the present study reports the preliminary results.

OBJECTIVES

To report the novel technique and preliminary results of clitoral hood reconstruction to cover an exposed glans after previous clitoroplasty in patients with congenital adrenal hyperplasia (CAH).

PATIENTS AND METHODS

Six female patients (mean age 13, range 4-21 years) with CAH sought medical help for clitoral concerns after previous reduction clitoroplasty. In two of the six patients, the main complaint was clitoral hypersensitivity or even pain. The clitoral glans was completely exposed in all patients, who were subsequently treated with a bi-laminar V-Y clitoral hoodplasty to create a mobile and natural-looking clitoral hood composed of an inner and outer preputial skin layer.

RESULTS

Postoperative covering of the glans was complete in five patients, and partial in one. The two patients with pre-operative pain became asymptomatic; all six patients were pleased with the cosmetic postoperative results.

CONCLUSION

Clitoral hoodplasty provides simple, yet effective, relief for women with cosmetic concerns or clitoral discomfort after previous feminizing surgery.

Abstract B16: Using human patient-derived organoids to identify genetic dependencies in pancreatic cancer

Pancreatic ductal adenocarcinoma (PDA) is one of the most lethal malignancies due to its late diagnosis and limited response to treatment. Tractable model systems to interrogate pathways involved in pancreatic tumorigenesis and to probe individual responses to novel therapies are urgently needed. To that end, we established methods to culture normal and neoplastic pancreatic duct cells as three-dimensional organoid cultures. Pancreatic organoids can be rapidly generated from resected tumors or fine needle biopsies, survive cryopreservation, and exhibit ductal- and disease-stage-specific characteristics. Following orthotopic transplant, neoplastic organoids recapitulated the full spectrum of tumor development by forming early-grade neoplasms that progressed to locally invasive and metastatic carcinomas, demonstrating the utility of organoids to model the stages of PDA tumorigenesis. Monolayer cell lines were generated from organoid cultures with high efficiency, creating a diverse collection of new PDA cell lines. To better understand pathways involved in PDA progression, we performed transcriptomic and proteomic analyses of murine organoids derived from normal pancreatic ducts, pancreatic intraepithelial neoplasias (PanINs), and PDAs. These datasets revealed expression changes associated with early and late pancreatic tumorigenesis. To identify genes dysregulated during pancreatic tumorigenesis whose depletion impaired human PDA cells, a CRISPR-Cas competition assay was employed. Taken together, pancreatic organoids offer a novel model system for studying pancreatic cancer biology and can be used to screen for genetic dependencies in PDA.

Citation Format: Lindsey A. Baker, Hervé Tiriac, Vincenzo Corbo, Sylvia F. Boj, Chang-il Hwang, Iok In Christine Chio, Danielle D. Engle, Myrthe Jager, Mariano Ponz-Sarvise, Mona S. Spector, Ana Gracanin, Tobiloba Oni, Kenneth H. Yu, Ruben van Boxtel, Meritxell Huch, Keith D. Rivera, John P. Wilson, Michael E. Feigin, Daniel Öhlund, Abram Handly-Santana, Christine M. Ardito-Abraham, Michael Ludwig, Ela Elyada, Brinda Alagesan, Giulia Biffi, Georgi N. Yordanov, Bethany Delcuze, Brianna Creighton, Kevin Wright, Youngkyu Park, Folkert H.M. Morsink, I. Quintus Molenaar, Inne H. Borel Rinkes, Edwin Cuppen, Yuan Hao, Ying Jin, Isaac J. Nijman, Christine Iacobuzio-Donahue, Steven D. Leach, Darryl J. Pappin, Molly Hammell, David S. Klimstra, Olca Basturk, Ralph H. Hruban, George Johan Offerhaus, Robert G.J. Vries, Hans Clevers, David A. Tuveson. Using human patient-derived organoids to identify genetic dependencies in pancreatic cancer. [abstract]. In: Proceedings of the AACR Special Conference: Patient-Derived Cancer Models: Present and Future Applications from Basic Science to the Clinic; Feb 11-14, 2016; New Orleans, LA. Philadelphia (PA): AACR; Clin Cancer Res 2016;22(16_Suppl):Abstract nr B16.

Modeling pancreatic cancer with organoids

Pancreatic ductal adenocarcinoma (PDA) is a highly lethal malignancy for which new treatment and diagnostic approaches are urgently needed. In order for such breakthroughs to be discovered, researchers require systems that accurately model the development and biology of PDA. While cell lines, genetically engineered murine models, and xenografts have all led to valuable clinical insights, organotypic culture models have emerged as tractable systems to recapitulate the complex three-dimensional organization of PDA. Recently, multiple methods for modeling PDA using organoids have been reported. This review aims to summarize these organoid methods in the context of other PDA models. While each model system has unique benefits and drawbacks, ultimately, organoids hold special promise for the development of personalized medicine approaches.

Model organoids provide new research opportunities for ductal pancreatic cancer

We recently established organoid models from normal and neoplastic murine and human pancreas tissues. These organoids exhibit ductal- and disease stage-specific characteristics and, after orthotopic transplantation, recapitulate the full spectrum of tumor progression. Pancreatic organoid technology provides a novel platform for the study of tumor biology and the discovery of potential biomarkers, therapeutics, and personalized medicine strategies.

The material convoy after age 50

OBJECTIVES

Possessions constitute a dynamic "material convoy" that accumulates across adulthood to furnish role enactments and the development of the self. Following a familiar life course arc, older people should hypothetically release the possessions that equipped the daily lives that they no longer have.

METHOD

We use new survey data on possession divestment from the 2010 Health and Retirement Study to assess activity on behalf of the material convoy after age 50.

RESULTS

After age 50, people are progressively less likely to divest themselves of belongings. After age 70, about 30% of persons say that they have done nothing in the past year to clean out, give away, or donate things, and over 80% have sold nothing. We tested whether divestments diminish with age because they do not seem necessary or because of health limitations, but the age pattern is robust, suggesting retention of the material convoy in later life.

DISCUSSION

Further research on this age pattern might consider housing, the construction of the self, and social networks as explanations for retention. Inertia toward the material convoy maintains the availability and comfort of things, but it may also lead to a predicament wherein the collection becomes a worry for self and others.

Prevalence of oral health problems in U.S. adults, NHANES 1999-2004: exploring differences by age, education, and race/ethnicity

Using the National Health and Nutrition Examination Surveys (NHANES) 1999-2004, the authors examined age patterns in oral health indicators by race/ethnicity and socioeconomic status related to edentulism, presence of root caries, and periodontal disease. Our analysis included subjects who were non-Hispanic White, Mexican American, and African American over the age of 20, and who participated in the NHANES oral health examination. African Americans experienced more oral health problems at younger ages; as age increased, so did racial disparities in oral health problems. Lower educational attainment was strongly associated with more oral health problems at all ages. These results may indicate a faster progression of oral health problems with age among African Americans, thus suggesting that the "earlier aging" of members of racial/ethnic minorities which has been reported in prior research may also be found in oral health.

Carbon, nitrogen, and phosphorus fluxes in household ecosystems in the Minneapolis-Saint Paul, Minnesota, urban region

Rapid worldwide urbanization calls for a better understanding of the biogeochemical cycling of those macroelements that have large environmental impacts in cities. This study, part of the Twin Cities Household Ecosystem Project, quantified fluxes of carbon (C), nitrogen (N), and phosphorus (P) at the scale of individual households in the Minneapolis-Saint Paul metropolitan area in Minnesota, USA. We estimated input and output fluxes associated with several components of household activities including air and motor vehicle travel, food consumption, home energy use, landscape, pets, and paper and plastic use for 360 owner-occupied, stand-alone households. A few component fluxes dominated total input fluxes of elements. For instance, air and motor vehicle transportation, together with home energy use, accounted for 85% of total C consumption and emissions. All total and component fluxes were skewed to varying degrees, suggesting that policies targeting disproportionately high fluxes could be an effective and efficient way to reduce pollution. For example, 20% of households contributed 75% of air travel emissions and 40% of motor vehicle emissions. Home energy use was more nearly normally distributed. Nitrogen fluxes were dominated by human diet and lawn fertilizer applications, which together accounted for 65% of total household N inputs. The majority of P inputs were associated with human diet, use of detergents, and pet food. A large portion of the variation among household fluxes of C, N, and P was related to a few biophysical variables. A better understanding of the biophysical, demographic, and behavioral drivers of household activities that contribute to C, N, and P fluxes is pivotal for developing accurate urban biogeochemical models and for informing policies aimed at reducing sources of pollution in urban ecosystems.

Psychopathic personality in children: genetic and environmental contributions

BACKGROUND

The current study investigates whether the underlying factor structure of psychopathic personality traits found in adults is similar to that in children and what the extent of the genetic and environmental influences are on these psychopathic traits.

METHOD

Psychopathic personality traits were assessed in a community sample of 1219 twins and triplets (age 9-10 years) through caregiver reports of each child's behavior using the Child Psychopathy Scale (CPS).

RESULTS

Confirmatory factor analyses revealed an optimal two-factor solution (callous/disinhibited and manipulative/deceitful) to the CPS subscales. Bivariate genetic modeling of the two computed factor scores revealed significant genetic as well as unique environmental influences on psychopathic personality traits in both boys and girls, with heritability estimates of 0.64 and 0.46, respectively, in boys and 0.49 and 0.58, respectively, in girls. No shared environmental influences on psychopathic personality traits were found.

CONCLUSIONS

The relationship between the two factors was mediated by both genetic and unique environmental factors common to both traits.

Poverty and Material Hardship in Grandparent-Headed Households

Using the 2001 Survey of Income and Program Participation, the current study examines poverty and material hardship among children living in 3-generation (n = 486), skipped-generation (n = 238), single-parent (n = 2,076), and 2-parent (n = 6,061) households. Multinomial and logistic regression models indicated that children living in grandparent-headed households experience elevated risk of health insecurity (as measured by receipt of public insurance and uninsurance)-a disproportionate risk given rates of poverty within those households. Children living with single parents did not share this substantial risk. Risk of food and housing insecurity did not differ significantly from 2-parent households once characteristics of the household and caregivers were taken into account.

Who are the Latino baby boomers? Demographic and economic characteristics of a hidden population

The United States is confronting two simultaneous demographic shifts with profound implications for public policy: population aging and increasing diversity. These changes are accelerating during a dramatic economic downturn, placing entitlement reform prominently on the national policy agenda. Using decennial census data from 2000, this paper examines the nexus of these trends by examining characteristics of Latino baby boomers. In the census data, Latinos constituted 10% of the 80 million boomers; roughly one-third of Latino boomers (37%) were born in the United States or abroad to a U.S. parent; 6% were born in a U.S. territory; 21% were naturalized citizens; and 36% were noncitizens. Compared to non-Latinos, Latino baby boomers had lower levels of education, home ownership, and investment income and higher rates of material hardship and poverty; however, there was considerable variation based on citizenship status. A better understanding of Latino baby boomers will help policy makers anticipate the retirement needs of baby boomers as the United States prepares for the aging of a racially and ethnically diverse population.

The Implications of Grandparent Coresidence for Economic Hardship among Children in Mother-Only Families

Estimates suggest that more than 6 million children live with at least one grandparent. Despite evidence establishing the growing prevalence of this arrangement, limited research has focused on estimating the implications of co-residence for the economic well-being of grandchildren. Using data from the 2001 panel of the Survey of Income and Program Participation, this paper examines levels of financial hardship among a particularly vulnerable group of children - those living in mother-only families. Findings suggest that children living in mother-only families that include a grandparent are substantially less likely to be living below or near the poverty level, compared to children living in mother-only families without a grandparent present. The financial security of children in these three-generation households is enhanced through significant economic contributions of the grandparents, and from household receipt of a wide range of financial resources, including means-tested cash transfers and other income such as Social Security.

PHD fingers in human diseases: disorders arising from misinterpreting epigenetic marks

Histone covalent modifications regulate many, if not all, DNA-templated processes, including gene expression and DNA damage response. The biological consequences of histone modifications are mediated partially by evolutionarily conserved "reader/effector" modules that bind to histone marks in a modification- and context-specific fashion and subsequently enact chromatin changes or recruit other proteins to do so. Recently, the Plant Homeodomain (PHD) finger has emerged as a class of specialized "reader" modules that, in some instances, recognize the methylation status of histone lysine residues, such as histone H3 lysine 4 (H3K4). While mutations in catalytic enzymes that mediate the addition or removal of histone modifications (i.e., "writers" and "erasers") are already known to be involved in various human diseases, mutations in the modification-specific "reader" proteins are only beginning to be recognized as contributing to human diseases. For instance, point mutations, deletions or chromosomal translocations that target PHD fingers encoded by many genes (such as recombination activating gene 2 (RAG2), Inhibitor of Growth (ING), nuclear receptor-binding SET domain-containing 1 (NSD1) and Alpha Thalassaemia and Mental Retardation Syndrome, X-linked (ATRX)) have been associated with a wide range of human pathologies including immunological disorders, cancers, and neurological diseases. In this review, we will discuss the structural features of PHD fingers as well as the diseases for which direct mutation or dysregulation of the PHD finger has been reported. We propose that misinterpretation of the epigenetic marks may serve as a general mechanism for human diseases of this category. Determining the regulatory roles of histone covalent modifications in the context of human disease will allow for a more thorough understanding of normal and pathological development, and may provide innovative therapeutic strategies wherein "chromatin readers" stand as potential drug targets.

Preventive health behaviors among grandmothers raising grandchildren

OBJECTIVES

We examined differential preventive health behavior among grandmothers who recently began raising a grandchild, grandmothers raising a grandchild for at least 2 years, and grandmothers not raising a grandchild.

METHODS

Data came from the 2000, 2002, and 2004 waves of the Health and Retirement Study. We ran multivariate logistic regression models to assess receipt of influenza vaccination, cholesterol screening, monthly breast self-exam, mammography, and Papanicolaou (Pap) tests among grandmothers aged 50 to 75.

RESULTS

Grandmothers who recently began raising a grandchild were significantly less likely to report influenza vaccination and cholesterol screening than grandmothers not raising grandchildren, even after we controlled for increased emotional and financial strains within the household. We also observed this association for Pap tests, although this finding was only marginally significant. Grandmothers who had been raising a grandchild for at least 2 years were significantly more likely to report influenza vaccination and monthly breast self-exam than grandmothers not raising grandchildren.

DISCUSSION

The enhancement of preventive behavior seen among long-term grandparent caregivers does not fully offset the suppression of preventive behavior during the transition into care; support groups should target a range of interventions toward the promotion of healthy behavior among new grandparent caregivers.

Depressive Symptoms Among Grandparents Raising Grandchildren: The Impact of Participation in Multiple Roles

Using the Health and Retirement Study, this research examines well-being among grandparents raising grandchildren during middle to late life, specifically looking at how other roles in which a grandparent is participating (such as worker, volunteer, parent or caregiver) may influence depressive symptoms among grandparent caregivers. Results indicate that grandparents who have recently begun raising a grandchild experience lower levels of well-being when compared to grandparents who are not raising a grandchild regardless of the grandparent's level of participation in roles beyond that of grandparent caregiver, while grandparents who have been raising a grandchild for longer periods of time seem to benefit from their participation in multiple roles. However, a higher level of participation in outside roles is associated with a decline in well-being among grandparents who stopped raising a grandchild, suggesting that, for these grandparents, participation in multiple roles acted mainly as a stressor, rather than as a resource.

Grandparents Raising Grandchildren in the United States: Changing Family Forms, Stagnant Social Policies

As a consequence of increased divorce rates, the proliferation of single-parent families, and patterns of economic stagnation, parents are increasingly relying on extended family to care for children. In the past few decades, a substantial increase in the number of grandparents raising grandchildren has been observed within the United States. Grandparents who raise their grandchildren are particularly vulnerable, as are the grandchildren in their care; however, U.S. policy currently presents many barriers, gaps, and unintended consequences for grandparent caregivers. In this paper, we use two theoretical paradigms 1) structural lag and 2) the political economy of aging perspective to argue that U.S. policy has not kept pace with the reality of the family and - as a result - those families who are most vulnerable often receive the least support. We propose that as family forms become more diverse a redefinition of the family to one that is less bound by residence and biology, to one based more on function, will be required.

Nitrogen transformations in a wetland receiving lagoon effluent: sequential model and implications for water reuse

Constructed wetlands could be components of low-tech systems to treat and reuse wastewater in arid region. A key function of the wetland would be to provide additional N removal. To improve design criteria, a sequential model of nitrogen transformations (organic N --> ammonium: ammonium --> nitrate: nitrate --> nitrogen gas) was successfully calibrated and verified for a wetland in Kingman, Arizona. A sequential model has the ability to "recognize" species of nitrogen in the influent and predict species of nitrogen in the effluent. Model scenarios show that increasing nitrification rates in the summer and denitrification rates in the winter would improve nitrogen removal efficiencies. Several lines of evidence suggest that wintertime denitrification may be limited by carbon supply. Winter carbon supply could be augmented by routing a portion of the water through channels planted with dryland vegetation.

Multicompartment ecosystem mass balances as a tool for understanding and managing the biogeochemical cycles of human ecosystems

Nitrogen remains a ubiquitous pollutant in surface and groundwater throughout the United States, despite 30 years of pollution control efforts. A detailed multicompartment N balance for the Central Arizona-Phoenix ecosystem is used to illustrate how an ecosystem-level approach can be used to develop improved N management strategies. The N balance is used to demonstrate how nitrate in pumped groundwater used for crop irrigation could be used to reduce inputs of commercial fertilizer and decrease N leaching to aquifers. Effectively managing N pollution also will require an understanding of the complex factors that control the N balance, including targeted regulations, individual human behavior, land-use conversion, and other ecosystem management practices that affect the N balance. These sometimes countervailing factors are illustrated with several scenarios of wastewater treatment technology and population growth in the Phoenix area. Management of N eventually must be coupled to management of other elements, notably carbon, phosphorus, and salts. We postulate that an ecosystem framework for pollution management will result in strategies that are more effective, fairer, and less expensive than current approaches.

MODIFIED YOUNG-DEES-LEADBETTER BLADDER NECK RECONSTRUCTION IN PATIENTS WITH SUCCESSFUL PRIMARY BLADDER CLOSURE ELSEWHERE: A SINGLE INSTITUTION EXPERIENCE

PURPOSE

Achievement of urinary continence in patients with the exstrophy-epispadias complex remains a challenge. We reviewed our experience with the modified Young-Dees-Leadbetter bladder neck repair in patients with bladder exstrophy who underwent primary bladder closure elsewhere.

MATERIALS AND METHODS

We retrospectively reviewed exstrophy charts and database of 57 male and 11 female with classic bladder exstrophy who underwent bladder neck repair at our institute and successful primary bladder closure elsewhere during the last 2 decades. Osteotomy was performed at primary closure in 14 (20%) cases and 9 (13%) patients at bladder neck repair in 9 (13%) to aid in stabilizing the urethra and pelvic ring, and to help reapproximate the pelvic floor musculature facilitating urinary continence.

RESULTS

Primary closure was done within 72 hours of life elsewhere in 41 (60%) patients, and between ages 72 hours and 5 years (most during the first month of life) in 27. Paraexstrophy skin flaps were used in 33 (48%) cases, and the most common complication was bladder outlet obstruction of the posterior urethra secondary to the skin flaps. Of the 68 patients 57 (83%) are continent and voiding per urethra without need for augmentation or clean intermittent catheterization, 9 (13%) required clean intermittent catheterization including 7 who underwent continent urinary diversion after failed bladder neck repair, and 2 are still incontinent due to a severe posterior urethral stricture. Urinary retention was the most common symptom after bladder neck repair which resolved following catheter dilation or prolonged suprapubic catheter drainage.

CONCLUSIONS

Successful early primary closure of a good bladder template is the most important determinant of eventual bladder capacity and compliance.

Modified Young-Dees-Leadbetter bladder neck reconstruction in patients with successful primary bladder closure elsewhere: a single institution experience

PURPOSE

Achievement of urinary continence in patients with the exstrophy-epispadias complex remains a challenge. We reviewed our experience with the modified Young-Dees-Leadbetter bladder neck repair in patients with bladder exstrophy who underwent primary bladder closure elsewhere.

MATERIALS AND METHODS

We retrospectively reviewed exstrophy charts and database of 57 male and 11 female with classic bladder exstrophy who underwent bladder neck repair at our institute and successful primary bladder closure elsewhere during the last 2 decades. Osteotomy was performed at primary closure in 14 (20%) cases and 9 (13%) patients at bladder neck repair in 9 (13%) to aid in stabilizing the urethra and pelvic ring, and to help reapproximate the pelvic floor musculature facilitating urinary continence.

RESULTS

Primary closure was done within 72 hours of life elsewhere in 41 (60%) patients, and between ages 72 hours and 5 years (most during the first month of life) in 27. Paraexstrophy skin flaps were used in 33 (48%) cases, and the most common complication was bladder outlet obstruction of the posterior urethra secondary to the skin flaps. Of the 68 patients 57 (83%) are continent and voiding per urethra without need for augmentation or clean intermittent catheterization, 9 (13%) required clean intermittent catheterization including 7 who underwent continent urinary diversion after failed bladder neck repair, and 2 are still incontinent due to a severe posterior urethral stricture. Urinary retention was the most common symptom after bladder neck repair which resolved following catheter dilation or prolonged suprapubic catheter drainage.

CONCLUSIONS

Successful early primary closure of a good bladder template is the most important determinant of eventual bladder capacity and compliance.

COMBINED BLADDER NECK RECONSTRUCTION AND EPISPADIAS REPAIR FOR EXSTROPHY-EPISPADIAS COMPLEX

PURPOSE

The achievement of satisfactory continence in the management of classic bladder exstrophy remains a surgical challenge. During the last 20 years a staged approach to the management of the exstrophy-epispadias complex has been used at many exstrophy centers to attain this goal. In select cases repairs can be combined to reduce the number of mandatory operations to achieve continence. We retrospectively review our experience with, and long-term results and complications of combined bladder neck reconstruction and epispadias repair.

MATERIALS AND METHODS

A total of 19 boys with classic bladder exstrophy (17) and complete male epispadias (2) underwent combined bladder neck reconstruction and epispadias repair between 1982 and 1999. Primary closure was performed elsewhere in 16 cases and osteotomy was performed at primary closure in 8 (42%). All patients have undergone modified Cantwell-Ransley epispadias repair except for 2 who underwent a Young procedure.

RESULTS

At the time of combined bladder neck and epispadias repair mean patient age was 5.2 years (range 2.5 to 10). Mean bladder capacity was 119 ml. (range 60 to 250). Of the 19 patients 13 (69%) are completely continent, and 2 (11%) are partially continent and 1 remained incontinent. Three patients did not gain satisfactory functional bladder capacity after combined repair, and underwent bladder augmentation and a continent diversion procedures.

CONCLUSIONS

Combined bladder neck and epispadias repair is applicable in experienced hands but careful patient selection and long-term followup are the most important issues to develop criteria to select those best to undergo this procedure.

Combined bladder neck reconstruction and epispadias repair for exstrophy-epispadias complex

PURPOSE

The achievement of satisfactory continence in the management of classic bladder exstrophy remains a surgical challenge. During the last 20 years a staged approach to the management of the exstrophy-epispadias complex has been used at many exstrophy centers to attain this goal. In select cases repairs can be combined to reduce the number of mandatory operations to achieve continence. We retrospectively review our experience with, and long-term results and complications of combined bladder neck reconstruction and epispadias repair.

MATERIALS AND METHODS

A total of 19 boys with classic bladder exstrophy (17) and complete male epispadias (2) underwent combined bladder neck reconstruction and epispadias repair between 1982 and 1999. Primary closure was performed elsewhere in 16 cases and osteotomy was performed at primary closure in 8 (42%). All patients have undergone modified Cantwell-Ransley epispadias repair except for 2 who underwent a Young procedure.

RESULTS

At the time of combined bladder neck and epispadias repair mean patient age was 5.2 years (range 2.5 to 10). Mean bladder capacity was 119 ml. (range 60 to 250). Of the 19 patients 13 (69%) are completely continent, and 2 (11%) are partially continent and 1 remained incontinent. Three patients did not gain satisfactory functional bladder capacity after combined repair, and underwent bladder augmentation and a continent diversion procedures.

CONCLUSIONS

Combined bladder neck and epispadias repair is applicable in experienced hands but careful patient selection and long-term followup are the most important issues to develop criteria to select those best to undergo this procedure.

The newborn exstrophy bladder inadequate for primary closure: evaluation, management and outcome

PURPOSE

The surgical approach to the small newborn exstrophy bladder inadequate for primary closure remains undetermined. Various methods for long-term management have been implemented. We evaluated our experience with late primary closure of the small exstrophied bladder template.

MATERIALS AND METHODS

Our institutional database of patients treated and followed for the exstrophy-epispadias complex was reviewed. Of these patients 19 had a bladder template that was too small to close in the newborn period. The treatment and outcome of these 19 patients were reviewed.

RESULTS

Of the 19 children who had delayed closure due to a small bladder template 14 were males and 5 were females. Followup from birth ranged from 2 to 36 years (mean 18 years). Primary closure was performed at a mean patient age of 13 months (range 6 months to 2 years). Pelvic osteotomy was performed in 16 patients. Of the 19 patients 9 achieved continence after gaining a bladder capacity sufficient for bladder neck reconstruction, 4 required enterocystoplasty to augment bladder volume and perform clean intermittent catheterization (2 per stoma and 2 per urethra), 1 required a colon conduit for an extremely small bladder, and 1 underwent cystectomy and ureterosigmoidostomy for rhabdomyosarcoma. Four patients are currently incontinent, including 3 who are awaiting bladder neck reconstruction and 1 who has frequent nighttime incontinence that is medically managed.

CONCLUSIONS

Delayed primary closure of the small bladder exstrophy template can allow the native bladder tissue adequate time to grow to a size feasible for successful closure. Epispadias repair can usually be performed at the same time and is facilitated by prior testosterone administration. Bladder neck reconstructive techniques have achieved continence without the need for augmentation or bladder replacement in 47% of the patients in our series. For patients who do not achieve adequate capacity for bladder neck reconstruction, preservation of the native bladder template facilitates future augmentation and ureteral reimplantation, thus requiring use of less bowel in the growing child.

A multi-institutional analysis of laparoscopic orchidopexy

OBJECTIVE

To combine and analyse the results from centres with a large experience of laparoscopy for the impalpable testis with small series, to determine the expected success rate for laparoscopic orchidopexy.

METHODS

A questionnaire was distributed to participating paediatric urologists; each contributor retrospectively reviewed the clinical charts for their cases of therapeutic laparoscopy for an impalpable testis, detailing 36 variables for each patient. The data were collated centrally into a computerized database. For inclusion, the testis was intra-abdominal (including 'peeping' at the internal ring) at laparoscopic examination, was not managed through an open approach and did not undergo orchidectomy. Three surgical groups were assessed, with success defined as lack of atrophy and intrascrotal position: group 1, primary laparoscopic orchidopexy; group 2, a one-stage Fowler-Stephens (F-S) orchidopexy; and group 3, a two-stage F-S orchidopexy.

RESULTS

Data were gathered from 10 centres in the USA, covering the period 1990-1999; 252 patients representing 310 testes were included and overall, 15.2% were lost to follow-up. There was no significant difference between success rates in the larger and smaller series. Atrophy occurred in 2.2% of 178 testes, 22.2% of 27 testes and 10.3% of 58 testes in groups 1-3, respectively. Testes were not in a satisfactory scrotal position in 0.6%, 7.4% and 1.7% of groups 1-3, respectively. The mean follow-up for each group was 7.7, 8.6 and 20.0 months, respectively. The overall success for all groups was 92.8% (97.2% group 1; 74.1% group 2; 87.9% group 3), with an atrophy rate of 6.1%.

CONCLUSION

Laparoscopic orchidopexy for the intra-abdominal testis, in both large and small series, can be expected to have a success rate higher than that historically ascribed to open orchidopexy. Within this series, single-stage F-S laparoscopic orchidopexy resulted in a significantly higher atrophy rate than the two-stage repair. However, when considering both F-S approaches, the laparoscopic approach gave greater success than previously reported for the same open approaches. Despite the weaknesses inherent in a retrospective unrandomized study, we conclude that laparoscopic orchidopexy is, if not the procedure of choice, an acceptable and successful approach to the impalpable undescended testicle.

Multivariate models of mixed assortment: phenotypic assortment and social homogamy for education and fluid ability

Phenotypic assortment is assumed to be the principal mechanism of spouse similarity in most biometrical studies. Other assortment mechanisms, such as social homogamy, may be plausible. Two models are presented that consider phenotypic assortment and social homogamy simultaneously (i.e., mixed assortment), where selective associations between social background factors (Model I) versus selective associations between total environments (Model II) distinguish the models. A series of illustrative analyses was undertaken for education and fluid ability available on a sample of 116 Swedish twin pairs and their spouses. On the basis of several fit criteria Model I was preferred over Model II. Both social homogamy and phenotypic assortment may contribute to spouse similarity for educational attainment and fluid ability. Furthermore, spouse similarity for fluid ability may arise indirectly from social homogamy and phenotypic assortment for educational attainment. Power analyses indicated greater observed power for Model I than Model II. Additional power analyses indicated that considerably more twin-spouse sets would be needed for Model II than Model I, to resolve social homogamy and phenotypic assortment. Effects of misspecification of mechanisms of spouse similarity are also briefly discussed.

Open laparoscopic access using a radially dilating trocar: experience and indications in 50 consecutive cases

BACKGROUND

Laparoscopy can be performed using needle access for initial insufflation or open access.

PATIENTS AND METHODS

A technique for open laparoscopic access to the abdomen using a radially dilating cannula was used in 52 operations in 50 patients. Indications included age <2 years, severe kyphosis, and creation of an umbilical stoma.

RESULTS

There was one case of minor leakage of carbon dioxide that did not affect the procedure being performed. There were two cases of preperitoneal placement, which were recognized immediately; in both, peritoneal access was easily obtained.

CONCLUSION

Open laparoscopic access is safely and easily performed with a radially dilating trocar. This is the preferred technique at our institution for patients who meet the criteria for open access.

Radical bulbar dissection to correct severe chordee and proximal hypospadias

PURPOSE

We describe a technique of proximal hypospadias correction that involves freeing the proximal normal bulbar urethra from perineal attachments to lengthen the ventral penis and decrease chordee.

MATERIALS AND METHODS

Correction was performed in 9 patients with a mean age of 11.5 months who had proximal hypospadias and severe chordee that was perineal in 2, mid scrotal in 6 and penoscrotal in 1. After the penis was degloved the bulbar urethra was detethered to or beyond the perineal body without lifting the urethra from the corpora cavernosa. Any remaining penile chordee was corrected and the urethral plate was transected only when chordee persisted. When the urethral plate was intact and the penis straight, tubularized incised plate urethroplasty was done to correct hypospadias in 1 stage. Otherwise 2-stage repair was performed.

RESULTS

Using this maneuver penile straightening was achieved in 2 of the 9 patients, resulting in a glanular urethral or penoscrotal meatus. Dorsal plication sutures required in 4 cases resulted in a mid shaft and penoscrotal meatus in 1 and 3, respectively. Residual chordee in the remaining 3 patients necessitated division of the urethral plate and 2-stage repair despite aggressive mobilization of the proximal urethra. Simultaneous tubularized incised plate urethroplasty was then performed in the 4 penoscrotal and 1 mid shaft meatus. All 6 patients who underwent a successful 1-stage procedure have excellent cosmetic results, while 1 required meatotomy. No fistula or chordee was present at a mean of 13.8 months of followup (range 3.9 to 27.1).

CONCLUSIONS

This safe, rapid technique may compensate for significant penile tethering and chordee in a subpopulation of patients with proximal hypospadias, such as 6 of the 9 in our study. It also allows successful tubularized incised plate urethroplasty to be done simultaneously.

The modified Cantwell-Ransley repair for exstrophy and epispadias: 10-year experience

PURPOSE

We evaluate our experience with the modified Cantwell-Ransley epispadias repair technique to determine the complications and long-term results.

MATERIALS AND METHODS

The modified Cantwell-Ransley epispadias repair was performed during the last 10 years in 93 males of whom 79 had classic bladder exstrophy and 14 had complete epispadias. Primary repair was performed in 65 boys with classic bladder exstrophy and 12 with epispadias, and secondary repair was done after prior failed reconstruction in 14 boys with classic exstrophy and 2 with complete epispadias.

RESULTS

At mean followup of 68 months 87 patients had a horizontal or downward angled penis while standing. The incidence of urethrocutaneous fistulas was 23% in the immediate postoperative period and 19% at 3 months. A urethral stricture at the proximal anastomotic area developed in 7 patients and 5 (4 with exstrophy and 1 with epispadias) had minor skin separations of the dorsal penile skin closure. Catheterization or cystoscopy in 77 cases revealed an easily negotiable neourethral channel.

CONCLUSIONS

The modified Cantwell-Ransley epispadias repair produces an excellent functional and cosmetic result.

Tmp21-I, a vesicular trafficking protein, is differentially expressed during induction of the ureter and metanephros

PURPOSE

To identify genes participating in the reciprocal induction of the metanephros and ureter.

MATERIALS AND METHODS

Embryonic day 14 Sprague-Dawley rat kidneys and ureters were microdissected into differentiating mesenchyme, ureteric buds, and extrarenal ureter and prepared for RT/PCR differential display. Differentially displayed cDNAs were reamplified, cloned, and sequenced. Expression was verified in the embryonic, newborn or adult kidneys by Northern blot hybridization or RT/PCR using sequence specific primers. A newborn rat kidney cDNA library was prepared and screened with probes of interest. Positive clones were screened, sequenced and compared to the GenBank/EMBL databases. A rabbit polyclonal antibody was raised to a synthetic peptide of the Tmp21-I protein and was used for immunohistochemistry.

RESULTS

From the cDNAs differentially displayed by the ureteric buds cDNA B11, is 254 bp in length. The gene for B11 is expressed in adult and newborn kidneys as two transcripts (3.4 kb and 1.3 kb). More importantly, RT/PCR on E14 kidneys using B11 sequence specific primers identified expression in the embryonic kidney at the beginning of induction. B11 cDNA library screening yielded clones with inserts of 1.3 kb. This sequence encodes Tmp21-I, a vesicular trafficking protein. Immunohistochemistry demonstrates that Tmp21-I is abundant in the nephrogenic cortex of the newborn kidney and as a nephron matures, the protein levels decline. The protein is essentially absent in the adult rat kidney.

CONCLUSIONS

Tmp21-I is a developmentally regulated gene expressed during kidney induction. Localized within the nephrogenic zone, it may direct the intracellular trafficking or secretion of proteins responsible for nephrogenesis.

An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion

OBJECTIVES

To delineate the clinical outcomes of color Doppler ultrasound (US) in the equivocal torsion patient.

METHODS

From 1992 to 1997, 130 patients (<23 years old) from 2 institutions underwent US imaging using a 7.5-mHz linear transducer to evaluate an acute scrotum equivocal, or of low suspicion, for torsion. The US reports and hospital charts of these patients were retrospectively reviewed.

RESULTS

After clinical and radiologic evaluation, torsion was excluded in 110 patients without surgical exploration. In 3 patients, intermittent testicular torsion was diagnosed and in 17 patients, emergent exploration was performed for US diagnosis of testicular torsion. Twenty-five patients (22.7%) were subsequently lost to follow-up. Follow-up of 85 patients with US negative for torsion (mean length of follow-up = 466.9 days) revealed no testicular atrophy in 83. Two patients underwent delayed orchiectomy/contralateral orchiopexy for missed testicular torsion. Of 17 patients with US positive for torsion, 9 underwent orchiectomy for a necrotic torsed testis, 7 viable torsed testes were found, and 1 torsed appendix testis was found. Therefore, color Doppler US for the equivocal acute scrotum yielded a 1% false-positive rate, sensitivity of 88.9%, and specificity of 98.8%.

CONCLUSION

When faced with ruling out testicular torsion, it is necessary to integrate the multiple pieces of patient data, knowing that each piece of data may have inaccuracies. With this in mind, this analysis of outcomes verifies that color Doppler US is an excellent adjunctive study in the clinically real situation in which the clinical evaluation is equivocal or low suspicion.

A multicenter outcomes analysis of patients with neonatal reflux presenting with prenatal hydronephrosis

PURPOSE

Approximately 10 to 30% of prenatal cases of hydronephrosis result in the postnatal diagnosis of vesicoureteral reflux. Using a new generic prenatal-postnatal data sheet developed by the Society for Fetal Urology the characteristics, natural history and outcome of prenatal hydronephrosis confirmed postnatally to be vesicoureteral reflux were documented at 3 centers.

MATERIALS AND METHODS

We performed a retrospective multicenter review of Society for Fetal Urology data sheets completed for each patient in whom prenatal hydronephrosis was proved to be postnatal vesicoureteral reflux from 1993 to 1998.

RESULTS

In 56 male and 15 female patients with prenatal hydronephrosis a total of 116 refluxing renal units were confirmed postnatally. Of the 116 renal units 112 were hydronephrotic prenatally. During gestation increased hydronephrosis was noted with voiding in 4 cases. Of the 112 hydronephrotic renal units only 26 ureters in 15 patients were seen prenatally. The obstetrician considered the diagnosis of vesicoureteral reflux in only 24% of the cases. Postnatally 116 refluxing renal units were identified. Initial postnatal ultrasound was normal in 25% of the cases. Bilateral reflux was present in 36 male and 9 female patients. In 10 of the 19 uncircumcised patients (53%) urinary tract infection developed despite antibiotic prophylaxis. In 15 of the 74 renal units with grades III to V reflux the condition resolved at an average patient age of 0.9 and 2.1 years in boys and girls, respectively. A total of 27 refluxing renal units were reimplanted.

CONCLUSIONS

The majority of prenatal reflux occurs in boys, and it is high grade and bilateral. The data sheets designed by the Society for Fetal Urology are useful data collection instruments. The presentation and natural history of vesicoureteral reflux are different in male and female individuals. In a significant number of renal units high grade reflux resolves spontaneously. Early circumcision may decrease the incidence of breakthrough urinary tract infection in this subpopulation. In addition, the effective management of prenatally detected reflux depends on multispecialty communication.

A multicenter outcomes analysis of patients with neonatal reflux presenting with prenatal hydronephrosis

PURPOSE

Approximately 10 to 30% of prenatal cases of hydronephrosis result in the postnatal diagnosis of vesicoureteral reflux. Using a new generic prenatal-postnatal data sheet developed by the Society for Fetal Urology the characteristics, natural history and outcome of prenatal hydronephrosis confirmed postnatally to be vesicoureteral reflux were documented at 3 centers.

MATERIALS AND METHODS

We performed a retrospective multicenter review of Society for Fetal Urology data sheets completed for each patient in whom prenatal hydronephrosis was proved to be postnatal vesicoureteral reflux from 1993 to 1998.

RESULTS

In 56 male and 15 female patients with prenatal hydronephrosis a total of 116 refluxing renal units were confirmed postnatally. Of the 116 renal units 112 were hydronephrotic prenatally. During gestation increased hydronephrosis was noted with voiding in 4 cases. Of the 112 hydronephrotic renal units only 26 ureters in 15 patients were seen prenatally. The obstetrician considered the diagnosis of vesicoureteral reflux in only 24% of the cases. Postnatally 116 refluxing renal units were identified. Initial postnatal ultrasound was normal in 25% of the cases. Bilateral reflux was present in 36 male and 9 female patients. In 10 of the 19 uncircumcised patients (53%) urinary tract infection developed despite antibiotic prophylaxis. In 15 of the 74 renal units with grades III to V reflux the condition resolved at an average patient age of 0.9 and 2.1 years in boys and girls, respectively. A total of 27 refluxing renal units were reimplanted.

CONCLUSIONS

The majority of prenatal reflux occurs in boys, and it is high grade and bilateral. The data sheets designed by the Society for Fetal Urology are useful data collection instruments. The presentation and natural history of vesicoureteral reflux are different in male and female individuals. In a significant number of renal units high grade reflux resolves spontaneously. Early circumcision may decrease the incidence of breakthrough urinary tract infection in this subpopulation. In addition, the effective management of prenatally detected reflux depends on multispecialty communication.

Urethral obstruction after primary exstrophy closure: what is the fate of the genitourinary tract?

PURPOSE

We assessed the impact of posterior urethral obstruction after primary bladder exstrophy closure.

MATERIALS AND METHODS

A review of the records of patients with classic bladder exstrophy at our institution identified 29 boys and 12 girls with a mean age of 11.75 years who had had posterior urethral outlet obstruction after closure was done in the neonatal period.

RESULTS

Of these 41 patients 75% underwent closure elsewhere. At closure osteotomies were done in 13 patients and 23 were younger than 72 hours. Paraexstrophy skin flaps were used at primary closure in 27 cases (66%). Obstruction presented as recurrent urinary tract infection, upper tract deterioration with or without renal failure, bladder stones, difficult catheterization, urethral stitch erosion, a full bladder on ultrasound, a prolonged dry interval, urinary retention, inability to catheterize, bladder rupture, rectal prolapse and epididymitis or prostatitis. Usually the initial obstructive episode developed within 60 days of closure and it was recurrent. Therapy included suprapubic catheter placement, vesicostomy, ureterostomy, nephrostomy and multiple urethral manipulations, such as dilation with or without steroid injection, internal urethrotomy, urethral stitch removal, clean intermittent catheterization or open urethroplasty. All 6 patients who underwent long-term diversion via vesicostomy, ureterostomy or a conduit for greater than 6 months required permanent bowel segments for reconstruction, while in 5 of the 6 who underwent short-term diversion via nephrostomy or suprapubic tube placement for less than 6 months reconstruction was bowel-free. Of the 36 children in whom functional reconstruction was performed 9 are undergoing staged reconstruction, reconstruction failed in 14, 4 are socially dry and 9 are continent.

CONCLUSIONS

Posterior urethral obstruction after exstrophy closure markedly decreases the success of staged bladder reconstruction, presents a significant risk to the upper urinary tract and should be detected early.

Embryonic development of the ureter

During human embryonic development, the ureteric bud, a simple epithelial tube that arises from the Wolffian duct, initiates a cascade of events which results in the formation of the metanephros and its collecting system. In this review, the anatomic and molecular basis of ureteric development are discussed. Although it is difficult to separate metanephrogenesis from ureterogenesis of the proximal segment, the data presented are biased toward the latter. Some of the factors involved in the budding and branching of the embryonic ureter and the maturation of the fetal ureter into a peristaltic conduit are discussed as presently understood. Finally, a brief description of congenital abnormalities in ureteral development is presented with some putative mechanisms.

Embryonic development of the ureter and bladder: acquisition of smooth muscle

To delineate the temporal and spatial acquisition of the smooth muscle of the ureter, Sprague-Dawley rat embryos and newborn pups were immunostained with alpha-smooth muscle actin (alpha-SM actin) antibody. Alpha-SM actin expression was first detected in the urinary tract at 16 days of gestation (E16) in a thin subserosal zone about the urogenital sinus. At this time, the E16 ureter is composed of a simple cuboidal epithelium which is surrounded by 1 to 2 layers of condensed alpha-SM actin negative spindle shaped cells. No immunostaining was detected along the ureter or its intrarenal branches until the 20th day of gestation (E20). Alpha-SM actin expression in the E20 ureter exhibited regional differences. The number of alpha-SM actin positive smooth muscle cells was greatest in the distal ureter, intermediate in the mid ureter, and least in the proximal ureter near the kidney. While smooth muscle formation in the bladder was subserosal, in the ureter it was subepithelial. During postnatal life, alpha-SM actin expression increased in both organs as all periepithelial spindle cells stained positive and intensified their staining. Smooth muscle differentiation of the ureter and bladder occurs later in embryonic life than other visceral and vascular organs and occurs in an ascending fashion from the bladder to the intrarenal collecting system. It is likely that the activation of visceral smooth muscle myogenesis within the urinary tract is governed by positional information specific to the embryonic development of each organ.

The staged approach to bladder exstrophy closure and the role of osteotomies

Since the 1970's, the staged reconstruction of bladder exstrophy has yielded consistent surgical success. The Johns Hopkins Hospital approach begins with early pelvic ring approximation with abdominal wall, bladder, and posterior urethral closure. Within the first 72 hours of life, the malleable pelvis can sometimes be approximated without osteotomies. Beyond this age, the author's prefer a combined vertical iliac and horizontal innominate osteotomy. Second, we typically perform the epispadias closure at 1 year of age. A modified Cantwell-Ransley technique is performed, usually yielding an increase in bladder capacity and very satisfactory results. In the last phase, the modified Young-Dees-Leadbetter continence procedure along with transtrigonal/cephalotrigonal ureteroneocystostomies are performed when the urethra is catheterizable, the bladder capacity is 60 cc or greater, and the child will participate in a postoperative voiding program (typically 4-5 years of age). This applied approach usually results in a continent, voiding patient with pleasing external genitalia and preserved renal function.

Restricted V beta usage by T cells infiltrating rejecting human lung allografts

TCR expression was evaluated in lung transplant patients to determine whether T cells infiltrating rejecting lung allografts employed restricted V beta elements. Serial bronchoalveolar lavage (BAL) specimens were obtained from six lung transplant recipients at approximately 3 wk, 6 wk, and 3 mo post-transplant. T cell lines were established by culturing lavage cells with irradiated donor splenocytes in the presence of low dose IL-2 for 3 wk, and TCR V beta usage was determined by quantitative reverse transcriptase-PCR. Patients were grouped into three categories based on TCR V beta profiles and the clinical status of the allograft. 1) In one patient, BAL-derived T cells expressed heterogeneous V beta repertoires at all time points evaluated. This patient did not experience graft rejection during the 16-mo period of observation, though respiratory infections were diagnosed. 2) In three patients, V beta usage by BAL-derived T cells was restricted during allograft rejection episodes, but was heterogeneous in the absence of rejection and during respiratory infections. In one of these patients, similar V beta repertoires were employed by BAL cells during multiple rejection episodes. 3) In two patients, restricted V beta usage by BAL-derived T cells was observed before and during rejection episodes. Collectively, these data illustrate that human lung allograft rejection, but not pulmonary infection, is associated with T cells expressing a limited number of V beta families. Restricted V beta usage by graft-reactive T cells may allow for the selective elimination of these cells using TCR-specific reagents, thereby promoting allograft-specific tolerance.