Contrast-enhanced voiding urosonography (CEVUS) as a safe alternate means of assessing vesicoureteral reflux in pediatric kidney transplant patients.

BACKGROUND: Although voiding cystourethrogram (VCUG) is currently the gold standard in VUR evaluation, there is ionizing radiation exposure. Contrast-enhanced voiding urosonography (CEVUS) uses ultrasound contrast agents to visualize the urinary tract and has been reported to be safe and effective in VUR evaluation in children. CEVUS application has yet to be specifically described in VUR evaluation in the pediatric kidney transplant population. The purpose of this study was to report the use of CEVUS and VCUG in evaluating and managing VUR in pediatric renal transplant patients. METHODS: Retrospective review was conducted for pediatric kidney transplant patients (18 years and younger) who underwent VCUG or CEVUS to assess for transplant VUR from July 2019 through June 2021. Demographic information, reason for VUR evaluation, fluoroscopy time, and postimaging complications were evaluated. Costs of imaging modalities were also considered. RESULTS: Eight patients were evaluated for transplant VUR during the study period. Of the 3 patients who underwent VCUG, all 3 had VUR (median grade 3). Median fluoroscopy time was 18 s and dose-area product was 18.7 uGy*m2 . Of the 5 patients who underwent CEVUS, 4 had VUR (median grade 4). There were no complications for either modality. Based on clinical and radiographic findings, patients were recommended no intervention, behavioral modification, or ureteral reimplantation. The total cost of CEVUS was $800 less than that of VCUG. CONCLUSION: CEVUS can provide an alternate means of safely evaluating VUR in kidney transplant patients with similar outcomes, potentially lower costs, and no exposure to ionizing radiation.

Risk Factors for Development of Pneumatosis Intestinalis after Pediatric Hematopoietic Stem Cell Transplantation: A Single-Center Case-Control Study.

The significance of pneumatosis intestinalis (PI) in pediatric patients following hematopoietic stem cell transplantation (HSCT) is poorly understood. A knowledge gap remains with respect to the etiology, risk factors, and evidence-based treatment of these patients. As a result, management is frequently based on each center's clinical practice, without standardization across treatment centers. In this single-center trial, we aimed to validate both previously proposed and additional risk factors for the development of PI and to examine our management and outcomes for these patients. We performed a retrospective case-control study examining risk factors for the development of PI in pediatric HSCT patients at a single tertiary referral children's hospital. We used univariate and multivariable conditional logistic regression analysis to explore differences in pharmacologic and other transplantation-specific risk factors. Between 2012 and 2019, PI was diagnosed in 212 patients at our pediatric hospital, of whom 42 were HSCT recipients. The majority of patients (88%; n = 37 of 42) with PI were diagnosed by X-ray. Eighteen patients (43%) were asymptomatic and diagnosed incidentally after imaging was obtained for standard post-transplantation surveillance or other nonrelated indications. All patients with PI were hospitalized and placed on strict bowel rest while receiving parenteral nutrition and antibiotics. Recurrence of PI occurred in 4 patients (10%) following their initial diagnosis. Increased doses of steroid exposure within 30 days of PI diagnosis (odds ratio [OR], 5.7; 95% confidence interval [CI], 2.1 to 15.3; P = .0006), presence of grade II-IV gastrointestinal acute graft-versus-host disease (GVHD) (OR, 5.3; 95% CI, 1.0 to 28.1; P = .05), and receipt of >50% of total daily nutrition by nasogastric (NG) tube feeds (OR, 22.0; 95% CI, 1.3 to 370.2; P = .03) were identified as independent risk factors for the development of PI. Intensity of the conditioning regimen, exposure to total body irradiation, stem cell source, donor type, HLA matching, use of mycophenolate mofetil, and presence of bacterial or viral infection at the time of PI diagnosis were not demonstrably associated with the development of PI in our study. We conclude that development of asymptomatic PI is a benign condition following HSCT, and that the risk for PI is increased in patients with gastrointestinal GVHD, patients receiving steroid therapy, and patients relying on supplemental NG tube feeds for at least one-half of their total daily nutrition.

Palpable pediatric chest wall masses.

Pediatric chest wall lesions are varied in etiology ranging from normal and benign to aggressive and malignant. When palpable, these lesions can alarm parents and clinicians alike. However, most palpable pediatric chest lesions are benign. Familiarity with the various entities, their incidences, and how to evaluate them with imaging is important for clinicians and radiologists. Here we review the most relevant palpable pediatric chest entities, their expected appearance and the specific clinical issues to aid in diagnosis and appropriate treatment.

Pediatric Abdominal Masses: Imaging Guidelines and Recommendations.

Pediatric abdominal masses are commonly encountered in the pediatric population, with a broad differential diagnosis that encompasses benign and malignant entities. The primary role of abdominal imaging in the setting of a suspected pediatric abdominal mass is to establish its presence, as nonneoplastic entities can mimic an abdominal mass, and to identify characteristic imaging features that narrow the differential diagnosis. In the setting of a neoplasm, various imaging modalities play an important role to characterize the mass, stage extent of disease, and assist in presurgical planning. The purpose of this article is to discuss a practical imaging algorithm for suspected pediatric abdominal masses and to describe typical radiological findings of the commonly encountered abdominal masses in neonates and children with emphasis on imaging guidelines and recommendations.

Pediatric rib pathologies: clinicoimaging scenarios and approach to diagnosis.

Pathologies involving the ribs are diverse in nature, including entities specific to the pediatric population as well as shared pathologies with adults. These can be either localized within or adjacent to the rib, but may also cause rib alteration as a component of a systemic process. To better understand these disorders, we discuss several common rib pathologies in the context of their clinical presentation and pertinent imaging findings. In addition, we review the imaging modalities that may be used to evaluate the ribs. Encompassing both the clinical and imaging aspects of pediatric rib pathologies, this review aims to increase pediatric and musculoskeletal radiologists' awareness of the spectrum of disease and how to leverage a pattern-based approach.

Comparison of Renal Parenchymal Volume Preservation Between Partial Nephrectomy, Cryoablation, and Radiofrequency Ablation Using 3D Volume Measurements.

PURPOSE: Small renal masses (SRM) can be managed via a variety of nephron-sparing procedures (NSPs), but the association between choice of NSP and renal parenchymal volume (RPV) preservation is not well understood. We sought to examine RPV preservation after partial nephrectomy (PN) performed via open, robotic, or laparoscopic approaches and thermal ablation (TA) performed via cryoablation (CA) or radiofrequency ablation (RFA). PATIENTS AND METHODS: The study was a retrospective review of three institutional databases of patients with a SRM <4 cm treated via one of the five NSPs (open PN, laparoscopic PN, robotic PN, percutaneous CA, or percutaneous RFA). The 30 most recent consecutive cases treated via each NSP were selected to obtain a total of 150 cases for analysis. Patient characteristics were obtained via manual chart review, and tumor characteristics were assessed via the R.E.N.A.L. nephrometry score. Using three-dimensional rendering software, preoperative and postoperative RPV was calculated for the tumor-bearing kidney, excluding the tumor itself (for preoperative images) or the postsurgical/ablative defect (for postoperative images). The percent change in RPV was compared between the procedure types. RESULTS: One hundred fifty cases were included in the final analysis, with 30 cases from each NSP category. While preoperative tumors were larger in the PN group, there was no difference in the mean nephrometry score between groups. The TA group was found to have a lower mean RPV loss (-8.1% vs -16.5%, p<0.005). There was no difference in the RPV loss between modalities of TA (CA vs RFA) or between approaches to PN (open, laparoscopic, robotic). Matched-pair analysis based on the tumor size and multivariate analysis indicated TA vs PN was independently associated with less RPV loss. CONCLUSIONS: TA is associated with less RPV loss than PN in the management of SRM, but there is no difference between modalities of TA (CA vs RFA) or between approaches to PN.

Effects of oral contraceptives or a gonadotropin-releasing hormone agonist on ovarian carcinogenesis in genetically engineered mice.

Although epidemiologic evidence for the ability of combined oral contraception (OC) to reduce the risk of ovarian cancer (OvCa) is convincing, the biological mechanisms underlying this effect are largely unknown. We conducted the present study to determine if OC also influences ovarian carcinogenesis in a genetic mouse model and, if so, to investigate the mechanism underlying the protective effect. LSL-K-ras(G12D/+)Pten(loxP/loxP) mice were treated with ethinyl estradiol plus norethindrone, contraceptive hormones commonly used in combined OC, or norethindrone alone, or a gonadotropin-releasing hormone agonist. The combined OC had a 29% reduction in mean total tumor weight compared with placebo (epithelial tumor weight, -80%). Norethindrone alone reduced mean total tumor weight by 42% (epithelial tumor weight, -46%), and the gonadotropin-releasing hormone agonist increased mean total tumor weight by 71% (epithelial tumor weight, +150%). Large variations in tumor size affected the P values for these changes, which were not statistically significant. Nonetheless, the OC reductions are consistent with the epidemiologic data indicating a protective effect of OC. Matrix metalloproteinase-2 activity was decreased in association with OC, indicating that OC may affect ovarian carcinogenesis by decreasing proteolytic activity, an important early event in the pathogenesis of OvCa. In contrast, OC increased invasion in a K-ras/Pten OvCa cell line established from the mouse tumors, suggesting that OC hormones, particularly estrogen, may have a detrimental effect after the disease process is under way. Our study results support further investigation of OC effects and mechanisms for OvCa prevention.

Empty follicle syndrome in the setting of dramatic weight loss after bariatric surgery: case report and review of available literature.

OBJECTIVE: To describe empty follicle syndrome, potentially due to route of human chorionic gonadotropin (hCG) administration, in a patient who had previously undergone bariatric surgery. DESIGN: Case report and review of literature. SETTING: Academic medical center. PATIENT(S): A 42-year-old nulliparous, morbidly obese woman who had presented for assisted reproduction treatment after having lost 175 pounds via gastric bypass surgery, resulting in abdominal skin redundancy. INTERVENTION(S): The patient's gastric bypass surgery had resulted in abdominal skin redundancy. In her first cycle, recombinant hCG was used with a luteal gonadotropin-releasing hormone (GnRH) agonist/recombinant follicle-stimulation hormone (FSH) protocol. At hCG administration, her estradiol level was 2342 pg/mL, and 18 follicles were measured. At retrieval, no oocytes were recovered, and her serum hCG level was 19 mIU/mL. In the subsequent cycle, identical ovarian stimulation was performed, with peak estradiol of 2891 pg/mL, but intramuscular hCG was administered. At retrieval, her serum hCG level was 45 mIU/mL, and 19 oocytes were recovered, resulting in 10 embryos. Five embryos were transferred, and a singleton pregnancy resulted. MAIN OUTCOME MEASURE(S): Recovery of oocytes. RESULT(S): Clinical pregnancy. CONCLUSION(S): Abdominal skin redundancy after bariatric surgery may alter the absorption of subcutaneously administered infertility medications. Additional studies are needed to treat infertile patients optimally after weight-reduction surgery.

Regulation of gonadotropin-releasing hormone gene expression.

Reproductive function is influenced by several internal and external cues, which ultimately exert their effects on the gonadotropin-releasing hormone (GnRH) neuron. As the final common pathway in the brain for regulating reproduction, GnRH neurons receive signals from multiple cell types, and alterations in GnRH production impact reproductive competence. Historically, the paucity of GnRH neurons and their scattered distribution in the brain have limited the study of GnRH gene expression. With transgenic technology, newer model systems (such as immortalized GnRH-expressing cell lines and GnRH-reporter gene transgenic mice) have been developed, making molecular studies possible. This article provides an update on the molecular mechanisms responsible for the regulation of GnRH gene expression, focusing on tissue-specific expression and transcriptional regulation. After an overview of GnRH gene structure, synthesis, and secretion, the model systems for studying GnRH neurons are examined. The molecular mechanisms that translate physiologic stimuli, such as nutritional status or stress, into changes in GnRH expression will be reviewed, concentrating on the regulatory regions within the GnRH gene promoter and the critical transcription factors.

Regulation of gonadotropin-releasing hormone in nonhypothalamic tissues.

It is well established that hypothalamic gonadotropin-releasing hormone (GnRH) controls reproductive function by stimulating the production of gonadotropins from the pituitary. GNRH gene and its receptor (GnRHR) have also been detected outside the hypothalamus, and a growing body of literature supports an extrapituitary role for GnRH action. The exact function of GnRH in these tissues is not known, but GnRH expression has been described in reproductive tissues, including the ovary, placenta, breast, testes, and prostate. This article provides an overview of the regulation of GnRH gene expression in nonhypothalamic reproductive tissues. After GnRH gene structure is reviewed, the physiologic role of GnRH and regulation of its expression in several reproductive tissues are examined. When possible, transcriptional regulation is discussed, but due to low levels of expression, transcriptional regulation of GnRH in extrahypothalamic tissues has been extremely difficult to study. Consequently, the factors that mediate GnRH gene expression in these tissues are only beginning to be identified.

In vivo identification of a 107-base pair promoter element mediating neuron-specific expression of mouse gonadotropin-releasing hormone.

To identify regions of the mouse GnRH (mGnRH) promoter that mediate tissue-specific gene expression, transgenic mice have been generated with fragments of mGnRH promoter fused to the luciferase reporter gene. In this manuscript, we examine transgenic mice, generated with -356/+28 bp and -249/+28 bp of the mGnRH gene. Both fragments of mGnRH promoter target ovarian expression of the luciferase transgene, but neuronal luciferase activity is detected only in the mice bearing the -356-bp fragment, suggesting that the DNA sequences essential for directing neuron-specific expression of the GnRH gene are located between -356 and -249 bp. Two consensus binding sites for Otx2 were identified in this promoter region and were confirmed to be functional. EMSAs demonstrated specific binding of Otx2 to the mGnRH promoter, and overexpression of Otx2 increased transcriptional activity of the mGnRH promoter in transient transfection studies. When both Otx2 binding sites were eliminated, overexpression of Otx2 had no effect. GnRH mRNA expression in immortalized GnRH-secreting cell lines was also found to correlate with Otx2 expression. In addition, transgenic mice, bearing the 356 fragment of the mGnRH gene in which the Otx2 binding sites were eliminated, have significantly lower luciferase activity in the neonatal brain compared with mice generated with intact Otx2 binding sites. Luciferase activity was, however, still present in the ovary. Our findings provide evidence that Otx2 may have a critical role in directing tissue-specific expression of the mGnRH gene to the neuron, but not the ovary.

Treatment of infertility in women with pituitary tumors.

Due to the pituitary's critical position, a pituitary tumor may disrupt gonadal function, either by its expanding size or the inappropriate secretion of hormones. Menstrual cycles may be disrupted even without frank hypogonadism, particularly in the case of hormone-secreting adenomas. Despite optimal medical and surgical management of pituitary tumors, ovulation-induction therapy with gonadotropins is often required to restore fertility in these women. This article will provide an overview of the therapeutic options available for women with infertility resulting from pituitary tumors. Treatment strategies including dopamine agonists, gonadotropins and the role of assisted reproductive technologies will be discussed. Unique pregnancy considerations in the female patient with hypopituitarism will also be addressed.

Insulin regulation of GnRH gene expression through MAP kinase signaling pathways.

In mammals, reproduction is acutely regulated by metabolic status. Insulin is an important nutritional signal from the periphery that may regulate the reproductive axis. To determine whether insulin acts directly on the GnRH neuron, we performed studies in mouse-derived GnRH-expressing cell lines. Both insulin receptor protein and mRNA were detected in these cells. A saturation radioligand binding assay revealed high affinity, low capacity binding sites for insulin in GnRH neurons. Insulin also stimulated GnRH promoter activity in GnRH neurons. This effect was blocked by pretreatment with the MEK inhibitor, PD98059, indicating a role for MAP kinase signaling. In transient transfection studies, insulin treatment stimulated expression of a 1250 bp mouse GnRH gene promoter fragment four-fold when compared to promoter activity in untreated cells. In contrast, insulin did not stimulate activity of a 587 bp fragment of the mGnRH gene promoter, indicating that the promoter elements mediating insulin stimulation of the GnRH promoter are located between -1250 and -587 bp. Our studies suggest that insulin may regulate reproductive function by direct effects on the GnRH neurons and specifically by stimulating GnRH gene expression.

Induction of apoptosis and ovarian cyst formation in the mouse ovary by dehydroepiandrosterone (DHEA).

Exogenous dehydroepiandrosterone (DHEA) produces ovarian cysts and atretic follicles in mice. We sought to test the hypothesis that the abnormal follicular development found after DHEA administration in mice results from aberrant ovarian apoptosis. DHEA was injected subcutaneouly for 15 days. Controls received an equivalent volume of vehicle. Follicle size was measured, and the proportion of ovarian follicles containing apoptotis was assessed by in situ end-labeling of DNA. DHEA resulted in a greater proportion of follicles with evidence of apoptosis (62.4% in the DHEA group [n = 789 follicles] vs. 53.0% in the vehicle group [n = 440 follicles]; p = 0.031). DHEA also produced larger follicles (mean diameter: 234.7um +/- 24.6um in the DHEA group vs. 204.6um +/- 11.4um in the vehicle group; p < 0.01). All of the DHEA-treated mice contained follicles > 500um while only one of the mice in the vehicle group contained a follicle > 500um in diameter (p < 0.001). We conclude that DHEA administration results in increased ovarian apoptosis and in larger follicle size, thereby producing a characteristic cystic and atretic appearance in the mouse ovary. This may be the mechanism by which androgens cause ovarian cyst formation.

Seventy-two hour continuous infusion flavopiridol in relapsed and refractory mantle cell lymphoma.

The cell cycle regulatory protein cyclin D1, which is over-expressed in 95-100% of mantle cell lymphomas (MCL), is a potential therapeutic target. Flavopiridol inhibits the cyclin-dependent kinase (CDK)4-cyclin D1 complex and induces apoptosis in lymphoma cell lines. Previous phase I clinical studies had demonstrated that this drug could be safely administered in humans, prompting further evaluation of flavopiridol as a single agent in MCL. Ten patients with relapsed or refractory MCL, who had received one prior chemotherapy regimen, were treated with flavopiridol 50 mg/m2/day given as a 72 h continuous intravenous infusion every 14 days. Treatment was well tolerated, and only one patient developed grade III-IV non-hematologic toxicity. However, there were no clinical responses; despite therapy, three patients maintained stable disease, and seven patients demonstrated progressive disease within two months. In relapsed and refractory MCL, flavopiridol is ineffective as a single agent given by 72 h continuous infusion at 50 mg/m2/day. Recent in vitro studies using human plasma suggest that higher plasma drug levels may be necessary to achieve clinical efficacy. In vitro studies of flavopiridol indicate that the agent is synergistic with DNA-damaging compounds. Further investigation into flavopiridol as a clinical agent should focus on alternative dosing schedules and the compound's potential use in combination chemotherapeutic regimens.

Identification of a discrete promoter region of the human GnRH gene that is sufficient for directing neuron-specific expression: a role for POU homeodomain transcription factors.

The human GnRH (hGnRH) gene is expressed, and the GnRH decapeptide produced, primarily in the GnRH neurons of the diencephalon. The molecular elements important for the cell-specific expression and regulation of the hGnRH gene are not well established at this time; therefore, we have used a transgenic mouse model to isolate cis-regulatory elements important for directing gene expression to GnRH neurons in the hypothalamus. Gene constructs consisting of various promoter deletion fragments of the hGnRH gene fused to the luciferase (LUC) reporter gene have been used to create transgenic mouse lines. Cell-specific expression, with the criterion being luciferase expression directed to GnRH neurons of the hypothalamus, was observed when 992 bp, but not 795 bp, of the hGnRH gene promoter were used. Tissue-specific expression was also observed when a deletion construct containing the region from -992 to -763 was fused to a minimal 48-bp promoter fragment fused to LUC. These data indicate that the region between -992 and -795 contains elements both essential and sufficient for targeting gene expression to GnRH neurons. This promoter region was found to contain two DNA-binding sites for the POU class of transcription factors, each of which specifically interacted with the POU homeodomain proteins Brn-2 and Oct-1. Functional studies demonstrated that Brn-2 increased promoter activity of the human and mouse GnRH genes.

Promoter sequences targeting tissue-specific gene expression of hypothalamic and ovarian gonadotropin-releasing hormone in vivo.

Molecular mechanisms directing tissue-specific expression of gonadotropin-releasing hormone (GnRH) are difficult to study due to the paucity and scattered distribution of GnRH neurons. To identify regions of the mouse GnRH (mGnRH) promoter that are critical for appropriate tissue-specific gene expression, we generated transgenic mice with fragments (-3446/+23 bp, -2078/+23 bp, and -1005/+28 bp) of mGnRH promoter fused to the luciferase reporter gene. The pattern of mGnRH promoter activity was assessed by measuring luciferase activity in tissue homogenates. All three 5'-fragments of mGnRH promoter targeted hypothalamic expression of the luciferase transgene, but with the exception of the ovary, luciferase expression was absent in non-neural tissues. High levels of ovarian luciferase activity were observed in mice generated with both -2078 and -1005 bp of promoter. Our study is the first to define a region of the GnRH gene promoter that directs expression to both neural and non-neural tissues in vivo. We demonstrate that DNA sequences contained within the proximal -1005 bp of the mGnRH promoter are sufficient to direct mGnRH gene expression to both the ovary and hypothalamus. Our results also suggest that DNA sequences distal to -2078 bp mediate the repression of ovarian GnRH.