Incidence of bacterial meningitis in Asia using enhanced CSF testing: polymerase chain reaction, latex agglutination and culture.

To enhance the detection of bacterial meningitis in an East Asian surveillance study, we employed cerebrospinal fluid (CSF) bacterial culture, latex agglutination (LA) and polymerase chain reaction-enzyme immunoassay (PCR-EIA) testing for Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (Sp). The sensitivity and specificity of CSF PCR-EIA testing was compared to LA and culture. A meningitis case was defined by one positive result for any of the three tests. The sensitivity of H. influenzae CSF PCR-EIA, LA, and culture was 100%, 40% and 57.5% respectively; and for Sp CSF PCR-EIA, LA and culture, the sensitivity was 100%, 58.3% and 66.7%, respectively. Hib and Sp specificity was 100% by each method. CSF PCR-EIA was more sensitive than culture or LA for the detection of Hib and Sp meningitis cases increasing their incidence by 74% and 50% compared to culture respectively. CSF PCR-EIA should be included for the detection of bacterial meningitis in surveillance studies.

Incidence of Haemophilus influenzae type b and other invasive diseases in South Korean children.

To determine incidence of invasive Haemophilus influenzae type b (Hib) disease in a defined population of Jeonbuk Province, Korea, children <5 years were evaluated in prospective, population-based surveillance of invasive bacterial diseases using standardized methods for patient referral, clinical evaluation and laboratory testing (optimized culture, latex agglutination, polymerase chain reaction). Vaccine utilization was assessed with vaccination histories of patients in surveillance, monthly data on Hib vaccine distribution and a coverage survey of clinic patients in study population. From September 1999 to December 2001, 2176 children were evaluated for possible meningitis, 1541 had no cerebrospinal fluid (CSF) findings of meningitis, 605 had CSF abnormalities (suspected bacterial meningitis) but no pathogen identified; six patients had probable Hib meningitis and eight had confirmed Hib meningitis. The annual suspected bacterial meningitis incidence was 258.4/100,000 <5 years and the probable/confirmed Hib meningitis incidence was 6.0/100,000 <5 years. Pneumococcal meningitis incidence was 2.1/100,000 <5 years and Group B streptococcal meningitis incidence was 0.17/1000 live births. A total of 69,589 Hib vaccine doses were distributed during the study. Hib vaccine coverage was negligible initially but increased to 16% (complete Hib immunization) and 27% (partial immunization) in final months of study. Suspected bacterial meningitis incidence was high but proven invasive Hib meningitis incidence was low. Hib was leading cause of bacterial meningitis yet bacterial pathogens were identified in only 4% of abnormal CSF. These findings may reflect truly low incidence, presumptive antibiotic treatment, partial Hib immunization, or incomplete clinical evaluations. Given the apparent Hib meningitis burden in Jeonbuk Province, additional studies to describe other invasive Hib syndromes, Hib-associated mortality and disability, and economic impact of Hib disease will be useful to guide public health decisions regarding routine Hib vaccine introduction.

[Epidemiologic surveillance for bacterial meningitis in 140 000 children under 5 years of age in Nanning district, Guangxi province].

OBJECTIVE: To characterize the incidence, epidemiologic features, etiologic agents and sequelae of bacterial meningitis in children under 5 years of age in Nanning, Guangxi. METHODS: A population-based surveillance was conducted to evaluate children with signs and symptoms of meningitis. All hospitals, township health centers and village clinics in the surveillance area were structured to participate in the case referral and evaluation. Cerebrospinal fluid (CSF) and blood specimens were obtained and processed using standardized microbiologic methods. RESULTS: During the 26-month surveillance period, among the children under 5 years old, a total of 1272 cases who met the screening criteria of meningitis were studied. 265 of 1272 cases were identified as clinically diagnosed meningitis, with an incidence rate of 86.36 per 100 000 population. The annual incidence rate under the 38 cases of confirmed bacterial meningitis appeared to be 12.38/100 000. Staphylococcus species accounted for the largest proportion of laboratory-confirmed bacterial meningitis, followed by E. coli and S. pneumoniae. The highest attack rate occurred in neonates < 1 month, followed by children aged 1 - 12 months in the confirmed patients. Meningitis caused by Sp and Hi mainly occurred in children aged 1 - 12 months. All cases of meningitis due to Hi and Sp were children aged 1 - 24 months. 13.16% and 0.00% of the cases survived with complications and sequelae, and the case-fatality rate was 18.42%. 40 bacterial isolates were identified from 1193 blood cultures and 23 from 1211 cerebrospinal fluid samples, but no Neisseria meningitidis was found. CONCLUSION: Meningitis due to Hi was first confirmed in Guangxi with the incidence of 0.98 per 100 000 population. The annual incidence rate of confirmed bacterial meningitis was 12.38 per 100 000, which was considered an important public health problem in children. Staphylococci was the predominant pathogen in confirmed bacterial meningitis.

The effects of intravesical lidocaine on bladder dynamics of children with myelomeningocele.

PURPOSE: Other studies have suggested that intravesical lidocaine may temporarily improve bladder dynamics but details of these effects and their application to children have not been examined. We evaluated the effects of intravesical lidocaine on bladder urodynamics of children with myelomeningocele and tried to correlate these effects with subsequent clinical response to oral oxybutynin. MATERIALS AND METHODS: Charts of children with myelomeningocele who had undergone urodynamic examinations from 1992 to 1998 were reviewed retrospectively. In children with uninhibited contractions or poor compliance 150 to 300 mg. lidocaine were instilled for 8 minutes and cystometry was repeated. Changes in bladder capacity and compliance, number of uninhibited contractions and bladder volume at which pressure of 40 cm. H2O was reached were recorded before and after the lidocaine instillation. Clinical response to subsequent treatment with oral oxybutynin was assessed from chart review. RESULTS: A total of 48 urodynamic studies in 22 girls and 20 boys with a mean age plus or minus standard deviation of 8.3 +/- 5.7 years and myelomeningocele were evaluable. After instillation of lidocaine, urodynamics showed increased bladder capacity in 70.8% of studies (34 of 48), with an average increase in volume of 66% (p <0.05). No change or decreased bladder capacity occurred in 29.2% of studies. Bladder compliance improved in 61.7% of the studies (29 of 47, p <0.05) and worsened in 38.3%. Bladder volume at which the pressure of 40 cm. H2O was reached increased in 77.8% of studies (14 of 18, p <0.05). After lidocaine the number of uninhibited contractions decreased by 3.2 in 56.8% of studies (21 of 37, p <0.05). Correlation of lidocaine induced changes in bladder capacity, compliance and number of uninhibited contractions with improvement on oral oxybutynin was 70.6%, 64.3% and 66.7%, respectively. CONCLUSIONS: Intravesical lidocaine can improve bladder capacity and compliance and decrease the number of uninhibited contractions in many children with neurogenic bladder caused by myelomeningocele. These observations suggest that intravesical lidocaine has effects on the neurogenic bladder that improve bladder dynamics. Although intravesical lidocaine testing may not reliably predict clinical response to oral oxybutynin at the prescribed dosages, a possible therapeutic role for intravesical lidocaine or similar agents should be explored further.

Evaluation of sonographic renal parenchymal area in the management of hydronephrosis.

PURPOSE: We used quantitative parameters of renal sonography to differentiate children with significant obstruction requiring surgical intervention from those without significant obstruction who were followed conservatively. MATERIALS AND METHODS: We retrospectively reviewed the records of children who underwent evaluation for hydronephrosis. Those with a history of vesicoureteral reflux, anatomical abnormalities or neurogenic bladder were excluded from study. Patients were divided according to hydronephrosis grade into groups 1-grades III and IV followed conservatively, 2-grades III and IV requiring surgical intervention, 3-unilateral grade II and 4-bilateral. All images were scanned into a computer. Renal parenchymal and pelvic area was determined using National Institutes of Health image software. Parenchymal-to-pelvic area ratios were calculated from all images. We evaluated the ability of these measurements to determine the likelihood of surgical intervention. RESULTS: The records of 81 children were available for analysis. Deterioration in parenchymal area growth was a predictor of surgical intervention. Such patients had catch-up growth of the affected kidney after pyeloplasty. A parenchymal-to-pelvic area ratio of greater than 1.6 on the initial ultrasound study after birth predicted cases that would need pyeloplasty in the future (p <0.05). No patient with grade II hydronephrosis required surgical intervention. CONCLUSIONS: Following serial parenchymal area on serial ultrasound is useful for evaluating children with hydronephrosis. Those with a parenchymal area below the nomogram for growth usually require pyeloplasty. A parenchymal-to-pelvic area ratio of less than 1.6 on the initial ultrasound study after birth in patients with prenatally diagnosed ureteropelvic junction obstruction or on initial ultrasound in those diagnosed postnatally indicated the need for surgical intervention in this limited series.

Effect of circumcision on prostatic bacterial colonization and subsequent bacterial seeding following transrectal ultrasound-guided prostate biopsies.

PURPOSE: This study was designed to compare the prevalence of prostatic bacterial growth between circumcised and uncircumcised males and determine whether the lack of circumcision results in a change in the incidence of bacterial seeding following prostate needle biopsy. MATERIALS AND METHODS: Forty-six men (21 circumcised and 25 uncircumcised) undergoing ultrasound and biopsy to rule out prostate cancer were evaluated with questionnaires regarding previous history of urinary tract infection (UTI), any symptoms suggestive of UTI, and obstructive voiding symptoms. None of the patients received preprocedure antibiotics. Preprocedure and postprocedure urine samples, prostate biopsy core, and postprocedure blood samples were obtained for culture. After the cultures were obtained, patients received oral antibiotics. RESULTS: Patient characteristics between circumcised and uncircumcised patients were similar in terms of age, prostate-specific antigen level, voiding symptoms, history of UTI, prostate biopsy technique, and incidence of prostate cancer. The prevalence of preprocedure bacteriuria was slightly higher in the uncircumcised men (14 [56%] of 25 patients) vs. the circumcised men (8/21 [38%] patients), although this was not statistically significant (r = .2, p = .1). The prevalence of postprocedure bacteriuria was significantly higher (p = .04) in the uncircumcised men (12/25 [48%] patients) vs. the circumcised men (4/21 [19%] patients). No correlation was found between circumcision status and incidence of bacterial colonization in the prostate tissue. A statistically significant difference (p = .003) was found between the lack of circumcision and postprocedure bacteremia. CONCLUSIONS: Circumcision status does not effect the prevalence of bacterial growth in the urine and the prostate tissue. Uncircumcised men have a higher incidence of bacteriuria and bacteremia following prostate needle biopsies.

Occurrence and risk factors of oral candidiasis treated with oral antifungals in seniors using inhaled steroids.

Oral candidiasis (OC) is a frequent side effect of inhaled corticosteroids (iCSTs). This study estimated occurrence and significance of risk factors of OC treated with antifungals in users of iCSTs under conditions of normal use. This retrospective analysis used data drawn from drug insurance plan records in Quebec, Canada. The sample contained 27,000 seniors using anti-asthma medications during 1990. Three years of data (1989-1991) were searched for use of oral antifungals concurrent with exposure to iCSTs. A case-control study examined factors leading to increased probability of first incidence of OC in new users of iCSTs. Three-year occurrence for OC was 7%. Increased risk for a first occurrence of OC was significantly associated with higher doses of iCST, increased length of iCST exposure, use of antibiotics, use of oral steroids, having three or more prescribers, a history of use of both high and low strengths of iCST, and concurrent use of oral steroids and diabetes medications. The occurrence of OC is relatively high. Knowledge of factors leading to increased risk could facilitate the targetting of patients who need timely intervention, under conditions of normal use.

Comparison of conduct-disordered behavior in crack-dealing versus nondealing juvenile offenders.

Currently, little research has investigated psychosocial functioning among juvenile crack dealers, and there appear to be few studies comparing dealers to nondealing juvenile offenders. The current study examined whether juvenile crack dealers display more severe conduct-disordered behavior than their nondealing delinquent peers. The records of 130 adolescent males committed to a residential training school were studied. Analyses indicated that crack dealers were younger when first arrested, had more arrests and commitments, and met more DSM-III-R conduct-disorder criteria than their nondealing delinquent peers. In addition, the DSM-III-R conduct-disorder criteria met by dealers were more severe, and dealers were more likely to be rearrested within six months following release. Overall, significant differences between crack dealers and nondealing juvenile offenders were found; dealers displayed a more delinquent history and a more serious and violent conduct disorder than their nondealing yet delinquent peers.

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.

Epidermal growth factor suppresses renal tubular apoptosis following ureteral obstruction.

OBJECTIVES: Acute unilateral ureteral obstruction (UUO) results in ipsilateral hydronephrosis characterized by a decrease in epidermal growth factor (EGF) mRNA expression and EGF protein levels in the distal renal tubules. UUO results in programmed cell death with increases in the characteristic markers of apoptosis. To suppress the apoptotic response during UUO, recombinant EGF was administered during renal obstruction and the ensuing molecular and histologic changes were studied. METHODS: Mature Sprague-Dawley rats underwent left ureteral obstruction and the kidneys were harvested at 24, 48, and 72 hours. Markers of apoptosis included DNA laddering pattern on agarose gel electrophoresis, in situ gap labeling of fragmented DNA for quantitative apoptotic body determination, polyadenylated mRNA expression of SGP-2, and in situ hybridization for sulfated glycoprotein-2 (SGP-2) mRNA. Studies were repeated in rats following administration of 10, 20, and 40 micrograms of subcutaneous recombinant EGF on a daily basis after UUO. RESULTS: Subcutaneous injection of EGF into unilaterally obstructed rats promotes renal tubular epithelial cell regeneration, as demonstrated by increased cortical mitotic activity. Systemic EGF supplementation in these unilaterally obstructed rats also resulted in a decrease in the intensity of the DNA laddering pattern associated with renal tubular apoptosis. An in situ labeling procedure to identify apoptotic nuclei in the ureterally obstructed kidneys revealed a 50% reduction in apoptosis after EGF administration. Northern blot analysis and in situ hybridization for SGP-2 mRNA or clustering gene product also revealed a decreased expression in the obstructed and EGF-treated renal parenchyma. CONCLUSIONS: These data suggest that EGF, apart from its known role as a mitogenic substance for renal tubular epithelial cells, is also a critical in vivo renal cell survival factor for the developmentally mature kidney.

Permanent disability: the legacy of tort litigation.

The therapeutic alliance essential during the long process between the injury and the final appeal in the resulting tort is discussed. The core thesis is that once the patient with orthopaedic problems initiates litigation, he or she starts to become invested in permanent disability, and the slide down the slippery slope of a lifetime of disability has begun. This is not a lament about the role of lawyers, courts, and litigation. They are facts, part of the working conditions of the orthopaedic physician. What happens after acknowledging these facts is the topic of discussion. How can one do the best job of damage control in the face of a totally toxic situation? How can the physician become a stabilizing force in the spin toward permanence in disability?

A practical guide for the diagnosis and treatment of pediatric pneumonia.

OBJECTIVE: To develop guidelines for the diagnosis and management of community-acquired pediatric pneumonia. OPTIONS: Clinical assessment, radiography, laboratory testing, and empirical antimicrobial therapy. OUTCOMES: Increased awareness of age-related causes, improved accuracy of clinical diagnosis, better utilization of diagnostic testing and the rational use of empirical antimicrobial therapy resulting in more rapid diagnosis, initiation of appropriate therapy and decreased morbidity and mortality. EVIDENCE: A MEDLINE search for relevant articles published from 1996 to September 1996 using the MeSH terms "pediatric," "pneumonia," "respiratory tract infection," "pneumonitis," "etiology," "diagnosis," "therapy," "antibiotics," "resistance," "radiology," "microbiology" and "biochemistry." VALUES: A hierarchical evaluation of the strength of evidence modified from the methods of the Canadian Task Force on the Periodic Health Examination was used. When application of the hierarchy was not feasible or appropriate, different evaluation criteria were used. BENEFITS, HARMS AND COSTS: Increased awareness of the causes of pneumonia, accurate diagnosis and prompt treatment should reduce costs associated with unnecessary investigations and complications due to inappropriate treatment. RECOMMENDATIONS: Age is the best predictor of the cause of pediatric pneumonia, viral pneumonia being most common during the first 2 years of life. The absence of a symptom cluster of respiratory distress, tachypnea, crackles and decreased breath sounds accurately excludes the presence of pneumonia (level II evidence). Bacterial cultures of samples from the nasopharynx and throat have no predictive value; however, Gram staining and culture of sputum from older children and adolescents are useful (level III evidence). Oral antimicrobial therapy will provide adequate coverage for most mild to moderate forms of pneumonia in children (level III evidence). Parenteral therapy is typically reserved for neonates and patients with severe pneumonia admitted to hospital (level III evidence). VALIDATION: These recommendations are based on consensus of Canadian experts in infectious diseases and microbiology. They are the only guidelines to address antimicrobial treatment from an age-related, etiologic perspective. SPONSOR: The development of these guidelines and the technical support and assistance of Core Health Inc. in preparing this manuscript were funded through an unrestricted educational grant from Abbott Laboratories Canada. The sponsoring company was not involved in determining the membership of the consensus group or the content of the guidelines.

Acute urinary retention secondary to urethral inflammation from a vaginal contraceptive suppository in a 17-year-old boy.

We report the case of a 17-year-old boy who developed acute urinary retention following unprotected intercourse. His partner employed for the first time a nonoxynol-9-based commercial vaginal contraceptive insert. During intercourse the patient felt severe burning pain in the urethra. He was subsequently unable to void. Flexible cystourethroscopy revealed gross mucosal erythema and inflammation in the distal urethra and navicular fossa. We discuss the clinical management and review relevant literature.

PIP: Reported is the case of a 17-year-old US boy who developed acute urinary retention due to severe urethral inflammation, secondary to absorbance of a nonoxynol-9-based contraceptive. He had a recent history of unprotected intercourse with his regular sex partner until she used, for the first time, a vaginal suppository containing nonoxynol-9. During intercourse on this occasion, the adolescent experienced severe burning pain in the urethra and was subsequently unable to void. He denied any prior history of urinary tract infection, sexually transmitted diseases, or urethral discharge prior to this episode. The only significant clinical findings at examination were an inflamed meatal mucosa and severe tenderness to palpation 2 cm proximal to the glans. Flexible cystourethroscopy revealed gross mucosal erythema and inflammation in the distal urethra and navicular fossa. A French Foley catheter was easily inserted into the bladder and 1000 cm of clear urine were drained. An indwelling catheter was kept in place for 48 hours until the patient voided successfully. This is the first reported case of severe urethritis and obstruction in a young male. In this case, urethral absorption of nonoxynol-9 caused a severe inflammatory reaction sufficient to obstruct the distal urethra. When evaluating young men with acute urinary retention, clinicians should inquire about recent use of contraceptive inserts.

Response and habituation of the human amygdala during visual processing of facial expression.

We measured amygdala activity in human volunteers during rapid visual presentations of fearful, happy, and neutral faces using functional magnetic resonance imaging (fMRI). The first experiment involved a fixed order of conditions both within and across runs, while the second one used a fully counterbalanced order in addition to a low level baseline of simple visual stimuli. In both experiments, the amygdala was preferentially activated in response to fearful versus neutral faces. In the counterbalanced experiment, the amygdala also responded preferentially to happy versus neutral faces, suggesting a possible generalized response to emotionally valenced stimuli. Rapid habituation effects were prominent in both experiments. Thus, the human amygdala responds preferentially to emotionally valenced faces and rapidly habituates to them.

Urology peer review at the National Institutes of Health.

PURPOSE: Urology is a field with many subspecialties and, as a consequence, urological research grant applications are distributed to a variety of different study sections at the National Institutes of Health (NIH). It has long been the conviction of urological investigators that urological grant funding suffers as a result of this distribution. We investigated the composition of these study sections to identify the prevalence of urological expertise (or lack thereof). The review challenges the concept that urological research grant applications are being subjected to adequate peer review. MATERIALS AND METHODS: Aided by personnel from the National Institute for Diabetes, and Digestive and Kidney Diseases, and the National Cancer Institute, 22 study sections to which urological grants are distributed were identified. A 3 to 5-year retrospective MEDLINE analysis of all the scientific publications of each study section member was done. Urological experts were identified by the criterion of having more than 1 urological publication published per year or a proportional equivalent. An equivalent analysis was performed for the study sections reviewing cardiology grants to serve as a comparison. RESULTS: Data analysis revealed that only 12 of 351 study section members reviewing urological grants are urological experts (3.4%). Only 3.1% of the collective published productivity of these members is in the broadly defined field of urological investigation. Omitting the published productivity of these 12 experts, less than 1% of the published works of the remaining 339 members reflects interest or expertise in urological investigations. Of the 22 study sections only 8 have urological expertise represented in their membership. Except for 1 study section, representation of urological experts was usually limited to 1 individual reflecting a 5.9 to 11.1% minority in these study sections. CONCLUSIONS: The lack of urological expertise represented on the NIH study sections reviewing basic and clinical urological research grant applications has far reaching ramifications. Consequently, grant applications on genitourinary diseases that commonly afflict a preponderance of Americans are inadequately reviewed at the NIH. Only through the provision of appropriate peer reviewers will this problem be solved.

Object-related activity revealed by functional magnetic resonance imaging in human occipital cortex.

The stages of integration leading from local feature analysis to object recognition were explored in human visual cortex by using the technique of functional magnetic resonance imaging. Here we report evidence for object-related activation. Such activation was located at the lateral-posterior aspect of the occipital lobe, just abutting the posterior aspect of the motion-sensitive area MT/V5, in a region termed the lateral occipital complex (LO). LO showed preferential activation to images of objects, compared to a wide range of texture patterns. This activation was not caused by a global difference in the Fourier spatial frequency content of objects versus texture images, since object images produced enhanced LO activation compared to textures matched in power spectra but randomized in phase. The preferential activation to objects also could not be explained by different patterns of eye movements: similar levels of activation were observed when subjects fixated on the objects and when they scanned the objects with their eyes. Additional manipulations such as spatial frequency filtering and a 4-fold change in visual size did not affect LO activation. These results suggest that the enhanced responses to objects were not a manifestation of low-level visual processing. A striking demonstration that activity in LO is uniquely correlated to object detectability was produced by the "Lincoln" illusion, in which blurring of objects digitized into large blocks paradoxically increases their recognizability. Such blurring led to significant enhancement of LO activation. Despite the preferential activation to objects, LO did not seem to be involved in the final, "semantic," stages of the recognition process. Thus, objects varying widely in their recognizability (e.g., famous faces, common objects, and unfamiliar three-dimensional abstract sculptures) activated it to a similar degree. These results are thus evidence for an intermediate link in the chain of processing stages leading to object recognition in human visual cortex.

Bladder neck closure in association with continent urinary diversion.

Bladder neck closure is not a standard part of continent urinary diversion. When bladder augmentation and continent urinary diversion are done simultaneously, it is frequently convenient and advantageous to leave the native bladder neck intact as long as there is a reasonable degree of intrinsic continence. Even in patients with marginal control the effect of lowering intravesical pressure and increasing intravesical volume will often produce acceptable continence. At times, particularly in patients who have undergone multiple surgical procedures involving the bladder neck, there is poor intrinsic resistance. To provide acceptable continence in these cases bladder neck closure is a necessary part of continent diversion. Between 1990 and 1993 we treated 6 male and 7 female patients, most of whom underwent simultaneous bladder augmentation and continent urinary diversion, and they had poor intrinsic outlet resistance. Patient age ranged from 8 to 22 years. Underlying diagnoses included thoracic myelomeningocele in 5 patients, bladder exstrophy in 5, bladder leiomyosarcoma in 1 and extensive pelvic trauma in 1 as well as 1 previously separated conjoined twin. Three patients had artificial urinary sphincter failure and 3 had failure of urethral sling procedures. A clean intermittent catheterization program had failed in 12 patients and all 13 had diurnal incontinence. Bladder neck and urethral resistance was evaluated using voiding cystourethrography and urodynamics to measure leak point pressure and bladder capacity. Reliable bladder neck closure is historically difficult to achieve and is best done at the time of diversion. We have had initial success in 12 of our 13 cases and subsequently in all 13 using a technique of bladder neck division, 2-layer closure and omental interposition between the bladder neck closure and urethra.

Perceived control and treatment outcome with chronic adolescent offenders.

The relationship between perceived control and treatment outcome was explored with chronic adolescent offenders who exhibit internalizing or externalizing behavior problems. Data were examined from the records of 307 male adolescents between the ages of 14 and 18 committed to a state training school for hard-core offenders. Adolescent offenders with externalizing behavior problems, such as aggression, showed a more favorable treatment outcome when they attributed overall successes to their own behavior and when they viewed themselves as worried or anxious. They showed a less favorable treatment outcome when they viewed themselves as generally happy. Adolescent offenders with internalizing behavior problems, such as anxiety or depression, tended to show less favorable treatment outcomes when they viewed themselves as being high in physical competence and when they attributed failures to themselves.

Renal tubular apoptosis after partial ureteral obstruction.

Partial ureteral obstruction in the weanling rat leads to hydronephrosis of the ipsilateral kidney and renal cell deletion through the process of programmed cell death known as apoptosis. The apoptotic response following partial ureteral obstruction in weanling Sprague-Dawley rats was studied using the traditional markers of apoptosis, including deoxyribonucleic acid (DNA) laddering pattern on agarose gel electrophoresis, in situ gap labeling of fragmented DNA for quantitative apoptotic body determination, polyadenylated messenger ribonucleic acid (mRNA) expression of sulfated glycoprotein-2, and polyadenylated mRNA expression of epidermal growth factor and transforming growth factor-beta. Partial ureteral obstruction resulted in a progressive increase in the intensity of DNA fragmentation associated with apoptosis during the initial 3 weeks. Quantitative apoptotic body counting revealed a 3-fold increase by week 3 of partial obstruction. This increase represented a level of apoptosis, which is 65% of that observed in complete ureteral obstruction. By week 2 of partial obstruction there was a 13-fold increase in the expression of sulfated glycoprotein-2 mRNA, as well as changes in the growth factor environment characterized by a decline in the constitutive expression of epidermal growth factor mRNA and an increase in the expression of transforming growth factor-beta mRNA. These altered levels represent changes in expression comparable to those observed during the apoptotic response following complete ureteral obstruction, although the time course is delayed by 2 to 3 weeks.