Sources of variation in nutrient loads collected through street sweeping in the Minneapolis-St. Paul Metropolitan Area, Minnesota, USA

Excess non-point nutrient loading continues to impair urban surface waters. Because of the potential contribution of tree litterfall to nutrient pollution in stormwater, street sweeping is a promising management tool for reducing eutrophication in urban and suburban regions. However, nutrient concentrations and loads of material removed through street sweeping have not been well characterized, impeding the development of pollution reduction credits and improvement of models for stormwater management. We evaluated the role of canopy cover over streets, street sweeper type, season, and sweeping frequency in contributing to variation in concentrations and loads of nitrogen (N), phosphorus (P), and solids recovered in street sweepings, using analyses of samples collected during regular street sweeping operations in five cities in the Minneapolis-St. Paul Metropolitan Area, Minnesota, USA. We expected that nutrient concentrations and loads would be highest in seasons and places of higher tree litterfall. We also expected that regenerative-air sweepers would recover higher loads compared to mechanical broom sweepers. Total N and P concentrations in sweepings increased most strongly with canopy cover in June, October, and November. Total N and P recovered in street sweepings similarly increased with canopy cover in June, October, and November, and peaked in early summer and autumn, times of high litterfall. In contrast, total dry mass in sweepings was greatest in early spring, following winter snowmelt. However, nutrient loads and concentrations did not differ between sweeper types. Our results add to growing evidence of the importance of street trees in contributing nutrient pollution to urban surface waters. Street sweeping focused on high-canopy streets during early summer and autumn is likely an effective management tool for stormwater nutrient pollution.

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.

A transition management framework to stimulate a circular phosphorus system

As the global population is projected to increase by two billion people by 2050, so will the demand for phosphorus (P), an essential nutrient for all living organisms and a major driver of eutrophication. To sustainably meet these challenges, we apply the conceptual framework of transition management (TM) to demonstrate how the trajectory of the current linear P use system could be strategically shifted toward a more circular P system. We present US case studies to examine P transitions management in intensive agriculture, wastewater disposal, and food waste management. Our goal is twofold. By first understanding past transitions in P management in the USA, we can build upon these insights for future management. This can then be applied to other global regions such as developing countries to bypass stages of transition as they intensify agriculture, incorporate sewers into cities, and expand waste management, to avoid becoming entrenched in unsustainable P management. We suggest how spaces for experimentation and collaboration can be created, how and which actor networks can be mobilized, and what action strategies and policies can be recommended to accelerate their transition to P sustainability. Our case studies show that while substantial improvements have been made, the transition toward a circular economy of P is far from complete. Our findings point to the value of utilizing TM for future progress in the US Development of TM frameworks for managing P in other regions of the world may enable them to achieve sustainable P development faster and more effectively than the USA.

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.

Managing Diffuse Phosphorus at the Source versus at the Sink

Judicious phosphorus (P) management is a global grand challenge and critical to achieving and maintaining water quality objectives while maintaining food production. The management of point sources has been successful in lowering P inputs to aquatic environments, but more difficult is reducing P discharges associated with diffuse sources, such as nonpoint runoff from agriculture and urban landscapes, as well as P accumulated in soils and sediments. Strategies for effective diffuse-P management are imperative. Many options are currently available, and the most cost-effective and practical choice depends on the local situation. This critical review describes how the metrics of P quantity in kg ha^-1 yr^-1 and P form can influence decision-making and implementation of diffuse-P management strategies. Quantifying the total available pool of P, and its form, in a system is necessary to inform effective decision-making. The review draws upon a number of " current practice" case studies that span agriculture, cities, and aquatic sectors. These diverse examples from around the world highlight different diffuse-P management approaches, delivered at the source in the catchment watershed or at the aquatic sink. They underscore workable options for achieving water quality improvement and wider P sustainability. The diffuse-P management options discussed in this critical review are transferable to other jurisdictions at the global scale. We demonstrate that P quantity is typically highest and most concentrated at the source, particularly at farm scale. The most cost-effective and practically implementable diffuse-P management options are, therefore, to reduce P use, conserve P, and mitigate P loss at the source. Sequestering and removing P from aquatic sinks involves increasing cost, but is sometimes the most effective choice. Recovery of diffuse-P, while expensive, offers opportunity for the circular economy.

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.

Total Value of Phosphorus Recovery

Phosphorus (P) is a critical, geographically concentrated, nonrenewable resource necessary to support global food production. In excess (e.g., due to runoff or wastewater discharges), P is also a primary cause of eutrophication. To reconcile the simultaneous shortage and overabundance of P, lost P flows must be recovered and reused, alongside improvements in P-use efficiency. While this motivation is increasingly being recognized, little P recovery is practiced today, as recovered P generally cannot compete with the relatively low cost of mined P. Therefore, P is often captured to prevent its release into the environment without beneficial recovery and reuse. However, additional incentives for P recovery emerge when accounting for the total value of P recovery. This article provides a comprehensive overview of the range of benefits of recovering P from waste streams, i.e., the total value of recovering P. This approach accounts for P products, as well as other assets that are associated with P and can be recovered in parallel, such as energy, nitrogen, metals and minerals, and water. Additionally, P recovery provides valuable services to society and the environment by protecting and improving environmental quality, enhancing efficiency of waste treatment facilities, and improving food security and social equity. The needs to make P recovery a reality are also discussed, including business models, bottlenecks, and policy and education strategies.

Can urban P conservation help to prevent the brown devolution?

Achieving better understanding phosphorus (P) flows through urban ecosystems is needed to conserve P, as non-renewable phosphate rock deposits become depleted and the global human population increases. A baseline mass flow analysis (MFA) for P developed for the Twin Cities Watershed (TCW, which includes most of the Minneapolis-St. Paul metropolitan region) showed that most P input was stored in the system (65%) or leaked from it (31%); only 4% was deliberately exported as useful products. In a realistic, comprehensive conservation scenario P input was reduced by 15%; deliberate export of P in the form of sewage sludge, food waste, and landscape waste was 68% of P input. In this scenario, increased deliberate export was accomplished by decreasing leakage (to 9% of input) and storage (to 23% of input). If used as agricultural fertilizer, the deliberately exported P in the conservation scenario would support about half of the food production required by the TCW.

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.

A distinct urban biogeochemistry?

Most of the global human population lives in urban areas where biogeochemical cycles are controlled by complex interactions between society and the environment. Urban ecology is an emerging discipline that seeks to understand these interactions, and one of the grand challenges for urban ecologists is to develop models that encompass the myriad influences of people on biogeochemistry. We suggest here that existing models, developed primarily in unmanaged and agricultural ecosystems, work poorly in urban ecosystems because they do not include human biogeochemical controls such as impervious surface proliferation, engineered aqueous flow paths, landscaping choices, and human demographic trends. Incorporating these human controls into biogeochemical models will advance urban ecology and will require enhanced collaborations with engineers and social scientists.

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.

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.

Genetics of educational attainment in Australian twins: sex differences and secular changes

The relative effects of genetic and environmental factors in producing individual differences in educational achievement are compared across women and men and over birth cohorts. In a large sample of Australian twin pairs, the heritability of self-reported educational attainment did not vary among women and men born before and after 1950. In a "psychometric" model of twin resemblance, based on separate self-reports in 1981 and 1989, genetic factors explained 57% of the stable variance in educational achievement, while environmental factors shared by twins accounted for 24% of the variance. Corrections for phenotypic assortative mating for educational level, however, suggested that estimated common-environmental effects could be entirely explained by the correlation between additive genetic values for mates. Taking this into account, heritability "true" educational attainment in Australia may be as high as 82% with the remaining variation being due to individual environments or experiences. Unlike previous studies in Scandinavian countries, results in Australia suggest that factors influencing educational success are comparable between women and men and for individuals born at different points during this century.

Models of spouse similarity: applications to fluid ability measured in twins and their spouses

Genetic influences have consistently been reported to be the principal explanation for resemblance among relatives for intelligence, with shared environmental effects playing a much smaller role. However, crucial to understanding the nature of environmental influences are the mechanisms of assortative mating. Phenotypic assortment, albeit widely assumed or modeled in biometrical analyses, may be less important than other assortment processes, such as social homogamy. Consequently, effects of shared environment may play a greater role than prior studies have suggested. The goal of this study was to resolve environmental and genetic influences on fluid ability based on alternative models of assortment by examining the similarity of monozygotic (MZ) and dizygotic (DZ) twins and their spouses. Raven's Progressive Matrices scores were available from a population-based Swedish sample of 138 twin kinships. The effects of both social homogamy and phenotypic assortment were tested simultaneously in each of two alternate assortment models. A factor/delta path model represented social homogamy as a common factor and phenotypic assortment as a delta path, while a delta/delta path model represented both social homogamy and phenotypic assortment as delta paths. Overall, the factor/delta path model was found to be superior. Results suggested that social homogamy completely explained spouse similarity; phenotypic assortment was not significant. The results of these analyses suggest the presence of shared environmental effects among twins and their spouses, which would have been underestimated if only phenotypic modeled phenotypic assortment may have underestimated the effects of environment.

Antisperm autoantibody responses to vasectomy and vasovasostomy in Fischer and Lewis rats

Antisperm autoantibodies were studied in Fischer and Lewis strains of rats after either vasectomy, vasectomy followed one month later by vasovasostomy, or sham operations. The time course of antibody response to sperm protein autoantigens was assayed by Western blot analysis of sera obtained at intervals up to 3 months. Rats of both strains responded to immunization with isologous spermatozoa with production of high titer hyperimmune sera. Sera from vasectomized Fischer rats showed antisperm antibodies on Western blots, but bands were stained with less intensity and frequency than for Lewis rats. In both Fischer and Lewis strains, major protein autoantigens were observed at 75-83, 68-71, 63, 57, 51, 41, and 21-23 kDa, lending support to the hypothesis that there is a set of dominant sperm autoantigens recognized by a consensus of postvasectomy rat sera. The lesser response of Fischer rats to vasectomy was not due to absence of dominant postvasectomy sperm autoantigens in Fischer sperm extracts, nor was it attributable to inability of Fischer rats to mount an immune response to these antigens, since immunization with isologous sperm was successful in raising antibodies to the dominant autoantigens. Vasovasostomy did not result in a general decrease in antisperm antibodies, and reactions to some antigens actually increased.

Leydig cell function after experimental testicular torsion despite loss of spermatogenesis

Little is known about specific testicular cell responses to periods of testicular torsion. In particular, the steroidogenic capacity of Leydig cells in the post-torsion testis is unknown. Male Sprague-Dawley rats (450-550 g) underwent no torsion (control) or a 720 degrees unilateral testicular torsion for either 0 (sham), or 1 or 2 Such torsions have previously been shown to cause progressive damage to the rat testis. One, 15, or 30 days after torsion repair all animals (n = 5-10/group) were prepared for testicular venipuncture and intravenous infusion of ovine luteinizing hormone (LH) via the femoral vein. Testicular venous blood was collected directly from the surface of the testis both 5 minutes prior to and 90 minutes after infusion of predetermined ED50 (0.1 microgram) or ED100 (0.5 microgram) doses of LH. Testicular venous serum (TVS) was assayed for testosterone (T) by radioimmunoassay. Control animal TVS T concentrations before LH infusion and 90 minutes after ED50 and ED100 LH stimulation were 103 +/- 25, 621 +/- 103, and 1,055 +/- 140 ng/ml, respectively. Testes having experienced a 1-hour torsion did not have a significantly (P < 0.05) reduced capacity to respond to ED50 and ED100 stimulation at either 15 and 30 days after the torsion. Testes having experienced a 2-hour torsion did have significantly reduced (P < 0.05) ED50 responses at both 1 hour and 30 days after torsion repair. More remarkably, significant steroidogenic reserve was still present in testes after torsion, which in previous studies had been shown to have permanent loss of spermatogenesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Temporal recognition of sperm autoantigens by IgM and IgG autoantibodies after vasectomy and vasovasostomy

Temporal patterns of IgM and IgG autoantibodies to sperm proteins were studied by western blot analysis at intervals after bilateral vasectomy, vasectomy followed one month later by vasovasostomy, or sham operations. Responses were detected to eight major autoantigens at 21-23, 36, 41, 51, 57, 63, 68-71 and 75-83 kDa, by study of staining patterns of sequential serum samples from individual animals and by analysis of the incidence of reaction to each protein. The four lower molecular weight antigens (21-23, 36, 41 and 51 kDa) provoked mainly IgG responses. The strongly stained set of higher molecular weight antigens (57, 63, 68-71 and 75-83 kDa) tended to show more clearly defined temporal patterns of IgM followed by IgG response, including a high incidence of IgM antibody at the 2-week interval. Three of the larger peptides (57, 63 and 68-71 kDa) appeared highly immunogenic, since some reactions were detected even in sham-operated rats. The classical patterns of IgM and IgG antibody responses to the majority of the dominant sperm autoantigens are in accord with the hypothesis that vasectomy mimics immunization with spermatozoa. The high incidence of IgM antibodies in the earliest sample, taken 2 weeks after vasectomy, suggests that the initial immunizing event takes place within about a week after the operation. Vasovasostomy did not bring about a decrease in antisperm antibodies. Instead, some animals demonstrated an increased reaction to certain antigens after reversal of vasectomy, even though the vasovasostomies were anatomically successful.

Influence of depression on the treatment of panic disorder with imipramine, alprazolam and placebo

This paper presents findings from a multisite study of 126 subjects meeting DSM-III-R criteria for Panic Disorder who also met criteria for a concurrent Major Depressive Episode, Dysthymia, or Depressive Disorder NOS. The study's primary aim was to discern the influence of varying degrees of depression on the comparative efficacy of alprazolam, imipramine and placebo on anxiety outcomes. A placebo-controlled, double-blind, parallel random assignment design was utilized over a total of 16 weeks. There was no medication effect on panic outcomes. At endpoint, percent of anticipatory anxiety (i.e., time spent worrying about having an anxiety attack) was significantly lower in the patients taking active medications vs. placebo. Phobic measures were significantly improved by alprazolam, vs. both imipramine and placebo early in the study; however, by week 8 both active medications were equally superior to placebo in the reduction of phobic symptoms. In addition, both active medications were significantly more effective than placebo in reducing depression. The same efficacy pattern (i.e., active medications superior to placebo) was observed on measures of general functioning. Importantly, there were no significant interactions observed between medication and presence of major depression on the depression measures, indicating that both alprazolam and imipramine were equally efficacious in treating the depression in patients with panic disorder and major depression. Since the patients enrolled in this study suffered from major depressive disorder in the mild to moderate severity range, these results may not be transferrable to patients with panic disorder and severe major depression.

Subsyndromal symptoms in bipolar disorder. A comparison of standard and low serum levels of lithium

Ninety-four patients with bipolar disorder participating in a random-assignment, double-blind, prospective maintenance trial of standard- (0.8 to 1.0 mmol/L) vs low-range (0.4 to 0.6 mmol/L) serum lithium levels were assessed to determine the presence and significance of subsyndromal symptoms during periods of remission and recovery. A significant relationship was found between prescribed serum lithium level and the probability of major affective relapse and the occurrence of subsyndromal symptoms. Patients given lithium carbonate to achieve low-range levels had 2.6 times the risk of major affective relapse as those given lithium for standard-range levels and nearly twice the risk of developing subsyndromal symptoms. Patients given the low-range therapy showed a greater variance in weekly Psychiatric Status Rating measures, and their symptoms were more likely to worsen at any time than were symptoms in their standard-level group counterparts. The first occurrence of subsyndromal symptoms increased the risk of major affective relapse fourfold. Following the onset of subsyndromal symptoms, the patients originally randomized to receive standard-range lithium therapy were still better protected from relapse than were patients randomized to receive low-range lithium treatment. Patients were two times more likely to develop depressive than hypomanic symptoms between acute episodes of illness. However, onset of hypomanic symptoms predicted subsequent major affective relapse twice as strongly as did depressive symptoms. Seventy-six percent of patients who became hypomanic had a major affective relapse, compared with 39% of patients who were subclinically depressed.

Electrodermal lability: individual differences affecting perceptual speed and vigilance performance in 9 to 16 year-old children

Studies on adults have suggested that a deterioration in performance (within session vigilance decrement) on a continuous performance task may be related to individual differences in baseline levels of electrodermal activity (electrodermal lability). This study investigated this relationship in 153 children, aged 9-16 years. A significant vigilance decrement was observed, as indicated by average decreases in perceptual sensitivity (d') over an 11.5-min time period. Although electrodermal labiles were overall more perceptually sensitive than electrodermal stabiles, results did not support the premise that the performance of stabiles decreases over time more than that of labiles. Performance on other cognitive tasks, involving tests of perceptual speed ability, did not appear to be highly related to vigilance performance. However labiles were not only better able to sustain their attention, but also performed better and faster on these cognitive tasks.