Islam.

Islam is one of the religions of the book, others being Judaism, Christianity, and Sabianism. It is the second largest religion in the world, the first being Christianity.

Selective Serotonin Reuptake Inhibitor (SSRI) Bleeding Risk: Considerations for the Consult-Liaison Psychiatrist.

PURPOSE OF REVIEW: To present a clinically oriented review of selective serotonin reuptake inhibitor (SSRI)-related bleeding issues commonly addressed by consult-liaison psychiatrists. RECENT FINDINGS: Concomitant medical, surgical, or hospital-based conditions exacerbate the risk of SSRI-related bleeding even though a review of the literature suggests it is only marginally elevated. Psychiatrists and other clinicians need to consider these conditions along with antidepressant benefits when answering the question: to start, hold, continue, or change the antidepressant? Where an evidence base is limited, mechanistic understanding may help consult-liaison psychiatrists navigate this terrain and collaborate with other medical specialties on responsible antidepressant management. Most often, the risk is cumulative; data are not directly applicable to complex clinical situations. This review incorporates a hematologic perspective and approach to bleeding risk assessment along with extant data on SSRI-induced bleeding risk ad specific medical conditions.

Extramedullary disease relapse and progression after blinatumomab therapy for treatment of acute lymphoblastic leukemia.

BACKGROUND: Blinatumomab has demonstrated encouraging activity in relapsed/refractory (r/r) and minimal residual disease-positive (MRD+) acute lymphoblastic leukemia (ALL). Extramedullary disease (EMD) relapse or relapse with CD19- disease has been observed after blinatumomab therapy in patients with r/r or MRD+ ALL. However, the pathophysiology and risk factors of treatment failure are not fully understood. METHODS: This study retrospectively reviewed the outcomes of adult patients with B-cell ALL treated with blinatumomab (n = 132) for either r/r (n = 103) or MRD+ disease (n = 29) at the authors' center (2013-2021) and analyzed factors associated with treatment response and EMD failure. RESULTS: The overall response rate was 64%. A lower marrow blast burden before blinatumomab (P = .049) and no history of previous EMD (P = .019) were significantly associated with a higher response. Among the patients who responded to blinatumomab, 56% underwent consolidation with allogeneic transplantation. Blinatumomab failure was observed in 89 patients; 43% of these patients (n = 38) either progressed or relapsed at extramedullary sites. A history of extramedullary involvement (53% vs 24%; P = .005) and retention of CD19 expression at the time of relapse/progression (97% vs 74%; P = .012) were associated with a higher risk for extramedullary failure. Central nervous system (CNS) failure after blinatumomab was encountered in 39% of the patients with EMD. CONCLUSIONS: A history of EMD predicted an inferior response to blinatumomab therapy with a higher risk for relapse/progression at extramedullary sites (particularly CNS). Consolidation with allogenic transplantation in patients who primarily responded to blinatumomab did not abrogate the risk of extramedullary relapse. The incorporation of extramedullary assessment and the intensification of CNS prophylaxis may help in addressing extramedullary failure. LAY SUMMARY: Extramedullary failure is common during blinatumomab therapy for relapsed/refractory acute lymphoblastic leukemia. A history of extramedullary disease predicts an inferior response to blinatumomab therapy and a higher risk for relapse/progression at extramedullary sites. Most extramedullary failure cases retain CD19 expression.

Low-Dose and Standard Overnight and Low Dose-Two Day Dexamethasone Suppression Tests in Patients with Mild and/or Episodic Hypercortisolism.

We previously reported on the lack of utility of the 1 mg overnight dexamethasone (DEX) test in mild and/or periodic Cushing's syndrome, as most patients with the condition suppressed to 1 mg DEX. It is possible that a lower dose of DEX as part of an overnight DEX test might be able to distinguish between mild and/or periodic Cushing's syndrome and those without the condition. The objective of the current study is to determine the sensitivity and specificity of a 0.25 mg overnight DEX suppression test, the standard 1 mg overnight DEX suppression test, and the two-day low-dose (Liddle test) DEX suppression test with and without correction for DEX levels in patients evaluated for mild and/or periodic Cushing's syndrome. Thirty patients determined to have Cushing's syndrome by biochemical testing and 14 patients determined not to have the condition had the 0.25 mg and standard 1 mg overnight DEX suppression test and the two-day low-dose DEX suppression tests. Our results show that morning serum cortisol and cortisol/DEX ratios following an overnight dexamethasone suppression test were similar in patients with Cushing's syndrome and those not having Cushing's syndrome. However, a morning cortisol value above 7.6 µg/dl following a dose of DEX of 0.25 mg was found in 12 patients with Cushing's syndrome and none in those not having Cushing's syndrome, suggesting that a high cortisol value after this low dose of dexamethasone can indicate that further testing for Cushing's syndrome is warranted. Our data suggest that the traditional 1 mg overnight or the 2 mg/2 day DEX suppression testing should no longer be used as a screening test in patients who could have mild and/or periodic Cushing's syndrome, while the 0.25 mg dose of DEX may pick up some patients with mild Cushing's syndrome.

Literature Review and Profile of Cancer Diseases Among Afghan Refugees in Iran: Referrals in Six Years of Displacement.

BACKGROUND: There is a paucity of research on the profile of cancers among displaced populations, specifically Afghan refugees in Iran. This study illustrates the pattern of cancers in this population, and highlights the challenges of cancer care in displaced people with the intent that this data will facilitate appropriate allocation of resources to improve care in this population. MATERIAL AND METHODS: This was a retrospective cross-sectional study, in which we collected the demographics and profile of cancers among Afghan refugees from 2005 to 2010 from referrals to the United Nations High Commissioner for Refugees (UNHCR) offices in Iran. Accrued evidence by other studies published between January 1993 and July 2014 pertaining to cancer diagnoses in refugees from Afghanistan, Tibet, Syria, Jordan, and Iraq was reviewed. RESULTS: Cancer diagnoses accounted for 3083 of 23 152 total referrals, with 49% female and 51% male cases; 23.3% were 0-17 years of age, 61.2% were 18-59, and 15.5% were above 60. The most common health referral for females and males (0-17) was malignant neoplasms of lymphatic and hematopoietic tissue, accounting for 34.2%. In the age groups 18-59 and above 60 for both male and females it was malignant neoplasm of the digestive system, occurring in 26.3% and 48.7%, respectively. CONCLUSIONS: In the setting of humanitarian crises especially war, cancer diagnoses among refugees is a major health burden both on the host countries and the international community with serious implications considering the recent growing trend in the Middle Eastern countries. The prevalence of certain cancer diagnoses among refugees, like gastrointestinal, respiratory, breast, and genitourinary cancers necessitates a multidirectional approach, primarily aimed at prevention and early detection. International partnerships are essential for improvement in cancer surveillance service availability, and delivery of the standard of care, in an overall effort to reduce the human cost, monetary, and resource associated burdens of cancer. Recommendations to implement effective prevention and management goals as well as improved record keeping in the refugee setting and the acquisition of secure and sustainable funding sources should be implemented in collaboration with global humanitarian agencies like UNHCR.

Lessons from the profile of kidney diseases among Afghan refugees.

BACKGROUND: Due to a paucity of research on the profile of kidney diseases among refugee populations, specifically Afghan refugees in Iran, this study aimed to illustrate the pattern of kidney disease among Afghan refugees in Iran and create a database for evaluating the performance of future health services. MATERIAL AND METHODS: This was a retrospective cross sectional study, in which we collected the demographics and profile of kidney diseases among Afghan refugees between 2005 and 2010 from referrals to the United Nations High Commissioner for Refugees (UNHCR) offices in Iran. RESULTS: The total number of referrals in this group of diseases was 3193 out of 23 152 with 41.5% female and 58.5% male. Regarding age distribution, 10.5% were 0-14 years of age, 78% were 15-59, and 11.5% were ≥60. The most common health referral for females and males (0-14) was end-stage renal disease (ESRD), accounting for 34.6%. This was also the main reason of referrals for females and males aged 15-59, accounting for 73.5% and 66.6%, respectively, and in both sexes in the ≥60 age range it was 63.1%. CONCLUSIONS: The pattern of our renal clinic referrals may gradually change to ESRD, which is associated with a huge economic burden. The need to provide health insurance to everyone or reform the health care system to provide coverage for more of the population can be justified and would improve cost effectiveness.

A retrospective study of demographic parameters and major health referrals among Afghan refugees in Iran.

INTRODUCTION: For nearly three decades, the two neighboring countries of Iran and Pakistan hosted millions of Afghans. Today, Afghans still represent the largest group of refugees in the world. This feature has greatly influenced provision of health care for this population. Due to a paucity of research on the health status of Afghan refugees in Iran, this study aim to make a vista on the pattern of different common diseases among Afghan refugees in Iran and use it as an index for performance evaluation of future health services to them. METHODS: This is a retrospective cross sectional study, in which we collected the demographic and medical data between 2005 and 2010 from referrals to the United Nations High Commissioner for Refugees (UNHCR) offices in Iran. We also considered a comparative review of the burden of disease estimates by the World Health Organization (WHO) for Afghanistan and Iran. RESULTS: Total numbers of referrals were 23,152 with 52.6% Female and 47.66% male. 29% were 0-14 years of age, 54% were 15-59, and 17% were 60+. The most common health referral for females and males (0-14) was perinatal diseases (15.16%, 15.2%, respectively). In the females (15-59) it was ophthalmic diseases (13.65%), and for males it was nephropathies (21.4%), and in both sexes (60+) age range it was ophthalmic diseases (21.3%, 19.9%, respectively). The largest ethnic group of afghan refugees in this study was Hazara (55%) followed by Tajik (14%), Fars (12%), Sadat (9%), and 10% others. Ophthalmic diseases were the major cause of referrals by Hazara, Tajik, Fars, and Sadat groups with 26%, 20%, 26%, and 27% respectively. Referrals by pashtun group were mostly for neoplasms (17%), among Uzbek group it was nephropathies (26%), and in Baluch group Hematopoietic disorders (25%). CONCLUSION: These data indicate higher referral rate for women 15-59 years of old and people in 60+ with ophthalmic diseases, neoplasms, and nephropathies. Even given certain intrinsic limitations of such a study, we believe these unique findings are worth further explanation. This implies the need for public health researchers to pursue prospective studies in these areas.

Gender Comparison in Referrals and Treatment Completion to Residential and Outpatient Alcohol Treatment.

BACKGROUND: Residential treatment for alcoholism is associated with high completion rates for clients, yet there appear to be gender disparities in patient referrals and treatment completion rates. We studied whether (A) gender is associated with differential patient placement to outpatient vs. residential treatment facilities and (B) completion rates differ by gender. METHODS: In this cross-sectional study, we analyzed the admission and discharge data from 185 publicly funded substance abuse treatment facilities across Los Angeles County between 2005 and 2010. RESULTS: Among the 33,745 studied cases, women were referred to residential treatment facilities less frequently than men (75% vs. 66%). The adjusted results derived from logistic regression models confirmed that females were more likely to be referred to outpatient treatment than to residential treatment facilities (odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.05-1.26). In addition, we observed that compared to White/Caucasian patients, all other races were associated with more referral to outpatient facilities (ie, less referral to residential facilities), indicating a racial disparity on the top of the observed gender disparity. However, there was no significant link between gender and treatment completion rates (OR: 0.93, 95% CI: 0.86-1.00). CONCLUSIONS: Women seem to have treatment completion rates comparable to men, yet they are less likely to be referred to residential treatment facilities. Hence, there still remains a gender disparity in alcoholic patient referrals. Further studies should delineate which specific therapeutic aspects and programmatic components of women-focused treatments are essential to augment positive treatment outcomes.

Continuation or discontinuation of pioglitazone when starting bedtime insulin in patients with poorly controlled type 2 diabetes in an inner-city population.

OBJECTIVE: We studied the impact of continuing versus discontinuing pioglitazone on hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), and weight when starting bedtime insulin in patients with poor glycemic control. METHODS: We retrospectively analyzed data from a 13-month randomized control trial on 77 patients with type 2 diabetes mellitus (DM), who despite maximum doses of three oral diabetes medications (metformin, sulfonylurea and pioglitazone) had HbA1C levels above 7.5%. Patients were randomized to either continuing or discontinuing pioglitazone in addition to starting and up-titrating bedtime insulin. HbA1C, FPG, and weight were assessed at baseline, 3months, 7months and 13months with the differences from baseline for the two groups compared at each of the three time points using the Wilcoxon rank sum test. RESULTS: We found that HbA1c was significantly lower at the 7-month (p=0.01) and 13-month time points (p=0.036), and FPG was significantly lower at all three time points in the group continuing pioglitazone compared with those discontinuing pioglitazone. Continuing pioglitazone resulted in a greater increase in weight at the 3-month (p=0.002), 7-month (p=0.0001) and 13-month (p=0.00003) time points. Patients with the lowest HbA1c (<8.2%) at baseline were more likely to benefit from continuing pioglitazone than those with higher baseline HbA1c. Patients who started insulin and discontinued pioglitazone had similar HbA1c, FPG and weight at the three time points as at baseline, suggesting that pioglitazone and bedtime insulin has similar glycemic effect in this population. CONCLUSIONS: We conclude that in patients with uncontrolled type 2 DM, continuing pioglitazone while concurrently starting bedtime insulin within a 13-month period led to a significant decrease in both HbA1c and FPG levels compared with those who did not receive pioglitazone; however weight increased during this period.

A survey of anesthesiologists' role, trust in anesthesiologists, and knowledge and fears about anesthesia among predominantly Hispanic patients from an inner-city county preoperative anesthesia clinic.

STUDY OBJECTIVE: To determine the difference between the Hispanic and non-Hispanic public's knowledge about anesthesia, anesthesiologist's expertise, and role of the anesthesiologist in and out of the operating room (OR). DESIGN: Cross-sectional survey. SETTING: Los Angeles inner-city county hospital preoperative anesthesia clinic. PATIENTS: Predominantly Hispanic population. INTERVENTIONS: A 54-question survey in English and Spanish was distributed to adult patients. MEASUREMENTS: Demographic data, knowledge of the anesthesiologist's roles/responsibilities, knowledge of anesthesia, trust in anesthesiologists, and fears related to anesthesia were collected. Descriptive analysis and multiple regression analysis of the data were used to report knowledge, trust, and fear, and the predictive role of patient characteristics. MAIN RESULTS: 300 (88% of eligible pts) completed the survey. Patient demographics were as follows: Hispanics (73%), female (63%), mean age 47 ± 14 years, high school-educated or below (71%), previous surgery (67%), possessing a chronic medical condition (49%), self-reported health of fair to poor (58%). Seventy percent of patients recognized anesthesiologists as specially trained doctors. Mean ± SD trust scores in doctors were 2.6 ± 1.2 out of a maximum 4. Patients with a better perception of their self-health (P < 0.01) and with higher knowledge scores (P < 0.01) had significantly higher trust in the doctors. Women (P = 0.01) patients, those patients with chronic medical condition (P < 0.02), and patients with greater knowledge scores had greater fear or concerns about anesthesia. Mean ± SD knowledge score about anesthesia was 6.3 ± 2.8 (range 0-13). Patients who had surgery previously (P < 0.01) had higher knowledge scores. CONCLUSION: Most Hispanic patients believe that anesthesiologists are specialist doctors and that they put patients to sleep, but these patients are uncertain of their exact role or function during surgery or outside of the OR. High concerns or fears about devastating but rare complications of anesthesia remain. Educational efforts should be directed at this group especially, with the goal of alleviating preoperative anxiety.

Multicentric Castleman's Disease and Kaposi's Sarcoma in a HIV-Positive Patient on Highly Active Antiretroviral Therapy.

Castleman's disease is a group of rare lymphoproliferative disorders. The plasmablastic multicentric Castleman's disease is frequently discovered in HIV-infected individuals in association with Kaposi sarcoma (HHV-8). Thirty-five year old male presented to our care with the main compliant of severe back pain for one week. His past medical problems include acquired immune deficiency syndrome diagnosed 12 years prior and Kaposi sarcoma, currently on highly active antiretroviral therapy (HAART). Radiographic imaging revealed hepatomegaly and diffuse lymphadenopathy. The HIV viral load was <20 polymerase chain reaction copies/mL, absolute CD4 count was 453 cells/mcL (490-1740 cells/mcL) and CD8 count was 4142 cells/mcL (180-1170 cells/ mcL). Excisional biopsy of the left supraclavicular lymph node was performed with pathological findings of HHV8+ Kaposi sarcoma in the background of multicentric Castleman's disease (plasmacytic variant). No evidence of transformation into large B-cell or plasmablastic lymphoma was noted. He was discharged on HAART and follow up to receive chemotherapy with cyclophosphamide, adriamycin, vincristine plus prednisone was started and rituximab plus prophylaxis for pneumocystis carinii. Multicentric Castleman's disease has become more relevant in recent years due to its association with HIV and HHV-8 (Kaposi sarcoma) and its potential to progress into plasmablastic B-cell lymphoma. The progression of MCD to B-cell lymphoma is a concern, especially in patients with HIV infection because it precludes the worst outcome and a high mortality, despite treatment. The most intriguing part of this case is that MCD occurred in a HIV-positive on HAART. This case signals a warning that a high suspicion for MCD can be justified even in those HIV-positive patients on HAART because the possibly of progression to plasmablastic B-cell lymphoma.

Subtotal Gastrectomy as "Last Resort" Consideration in the Management of Refractory Rumination Syndrome.

Rumination syndrome is a behavioral disorder resulting in effortless regurgitation of undigested food within minutes of meal intake that is subsequently either re-swallowed or ejected. It is commonly misdiagnosed, patients often undergo extensive testing and multiple therapies, many of which are directed at suspected gastroparesis. A 25-year-old Caucasian female initially presented to our care 1 year ago with a 4-year history of nausea and vomiting occurring in the immediate postprandial period, specifically within 15 minutes from oral intake. She had an extensive history of multiple diagnostic, therapeutic and surgical procedures over the previous 4 years which included cholecystectomy, botulin toxin injection into the pyloric sphincter, pyloroplasty, placement of a gastric stimulator and jejunal feeding tube with no sustained results. On a previous admission we determined the functional status of the stomach by obtaining full thickness gastric biopsies during a diagnostic laparoscopy. This revealed an adequate population number of cells of Cajal and myenteric neurons as well as normal stomach muscle. After 1 year of attempting "breathing relaxation techniques", while being nutritionally maintained by nocturnal jejunostomy feedings, the patient presented again to our care with refractory nausea and vomiting and unable to work or function. Her weight was 90 lbs. She underwent a subtotal gastrectomy (80%) with Roux-en-Y reconstruction and continuation of jejunostomy feeding. The refractory nausea and vomiting significantly improved over the 4 weeks after discharge and breathing exercises were continued. On subsequent follow-up visits over a 6-month course, the refractory nausea and vomiting had resolved by more than 85% with and improvement in her BMI and quality of life.The recommended treatment of rumination syndrome is focused on breathing exercises and relaxation techniques to "distract" while eating. We believe our case is the first reported where a subtotal gastrectomy has been used to help overcome refractory rumination along with the usual therapy. This surgery is a "last resort" consideration to improve quality of life, returning the patient to employment and functional social status.

Corrigendum: Cooper et al, Subtotal Gastrectomy as "Last Resort" Consideration in the Management of Refractory Rumination Syndrome.

[This corrects the article DOI: 10.14740/gr594w.].

Combination chemotherapy regimen in a patient with metastatic malignant pheochromocytoma and neurofibromatosis type 1.

PATIENT: Female, 55 FINAL DIAGNOSIS: Metastatic malignant pheochromocytoma Symptoms: Chest pain • tachycardia • tachypnea MEDICATION: - Clinical Procedure: - Specialty: Oncology. OBJECTIVE: Rare disease. BACKGROUND: Malignant pheochromocytoma is defined as the occurrence of the tumor in an area that is normally devoid of chromaffin tissue, direct tumor invasion, and/or metastasis. Metastatic malignant pheochromocytoma is very rare. Malignant pheochromocytoma carries a poor prognosis with a 5-year survival rate of 44%. The majority of pheochromocytoma cases are sporadic, but a small portion (10%) can be associated with hereditary syndromes such as neurofibromatosis type 1 (NF1). CASE REPORT: A 55-year-old Hispanic woman presented to our care with chest pain. Her past medical problems included hypertension, neurofibromatosis type 1 (NF1), and pheochromocytoma status after right laparoscopic adrenalectomy, which was converted to open procedure about 19 months ago. Initial vital signs were significant for tachycardia, tachypnea, and hypertension. Computed tomography (CT) angiography of the chest was performed to rule out a pulmonary embolism, but instead revealed multiple bilateral lung nodules measuring up to 8 mm, consistent with metastasis. CT of the abdomen and pelvis revealed a lytic lesion in the posterior aspect of the left pedicle and transverse process of L4, and the neck/greater trochanter of the left femur. MIBG scan revealed widespread metastatic disease. She received an outpatient chemotherapy regimen of cyclophosphamide, dacarbazine, and vincristine. CONCLUSIONS: Metaiodobenzylguanidine (MIBG) is an alkyl-guanidine derivative similar to noradrenaline, which accumulates in tissue derived from neural crest cells. Current medical literature suggests that therapeutic 131I MIBG has a response rate of 50-75%. Combination chemotherapy using cyclophosphamide, vincristine, and dacarbazine has been the most widely used regimen for malignant pheochromocytoma. This combination of chemotherapy has been shown to have a high response rate and symptomatic improvement. Numerous therapeutic regimens exist for metastatic malignant pheochromocytoma; however, no regimen has been shown to have a benefit significantly superior to the others.

A Review of Programs, Components and Outcomes in Biomedical Research Faculty Development.

BACKGROUND/OBJECTIVE: To review, compare and synthesize current faculty development programs and components. Findings are expected to facilitate research that will increase the competency and competitiveness of less-established biomedical research faculty. METHODS: We reviewed the current literature on research faculty development programs, and report on their type, components, outcomes and limitations. RESULTS: Nineteen articles met inclusion criteria. There were no prospective studies; most were observational and all lacked a control group. Mentoring was the most successful program type, and guided and participatory learning the most successful enabling mechanism, in achieving stated program goals. CONCLUSIONS: Our findings are limited by the small number of current studies, wide variation in implementation, study design, and populations, and the lack of uniform metrics. However, results suggest that future prospective, randomized studies should employ quantitative criteria, and examine individual, human factors that predict "success."

Case report: portal hypertension secondary to isolated liver tuberculosis.

In this report, we present a case of isolated liver tuberculosis (TB) as a cause of non-cirrhotic portal hypertension leading to bleeding esophageal varices. Although TB has been known to cause portal hypertension in a variety of ways, this case was notable for the presence of periportal inflammation and granulomas, also seen in hepatic schistosomiasis. Herein, we discuss isolated liver TB and the differential diagnosis of non-cirrhotic portal hypertension. In endemic areas, TB should be considered in the differential diagnosis of non-cirrhotic portal hypertension.

Renal amyloidosis in a child with neutropenia.

Amyloidosis represents a heterogeneous group of disorders of protein metabolism and is characterized by deposition of fibrillar proteins in the intra- and extracellular spaces. Here, a case of generalized amyloidosis associated with neutropenia is presented. She had a medical history of multiple bacterial infections. At the age of 14 years, she developed nephrotic syndrome. An increase of antigenic stimulation during the intermittent bouts of acute infections would have been the main factor responsible for the development of secondary amyloidosis in this case. To the best of our knowledge, coexistence between neutropenic disorders and renal amyloidosis in children has not been reported till date. The purpose of this report is to present a case of secondary amyloidosis associated with neutropenia in pediatric age group, probably for the first time.

Long-term upper and lower urinary tract functions in children with posterior urethral valves.

OBJECTIVE: Several factors have been identified as predictive of future renal function in children with posterior urethral valves (PUV). Our aim was to analyse upper and lower urinary tract outcome in patients with PUV, and determine any factors from the period of early management that were predictive of future renal function. METHODS: The charts of 67 boys (mean age 2.4 years) diagnosed with PUV were reviewed. The most common presenting symptom was dribbling in 43.2% and UTI in 28.3%. Twenty-three (34.8%) patients developed end-stage renal disease aged 1-15 years. The mean time of renal survival was calculated as 7.8 (SEM=0.73) years. RESULTS: Incontinence in patients over 5 years old, lower urinary tract dysfunction, serum creatinine level in first year or at the time of diagnosis, and presence of vesicoureteral reflux and high-grade bilateral reflux were significant risk factors for occurrence of renal failure in the future. Lower tract dysfunction was seen in 58.6% of patients. Postnatal diagnosis and presence of high-grade reflux were significant risk factors for the future occurrence of lower urinary tract dysfunction. CONCLUSION: It is important to recognize that PUV have consequences not only during childhood or before treatment, but also during or after the treatment period. Long-term assessment and follow-up of upper and lower urinary tract functions after valve ablation is necessary.

Management and outcome of steroid-resistant nephrotic syndrome in children.

INTRODUCTION: Steroid-resistant nephrotic syndrome (SRNS) is uncommon in children, but often leads to ESRD. We report our experience with SRNS and its treatments and outcomes. MATERIALS AND METHODS: We assessed 73 children with SRNS admitted to Ali Asghar Children Hospital in Tehran, Iran. Their clinical presentations, treatment, and disease courses were reviewed. The mean follow-up duration was 6.0 +/- 4.2 years. Moreover, survival times were calculated and the Cox regression method was used to determine variables able to predict survival of the kidneys. RESULTS: Age at the onset of the disease, sex, and hematuria were not predictive of the response to treatment with immunosuppressive drugs in the children with SRNS. The type of resistance (early or late) was associated with the responsiveness to immunosuppressives. Response to any of the immunosuppressive drugs determined the responsiveness to other immunosuppressive drugs. Cyclosporine was more effective than cyclophosphamide as initial therapy. The mean kidney survival time was 11.62 years. Kidney survival rates were 94.6%, 70.0%, 56.0%, and 34.0% at 1, 5, 10, and 15 years, respectively, in patients with initial resistance to steroid, while these were 100%, 100%, 83.0%, and 83.0% in those with late resistance, respectively (P = .03). CONCLUSIONS: We showed that patients with late steroid resistance had better response to immunosuppressive drugs than patients with early resistance. We also showed that resistance to immunosuppressive therapies increased the risk of resistance to other immunosuppressive drugs. Achievement of complete or partial remission with any therapy reduced the risk of ESRD.