The modern endoscopic approach to ureterocele

PURPOSE: During the last 20 years the surgical approach to ureterocele has evolved from major open surgery to minimally invasive endoscopic puncture. We believe that the endoscopic approach decreases the need for open surgical procedures. We identified specific factors that predict the need for repeat surgery. MATERIALS AND METHODS: We reviewed the charts of 60 new patients with ureterocele treated with primary endoscopic incision between 1991 and 1995. Followup ranged from 4 to 62 months (mean 20). Mode of presentation, ureterocele location, associated vesicoureteral reflux and association of the ureterocele with a duplex system were evaluated. Ureterocele wall thickness was assessed subjectively via radiographic and cystoscopic methods, and categorized as thin, intermediate and thick. RESULTS: All 9 patients with a single system ureterocele had an intravesical ureterocele. No patient had associated reflux nor did any require a secondary open procedure. In 3 cases new onset ipsilateral reflux into the ureterocele spontaneously resolved. Of the 51 patients with a duplex system and associated ureterocele 19 (37%) required a secondary open procedure. The ureterocele was intravesical and ectopic in 22 (43%) and 29 (57%) cases, respectively. Reflux was associated with the ureterocele in 27 patients (53%), and 12 (44%) required a secondary open procedure. A total of 11 patients underwent ureteral reimplantation of 15 refluxing renal units and only 2 renal units required ureteral tapering. Reflux is no longer present in 14 of the 15 renal units (93%). Patients with a thick walled ureterocele required repeat puncture more frequently than those with a nonthick ureterocele. CONCLUSIONS: With the use of modern endoscopic techniques children with intravesical and single system ureteroceles require secondary open surgery less frequently than those with ectopic and duplex system ureteroceles. The mode of presentation does not predict the need for a repeat open procedure. Thick walled ureteroceles require repeat endoscopic puncture more frequently than thin and intermediate walled ureteroceles.     

Head‐locking durability of fixed and variable angle locking screws under repetitive loading

Polyaxial locking screws are increasingly applied in fracture fixation. To investigate the durability of the head‐locking mechanism, the removal torque of variable angle (VA) and fixed angle (FA) stainless steel and titanium locking screws was investigated without and after a cyclic loading test. Stainless steel (St) and titanium (Ti) 2.4 mm orthogonally inserted FA screws and 2.4 mm VA screws inserted in different inclinations (0°–15°) (n = 6 per group) were locked at 0.8 Nm. Removal torque was determined without (W) and after (A) cyclic loading (sinusoidal load, 5 Hz, constant amplitude of 25 N, up to 10′000 cycles, or failure). Significant differences in‐between the groups were detected by Student's t‐test (p < 0.05). Except VA Ti in 0deg and FA, all groups exhibited a drop in removal torque below the insertion torque without and after cyclic testing. The removal torque was (St: FA W:0.81 Nm ± 0.04 A:0.72Nm ± 0.04; VA0deg W:0.73 Nm ± 0.04 A:0.65 Nm ± 0.05; VA15deg W:0.51 Nm ± 0.05 A:0.50 Nm ± 0.08; Ti: FA W:0.82 Nm ± 0.03 A:0.70 Nm ± 0.04; VA0deg W:0.80 Nm ± 0.02 A:0.72 Nm ± 0.05; VA15deg W:0.55 Nm ± 0.03 A:0.54 Nm ± 0.06). In all groups, the removal torque after cyclic testing did not drop below 16% of the removal torque without cyclic testing. No head loosening was observed after cyclic testing. Stainless steel and titanium 2.4 mm fixed and variable angle locking screws provide a stable and lasting head‐locking mechanism. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:949–952, 2016.     

Total energy expenditure during arduous wildfire suppression

PURPOSE: The purpose of this investigation was to determine the total energy expenditure (TEE) by using the doubly labeled water (DLW) methodology during 5 d of wildfire suppression in Montana, California, Florida, Washington, and Idaho. METHODS: Seventeen wildland firefighters (from three Interagency Hot Shot crews, N = 8 men, height = 177 +/- 7 cm, weight = 74.6 +/- 6.4 kg, age = 24.5 +/- 1.8 yr; N = 9 women, height = 170 +/- 7 cm, weight = 65.2 +/- 8.0 kg, age = 25.0 +/- 1.3 yr) served as subjects. Before wildland fire suppression, each subject was given an oral dose of 2H2O and H218O (approximately 0.23 g 2H2O.kg estimated TBW-1 and 0.39 g H218O.kg estimated TBW-1). Urine samples were collected between 0400 and 0600 daily. TEE was calculated using the two-point method for days 1-3 and 1-5, with the TEE for days 4-5 calculated by extrapolation. Urine samples from other crew members not participating in the DLW protocol were collected at the same times and used to adjust calculations of isotopic elimination for background shifts. RESULTS: TEE was 17.4 +/- 3.7 and 17.5 +/- 6.9 MJ.d-1 during days 1-3 and 4-5, respectively. The energy expenditure associated with physical activity (EEA) was 8.8 +/- 3.0 and 8.9 +/- 6.1 MJ.d-1 for days 1-3 and 4-5, respectively. CONCLUSION: The current data demonstrate consistently high daily energy expenditure in the wildland firefighter. These data also demonstrate that the doubly labeled water methodology is an appropriate methodology for the measure of TEE during unpredictable field operations if adjustments are made for changes in background enrichment and elevated water turnover.     

Buccal mucosal grafts: lessons learned from an 8-year experience

PURPOSE: We evaluated our 8-year experience with buccal mucosal grafts in complex hypospadias and epispadias repair. MATERIALS AND METHODS: We reviewed the records of 29 patients in whom a total of 30 buccal mucosal grafts were placed as part of urethral reconstruction between 1991 and 1999. At surgery 16 tubes and 14 onlays were constructed and 24 of 30 repairs involved the meatus. All patients were followed at least 6 months postoperatively (median 5.3 years). Beginning in 1995 meatal design was enlarged to a racquet handle shape and patients were asked to perform meatal self-dilation for 6 months postoperatively. RESULTS: Complications developed in 17 of our 30 cases (57%) and reoperation was done in 10 (33%). All complications were evident by 11 months postoperatively except 1 that presented as recurrent stricture disease at 3 years. Complications developed in 5 and 12 of 15 patients who underwent surgery between 1995 and 1999, and before 1995, respectively (p = 0.027). No patient has had meatal stenosis since 1995. Complications included meatal stenosis in 5 cases, stricture in 7, glanuloplasty, meatal and complete graft breakdown in 1 each, and fistula in 2. Onlays were more likely to result in stricture than tube grafts (6 of 14 cases versus 1 of 16, p = 0.034). CONCLUSIONS: The complication and reoperation rates of buccal mucosal grafts are 57% and 33% at 5 years of followup. Changes in meatal design and temporary postoperative meatal dilation have improved the outcome in the last 5 years. Buccal mucosa remains a good choice in patients who require extragenital skin for urethral reconstruction.     

Laser tissue soldering for hypospadias repair: results of a controlled prospective clinical trial

PURPOSE: Laser tissue soldering has been shown to provide safe and effective tissue closure by creating an immediate leak-free anastomosis with minimal scar formation. We compared the results of laser tissue soldering and conventional suturing for hypospadias repair. MATERIALS AND METHODS: A consecutive group of 138 boys 4 months to 8 years old (mean age 15 months) was divided into a standard suturing (84) and a sutureless laser (54) hypospadias repair group. Urethral repair was defined as simple (Thiersch-Duplay or Snodgrass) and complex (onlay island flap or tube) in 101 and 37 cases, respectively. Laser tissue soldering was performed with 50% human albumin solder doped with 2.5 mg./ml. indocyanine green dye using an 808 nm. diode laser at 0.5 W. In the laser group sutures were used for tissue alignment only. At surgery neourethral and penile length, operative time for neourethral construction and the number of sutures or throws were measured. Postoperatively patients were examined for complications of wound healing, stricture or fistula. RESULTS: Mean patient age, urethral defect severity, type of repair, neourethral length and stenting time plus or minus standard error of mean were not significantly different in the 2 groups. Mean operative time was a fifth as long for laser tissue soldering in simple and complex hypospadias repair compared to controls (1.5 +/- 0.1 and 5.1 +/- 0.3 versus 8.5 +/- 0.8 and 26.7 +/- 1.7 minutes, respectively, p <0.001). The mean number of sutures used for tissue alignment in the laser group for simple and complex repair was significantly less than in controls (3.0 +/- 0.2 and 8.2 +/- 0.6 versus 8.5 +/- 0.8 and 23.2 +/- 1.5, respectively, p <0.001). All patients were followed a mean of 12 months (minimum 6, maximum 22). The complication rate was 4.7% in the laser group and 10.7% in controls with fistula in 2 of 54 cases, and fistula and meatal stenosis in 7 and 2 of 84, respectively. CONCLUSIONS: These preliminary results indicate that laser tissue soldering for hypospadias repair may be performed in almost sutureless fashion and more rapidly than conventional suturing. The ease of the laser technique and the lower complication rate in the laser group indicate that laser tissue soldering is an acceptable means of tissue closure in hypospadias repair.     

Exercise physiology versus inactivity physiology: an essential concept for understanding lipoprotein lipase regulation

Some health-related proteins such as lipoprotein lipase may be regulated by qualitatively different processes over the physical activity continuum, sometimes with very high sensitivity to inactivity. The most powerful process known to regulate lipoprotein lipase protein and activity in muscle capillaries may be initiated by inhibitory signals during physical inactivity, independent of changes in lipoprotein lipase messenger RNA.     

Abnormal testicular histology in Michelin tire syndrome

An 8-year-old male is described with Michelin tire syndrome and an abnormal testicular histology which has not previously been reported in this syndrome.     

Different glycemic indexes of breakfast cereals are not due to glucose entry into blood but to glucose removal by tissue

BACKGROUND: The glycemic index (GI) of a food is thought to directly reflect the rate of digestion and entry of glucose into the systemic circulation. The blood glucose concentration, however, represents a balance of both the entry and the removal of glucose into and from the blood, respectively. Such direct quantification of the postprandial glucose curve with respect to interpreting the GI is lacking in the literature. OBJECTIVE: We compared the plasma glucose kinetics of low- and high-GI breakfast cereals. DESIGN: On 2 occasions, plasma insulin concentrations and plasma glucose kinetics (by constant-rate infusion of [6,6-(2)H(2)]glucose) were measured in 6 healthy males for 180 min after they fasted overnight and then consumed an amount of corn flakes (CF) or bran cereal (BC) containing 50 g available carbohydrate. RESULTS: The GI of CF was more than twice that of BC (131.5 +/- 33.0 compared with 54.5 +/- 7.2; P < 0.05), despite no significant differences in the rate of appearance of glucose into the plasma during the 180-min period. Postprandial hyperinsulinemia occurred earlier with BC than with CF, resulting in a 76% higher plasma insulin concentration at 20 min (20.4 +/- 4.5 compared with 11.6 +/- 2.1 micro U/mL; P < 0.05). This was associated with a 31% higher rate of disappearance of glucose with BC than with CF during the 30-60-min period (28.7 +/- 3.1 compared with 21.9 +/- 3.1 micro mol. kg(-)(1). min(-)(1); P < 0.05). CONCLUSION: The lower GI of BC than of CF was not due to a lower rate of appearance of glucose but instead to an earlier postprandial hyperinsulinemia and an earlier increase in the rate of disappearance of glucose, which attenuated the increase in the plasma glucose concentration.     

Effects of pregnancy on muscarinic receptor density and function in the rabbit urinary bladder.

The contractile response of the rabbit urinary bladder to field stimulation consists of both cholinergic and purinergic components. In general, approximately 60% of the contractile response to field stimulation is cholinergic and 40% is purinergic. Although the purinergic response represents a significant proportion of the initial (phasic) pressure response to field stimulation of the isolated whole bladder, it contributes only 10-15% of the ability of field stimulation to empty the bladder. The current study investigates the effects of pregnancy on the contractile responses of the isolated urinary bladder to cholinergic and purinergic stimulation. The results of these studies indicate that pregnancy induces substantial changes in the physiology and pharmacology of the urinary bladder. The following data are consistent with the theory that pregnancy substantially increases the relative purinergic component of the response to field stimulation (and presumably neuronal stimulation): (1) there was a significantly greater response of the bladders isolated from pregnant rabbits to low-frequency field stimulation; (2) atropine was more effective at inhibiting the pressure generation of bladders isolated from virgin female rabbits; (3) field stimulation was more effective at emptying bladders isolated from virgin female rabbits; (4) the response of the bladders from pregnant rabbits to bethanechol was significantly reduced, whereas the response to ATP was significantly increased. In addition to these effects of pregnancy on bladder physiology, pregnancy induced a 50% decrease in the muscarinic receptor density of the urinary bladder body, which correlated very well with the 50% decrease in the contractile response to bethanechol.     

Resection of abdominal solid organs using high-intensity focused ultrasound

Our objective was to evaluate high-intensity focused ultrasound (HIFU) for minimizing blood loss during surgery by hemodynamically isolating large portions of solid organs before their resection. A high-power HIFU device (in situ intensity of 9000 W/cm(2), frequency of 3.3 MHz) was used to produce a wall of cautery for sealing of blood vessels along the resection line in surgically exposed solid organs (liver lobes, spleen and kidneys) of eight adult pigs. Following HIFU application, the distal portion of the organ was excised using a scalpel. If any blood vessels were still bleeding, additional HIFU application was used to stop the bleeding. The resection was achieved in 6.0 +/- 1.5 min (liver), 3.6 +/- 1.1 min (spleen) and 2.8 +/- 0.6 min (kidneys) of HIFU treatment time, with no occurrence of bleeding for up to 4 h (until sacrifice). The coagulated region at the resection line had average width of 3 cm and extended through the whole thickness of the organ (up to 4 cm). Blood vessels of up to 1 cm in size were occluded. This method holds promise for future clinical applications in resection of solid tumors and hemorrhage control from high-grade organ injuries.