Oxidation-reduction imaging of myoglobin reveals two-phase oxidation in the reperfused myocardium.

Myocardial infarction (MI) is a serious acute cardiovascular syndrome that causes myocardial injury due to blood flow obstruction to a specific myocardial area. Under ischemic-reperfusion settings, a burst of reactive oxygen species is generated, leading to redox imbalance that could be attributed to several molecules, including myoglobin. Myoglobin is dynamic and exhibits various oxidation-reduction states that have been an early subject of attention in the food industry, specifically for meat consumers. However, rarely if ever have the myoglobin optical properties been used to measure the severity of MI. In the current study, we develop a novel imaging pipeline that integrates tissue clearing, confocal and light sheet fluorescence microscopy, combined with imaging analysis, and processing tools to investigate and characterize the oxidation-reduction states of myoglobin in the ischemic area of the cleared myocardium post-MI. Using spectral imaging, we have characterized the endogenous fluorescence of the myocardium and demonstrated that it is partly composed by fluorescence of myoglobin. Under ischemia-reperfusion experimental settings, we report that the infarcted myocardium spectral signature is similar to that of oxidized myoglobin signal that peaks 3 h post-reperfusion and decreases with cardioprotection. The infarct size assessed by oxidation-reduction imaging at 3 h post-reperfusion was correlated to the one estimated with late gadolinium enhancement MRI at 24 h post-reperfusion. In conclusion, this original work suggests that the redox state of myoglobin can be used as a promising imaging biomarker for characterizing and estimating the size of the MI during early phases of reperfusion.

What Role do Mitochondria Have in Diastolic Dysfunction? Implications for Diabetic Cardiomyopathy and Heart Failure With Preserved Ejection Function.

ABSTRACT: Diastolic dysfunction is common to both diabetic cardiomyopathy and heart failure with preserved ejection fraction (HFpEF). Although commonly attributed to increased fibrosis, alterations in mitochondrial function and associated Ca2+ handling may contribute to impaired cardiac function. With mitochondrial dysfunction, increased reactive oxygen species (ROS), inflammation, and decreased adenosine triphosphate/adenosine diphosphate ratio may lead to increased extracellular matrix and diminished contractile relaxation. In this article, we discuss recent research implicating deficient mitochondria-associated endoplasmic reticulum membranes (MAMs) as it relates to impaired metabolic function and what role that may have in diastolic dysfunction in diabetic cardiomyopathy. The contribution of mitochondrial dysfunction to diastolic dysfunction in HFpEF is less established, but equally credible based on preclinical studies. However, there are notable differences between diabetic cardiomyopathy and HFpEF. Recent evidence implicates impaired endoplasmic reticulum signaling, in particular the unfolded protein response (UPR), in the pathogenesis of HFpEF. With HFpEF, enhanced pressure on the mitochondrial "gas pedal" because of increased cytosolic Ca2+ may perturb mitochondrial homeostasis. For diabetic cardiomyopathy and HFpEF, a better understanding of how altered cellular ion and redox status affect mitochondrial function is needed. Finally, we discuss the implications that mitochondrial dysfunction may have in devising novel therapeutic strategies for diabetic cardiomyopathy and HFpEF.

Non-adherence to antihypertensive medications in Lebanese adults hospitalized for hypertensive urgency and its cost.

BACKGROUND: Drug non-adherence is assumed to play an important role in development of hypertensive urgency, which is a common health problem resulting in frequent emergency department admissions and thus increased healthcare spending wastage. The objective of this study is to assess the rate of non-adherence to antihypertensives and to evaluate influencing factors predicting this behavior in Lebanese hypertensive adults. In addition, this study aim to estimate the cost of hospitalization for hypertensive urgency covered by the Ministry of Public Health in patients' non-adherent to their antihypertensives. METHODS: A multi-methods approach is used comprising a cross-sectional study, additionally to an observational, retrospective, cost of illness study. A cross-sectional questionnaire based study is conducted from May to Dec, 2019 to address the study objective. Using the Ministry of Public Health hospitalization data during 2019, the cost of hospitalization for hypertensive urgency is assessed. Multivariable analysis is performed to calculate the adjusted odd ratios by fitting a logistic regression model. RESULTS: The cross-sectional study includes 494 participants and shows that 43.0% of patients hospitalized and covered by the Ministry of Public Health are non-adherent. The univariate regression model shows that adherence to antihypertensive medications is significantly associated with age (p-value = 0.005) and follow-up visits (p-value = 0.046). The odds of adherence for participants earning more than USD 2000 was 3.27 times that for those who earn less than USD 1000 (p = 0.026). The estimated cost of hospitalization for non-adherent patients is USD 452,353 in 2019. CONCLUSION: Non-adherence associated hospitalization costs represents a financial burden to Lebanese health system.

Impact of Fasting on Cardiovascular Outcomes in Patients With Hypertension.

ABSTRACT: Fasting has been frequently practiced for religious or medical purposes worldwide. However, limited literature assesses the impact of different fasting patterns on the physiologic and cardiac-related parameters in patients with hypertension. This review aims to examine the effect of fasting on cardiovascular outcomes in hypertensive patients. Medline, Embase, and Cochrane library were systematically screened until March 2021 for observational prospective cohorts investigating the effect of fasting on cardiovascular outcomes. Articles were assessed by searching for hypertension and fasting, both as Medical Subject Headings (MeSH) terms and text words. The review included studies assessing Ramadan, intermittent, and water-only fasting. Water-only fasting reduces body weight, blood pressure, and lipolytic activity of fasting hypertensive patients without affecting average heart rate. Ramadan fasting enhances lipid profile, although it shows conflicting results for body weight, blood pressure, and heart rate variability. Considering the limited studies in this field, further research should be conducted to support the clinical impact of fasting on the cardiovascular health of patients with hypertension.

Patients' knowledge and awareness about patient support programs: a cross-sectional study on Lebanese adults with chronic diseases.

OBJECTIVE: Patient Support Programs (PSPs) have become a trend among pharmaceutical companies and a standard service offering to patients. The objective of the present study is to describe the status of PSPs in Lebanon and to assess the extent of knowledge and awareness among Lebanese patients about the PSPs. METHODS: A cross-sectional study was conducted between April and July 2017. A convenient sample of patients was randomly selected from outpatient clinics at four hospitals within the Greater Beirut Area. A questionnaire was used to address the study objective. Bivariate analysis was performed using the Chi-square test. Data were analyzed by using SPSS version 23. RESULTS: Out of 385 patients who participated in the study, 45.45 percent were aged between 46 and 66 years. None of them indicated that they were enrolled in a PSP, and only 13 percent of the respondents were aware of the existence of such a program. In terms of adherence habits, 55.6 percent of the patients self-reported that they do not skip any dose of their medication and consume their medication as prescribed by their healthcare providers. The main reason for nonadherence reported by the majority of nonadherent participants 144 (84.2%) was simple forgetfulness. CONCLUSIONS: There is a severe lack of awareness of PSPs in Lebanon. Given the important role that PSPs play in creating value for patients-in terms of healthcare follow-up practices, improved adherence habits, and cost savings-there should be a more substantial effort by pharmaceutical companies to expand and promote their PSPs in the Lebanese market.

Survey investigating the knowledge and awareness of payers and patient advocacy groups about the health technology assessment process in Lebanon.

The survey aims to assess the knowledge and awareness of Reimbursement Bodies (RBs) and Patient Advocacy Groups (PAGs) in Lebanon and the possible involvement of patients in the health technology assessment (HTA) process in the absence of a well-established HTA structure and to identify the actions to be taken at this level. Structured questionnaires were administered to eleven key participants from both RBs and PAGs. The survey utilized two different questionnaires, each composed of two open-ended questions and ten close-ended questions. RBs recognized the need for clinical and technical guidelines to optimize the HTA process, whereas PAGs stated that they are familiar with the current assessment and reimbursement process. A lack of interaction between the payers and the PAGs was reported mainly due to the absence of laws that involve patients in the assessment process. All the payers and three out of five of PAGs encouraged the involvement of PAGs in the assessment process. They reported that patients require support, education, and training to be efficiently involved. A short-term plan for involving patients in the assessment process can be implemented in light of RBs' and PAGs' openness for such involvement. In the long run, the collaboration between both parties needs to be more formalized and structured. Education and training programs are to be suggested for other PAGs. The institutionalization of an HTA body that unifies all the fragmented RBs, including a patient's representation to optimize the reimbursement process and to engage patients, is recommended.

Reduced reticulum-mitochondria Ca2+ transfer is an early and reversible trigger of mitochondrial dysfunctions in diabetic cardiomyopathy.

Type 2 diabetic cardiomyopathy features Ca2+ signaling abnormalities, notably an altered mitochondrial Ca2+ handling. We here aimed to study if it might be due to a dysregulation of either the whole Ca2+ homeostasis, the reticulum-mitochondrial Ca2+ coupling, and/or the mitochondrial Ca2+ entry through the uniporter. Following a 16-week high-fat high-sucrose diet (HFHSD), mice developed cardiac insulin resistance, fibrosis, hypertrophy, lipid accumulation, and diastolic dysfunction when compared to standard diet. Ultrastructural and proteomic analyses of cardiac reticulum-mitochondria interface revealed tighter interactions not compatible with Ca2+ transport in HFHSD cardiomyocytes. Intramyocardial adenoviral injections of Ca2+ sensors were performed to measure Ca2+ fluxes in freshly isolated adult cardiomyocytes and to analyze the direct effects of in vivo type 2 diabetes on cardiomyocyte function. HFHSD resulted in a decreased IP3R-VDAC interaction and a reduced IP3-stimulated Ca2+ transfer to mitochondria, with no changes in reticular Ca2+ level, cytosolic Ca2+ transients, and mitochondrial Ca2+ uniporter function. Disruption of organelle Ca2+ exchange was associated with decreased mitochondrial bioenergetics and reduced cell contraction, which was rescued by an adenovirus-mediated expression of a reticulum-mitochondria linker. An 8-week diet reversal was able to restore cardiac insulin signaling, Ca2+ transfer, and cardiac function in HFHSD mice. Therefore, our study demonstrates that the reticulum-mitochondria Ca2+ miscoupling may play an early and reversible role in the development of diabetic cardiomyopathy by disrupting primarily the mitochondrial bioenergetics. A diet reversal, by counteracting the MAM-induced mitochondrial Ca2+ dysfunction, might contribute to restore normal cardiac function and prevent the exacerbation of diabetic cardiomyopathy.

Critical appraisal of STAT3 pattern in adult cardiomyocytes.

The signal transducer and activator of transcription 3, STAT3, transfers cellular signals from the plasma membrane to the nucleus, acting as a signaling molecule and a transcription factor. Reports proposed an additional non-canonical role of STAT3 that could regulate the activity of complexes I and II of the electron transport chain and the opening of the mitochondrial permeability transition pore (PTP) after ischemia-reperfusion in various cell types. The native expression of STAT3 in heart mitochondria, together with a direct versus an indirect transcriptional role in mitochondrial functions, have been recently questioned. The objective of the present study was to investigate the cellular distribution of STAT3 in mouse adult cardiomyocytes under basal and stress conditions, along with assessing its presence and activity in cardiac mitochondria using structural and functional approaches. The analysis of the spatial distribution of STAT3 signal in the cardiomyocytes interestingly showed that it is transversely distributed along the T-tubules and in the nucleus. This distribution was neither affected by hypoxia nor by hypoxia/re­oxygenation conditions. Focusing on the mitochondrial STAT3 localization, our results suggest that serine-phosphorylated STAT3 (PS727-STAT3) and total STAT3 are detected in crude but not in pure mitochondria of mouse adult cardiomyocytes, under basal and ischemia-reperfusion conditions. The inhibition of STAT3, with a pre-validated non-toxic Stattic dose, had no significant effects on mitochondrial respiration, but a weak effect on the calcium retention capacity. Overall, our results exclusively reveal a unique cellular distribution of STAT3 in mouse adult cardiomyocytes, along the T-tubules and in nucleus, under different conditions. They also challenge the expression and activity of STAT3 in mitochondria of these cells under basal conditions and following ischemia-reperfusion. In addition, our results underline technical methods, complemental to cell fractionation, to evaluate STAT3 roles during hypoxia-reoxygenation and at the interface between nucleus and endoplasmic reticulum.

Loss of STAT3 in mouse embryonic fibroblasts reveals its Janus-like actions on mitochondrial function and cell viability.

STAT3 has been implicated in mitochondrial function; however, the physiological relevance of this action is not established. Here we studied the importance of STAT3 to the cellular response to stimuli, TNFα and serum deprivation, which increase mitochondrial reactive oxygen species (ROS) formation. Experiments were performed using wild type (WT) and STAT3 knockout (KO) mouse embryonic fibroblasts (MEF). Both WT and STAT3 KO MEF expressed similar levels of tumor necrosis factor receptor 1 (TNFR1) and exhibited comparable IκBα degradation with TNFα. However, in the absence of STAT3 nuclear accumulation of NFκB p65 with TNFα was attenuated and induction of the survival protein c-FLIPL was eliminated. Nonetheless, WT MEF were more sensitive to TNFα-induced death which was attributed to necrosis. Deletion of STAT3 decreased ROS formation induced by TNFα and serum deprivation. STAT3 deletion was associated with lower levels of complex I and rates of respiration. Relative to WT cells, mitochondria of STAT3 KO cells released significantly more cytochrome c in response to oxidative stress and had greater caspase 3 cleavage due to serum deprivation. Our findings are consistent with STAT3 being important for mitochondrial function and cell viability by ensuring mitochondrial integrity and the expression of pro-survival genes.

Applying fractal dimension and image analysis to quantify fibrotic collagen deposition and organization in the normal and hypertensive heart.

Hearts of mice with reduction of function mutation in STAT3 (SA/SA) develop fibrotic collagen foci and reduced systolic function with hypertension. This model was used to determine if fractal dimension and image analysis can provide a quantitative description of myocardial fibrosis using routinely prepared trichome-stained material. Collagen was characterized by relative density [integrated optical density/area (IOD/A)] and fractal dimension (D), an index of complexity. IOD/A of collagen in wild type mice increased with hypertension while D decreased, suggesting tighter collagen packing that could eventually stiffen the myocardium as in diastolic heart failure. Reduced STAT3 function caused modest collagen fibrosis with increased IOD/A and D, indicating more tightly packed, but more disorganized collagen than normotensive and hypertensive controls. Hypertension in SA/SA mice resulted in large regions where myocytes were lost and replaced by fibrotic collagen characterized by decreased density and increased disorder. This indicates that collagen associated with reparative fibrosis in SA/SA hearts experiencing hypertension was highly disorganized and more space filling. Loss of myocytes and their replacement by disordered collagen fibers may further weaken the myocardium leading to systolic heart failure. Our findings highlight the utility of image analysis in revealing importance of a cellular protein for normal and reparative extracellular matrix deposition.

Outcomes of Hypospadias Repair Based on Surgical Techniques: A 4-Year Retrospective Study.

Purpose: This study aimed to report the outcomes of hypospadias repair performed at a tertiary-level hospital during 2018 to 2021. Methods: A retrospective chart review of 119 patients was performed. Results: The most frequent coronal hypospadias cases were distal. However, the most common scrotal hypospadias cases were proximal. The average age at the time of the first surgery was 2.4 years (standard deviation, ±2.3 years). The tubularised incised plate technique was performed for 57 of these 119 patients. Urethral fistula was the most common complication associated with distal and proximal cases (23.96% and 30.43%, respectively). No significant correlation was observed between any complication and the surgical technique. Based on the logistic regression model, the duration of urethral stenting was statistically significant (p=0.025), indicating that a urinary catheter duration of more than 5 days resulted in a 2.9-times increased risk of postoperative urethral fistula. Conclusion: Prolonged urethral stenting for more than 5 days may result in subsequent urethral fistula development. Neither the severity of hypospadias nor the surgical technique seems to affect postoperative complications.

Heart failure with preserved ejection fraction: emerging drug strategies.

Approximately half of heart failure patients have a normal ejection fraction, a condition designated as heart failure with preserved ejection fraction (HFpEF). This heart failure subtype disproportionately affects women and the elderly and is commonly associated with other cardiovascular comorbidities, such as hypertension and diabetes. HFpEF is increasing at a steady rate and is predicted to become the leading cause of heart failure within a decade. HFpEF is characterized by impaired diastolic function, thought to be due to concentric remodeling of the heart along with increased stiffness of both the extracellular matrix and myofilaments. In addition, oxidative stress and inflammation are thought to have a role in HFpEF progression, along with endothelial dysfunction and impaired nitric oxide-cyclic guanosine monophosphate-protein kinase G signaling. Surprisingly a number of clinical studies have failed to demonstrate any benefit of drugs effective in heart failure with systolic dysfunction in HFpEF patients. Thus, HFpEF is one of the largest unmet needs in cardiovascular medicine, and there is a substantial need for new therapeutic approaches and strategies that target mechanisms specific for HFpEF. This conclusion is underscored by the recently reported disappointing results of the RELAX trial, which assessed the use of phosphodiesterase-5 inhibitor sildenafil for treating HFpEF. In animal models, endothelial nitric oxide synthase activators and If current inhibitors have shown benefit in improving diastolic function, and there is a rationale for assessing matrix metalloproteinase 9 inhibitors and nitroxyl donors. LCZ696, a combination drug of angiotensin II receptor blocker and neprilysin inhibitor, and the aldosterone receptor antagonist spironolactone are currently in clinical trial for treating HFpEF. Here we present an overview of the etiology and diagnosis of HFpEF that segues into a discussion of new therapeutic approaches emerging from basic research and drugs currently in clinical trial that primarily target diastolic dysfunction or imbalanced ventricular-arterial coupling.

Chronic anabolic androgenic steroid administration reduces global longitudinal strain among off-cycle bodybuilders.

BACKGROUND: Supra-physiologic doses of anabolic androgenic steroids (AAS) lead to multiple cardiovascular complications. The long-term clinical effect of AAS overuse on cardiac structure and function, which persists during off-cycle periods, remains unclear. METHODS: A total of 15 sedentary subjects and 79 bodybuilders (26 AAS non-users and 53 AAS-users), matched for age and male gender, were assessed in a cross-sectional design for echocardiography measures. AAS-users were included during an off-cycle phase, abstained from AAS for at least 1 month. 2D standard M-mode and speckle tracking echocardiography were used to measure cardiac dimensions and functions. RESULTS: Inter-ventricular septum and posterior wall thickness were significantly higher among chronic off-cycle AAS-users compared to AAS non-users and sedentary group. Off-cycle AAS-users showed lower E/A ratio of the diastolic function. Left ventricular systolic function was not affected in terms of ejection fraction, but significant subclinical systolic dysfunction, assessed by GLS, was observed for chronic off-cycle AAS-users compared to AAS non-users (GLS = -16.8% vs. -18.5%, respectively; p = 0.001). Diameter of left atrium and right ventricle were significantly enlarged among off-cycle AAS-user bodybuilders (p = 0.002 and 0.040). TAPSE and RV S', and cardiac vasculature of aorta were comparable in all groups. CONCLUSIONS: This study demonstrates that during off-cycle phase, AAS-users show long-term impaired GLS, even after considerable AAS abstain, despite normal LVEF. It highlights the importance of following GLS to predict hypertrophy and heart failure events, and not relying on LVEF alone. In addition, the hypertrophic effect of chronic AAS consumption is transitional during AAS washout periods.

Impaired cardiac structure and systolic function in athletes using supra-physiological doses of anabolic androgenic steroids.

OBJECTIVES: Athletes are increasingly using supra-physiological doses of anabolic androgenic steroids without weighing health side effects. This study aims to conjointly evaluate the effect of supraphysiological doses of anabolic androgenic steroids on global cardiovascular structure and functional capacity. DESIGN: Cross-sectional study. METHODS: 92 males enrolled in the study, including 18 sedentary subjects, 26 anabolic androgenic steroid non-user athletes, and 48 anabolic androgenic steroid-user athletes. Two-dimensional echocardiography was done to evaluate the cardiovascular structure and function. RESULTS: Anabolic androgenic steroid-users presented increased cardiac remodeling of the left ventricle and left atrium compared to control groups (p < 0.001). Anabolic androgenic steroid-users showed increased left ventricular mass/body surface area versus control groups (p < 0.001), with 28 steroid-users (58.3 %) having cardiac remodeling, which is more than control groups (p < 0.001). Anabolic androgenic steroid-users presented lower diastolic function (E and E/A) compared to non-users (p = 0.003 and <0.001, respectively). Ejection fraction was decreased among anabolic androgenic steroid-users versus the sedentary group only (p = 0.020), while anabolic androgenic steroid-users presented reduced global longitudinal strain of 15.43 % compared to both control groups (p < 0.001). Moreover, anabolic androgenic steroid-users experienced more tricuspid valve regurgitation (p = 0.001). CONCLUSIONS: Anabolic androgenic steroid consumption is associated with global cardiac remodeling with increased dimensions of the left ventricle, and atrium. Anabolic androgenic steroid-users present left ventricular hypertrophy with reduced subclinical systolic function. Moreover, anabolic androgenic steroid consumption is correlated with valve regurgitation and dilation of the sino-tubular junction.

Antimesenteric sleeve tapering enteroplasty with end-to-end anastomosis versus primary end-to-side anastomosis for the management of jejunal/ileal atresia.

BACKGROUND/OBJECTIVE: Small bowel atresia commonly causes neonatal intestinal obstructions. Technical problems are associated with the surgical management of atresia using primary end-to-end anastomosis. Furthermore, the significantly dilated proximal loop may be associated with the stasis of intestinal fluid, thus increasing pressure on the anastomosis and prolonging fasting time before initiation of oral intake. This study aimed to perform antimesenteric tapering of the proximal loop using a linear stapler to reduce its diameter and facilitate anastomosis with the distal loop. METHODS: This retrospective study included 57 neonates diagnosed with jejunoileal atresia. They were categorised into two groups: Group A (n = 29), which included neonates treated using antimesenteric sleeve enteroplasty tapering using a linear stapler and Group B (n = 28), which included neonates treated at the primary end of the proximal loop to the side of the distal loop anastomosis. RESULTS: The mean operative time was 122.5 min in group A vs. 118 min in group B, and the mean duration to reach full oral intake was 17 days in group A vs. 20.2 days in group B (p = 0.03). The mean length of hospital stay was 25 and 35 days in groups A and B, respectively (p = 0.042). CONCLUSION: Tapering the proximal dilated bowel loop to achieve anastomosis with the distal loop improved the transient time, reduced stasis and its associated translocation and colonisation, and allowed for early initiation and maintenance of oral intake. All these parameters shortened the overall length of hospital stay.

Peri-Kasai portoenterostomy sutures anchoring the jejunal loop to Glisson capsule: A novel modification to reduce the incidence of cholangitis.

BACKGROUND: Kasai portoenterostomy (KPE) is the standard surgical management for biliary atresia (BA). To improve the outcome these infants were operated on within the first two months of life. The success of the procedure is reflected by clearance of jaundice and either absence or occurrence of fewer attacks of cholangitis. The failure of the procedure indicates liver transplantation (LT). OBJECTIVE: to reduce the incidence of the recurrent attacks of cholangitis by peri-KPE sutures anchoring the jejunal loop to the Glisson capsule. METHODS: It is a retrospective study that included 45 infants diagnosed with BA and who were operated on at an age younger than 60 days. They were categorized into two groups, Group A (n = 23) included infants treated with the classic KPE, and Group B (n = 22) included infants treated in the same way plus peri KPE sutures anchoring the jejunal loop to the Glisson capsule. RESULTS: The mean operative time in Group A was 149.3 min versus 164.8 min in Group B (p-value 0.039). The mean level of bilirubin was 2.2 versus 2.1 in Group A and Group B respectively at two years follow up. The total attacks of cholangitis per patient were significantly lower in Group B than in Group A (cutoff value = 3), which was reflected by the significant reduction of the incidence of LT in Group B. CONCLUSION: peri KPE sutures anchoring the jejunal loop to the Glisson capsule significantly reduced the incidence of recurrent attacks of cholangitis and subsequently decreased the requirement of LT on the short-term follow-up.

Hybrid Mathieu Urethroplasty vs. Tubularized Incised Plate Urethroplasty for the Management of Distal Penile Hypospadias With a Small Glans.

Introduction: Distal hypospadias is a common anomaly. Different surgical techniques have evolved through the years to manage this anomaly. Several factors may affect the prognosis. One of them is glans size. We compared the hybrid Mathieu urethroplasty (HMU) and the tubularized incised plate urethroplasty (TIPU) for the management of distal hypospadias with a small glans. Methods: Sixty-eight patients with distal hypospadias were included and categorized into two groups. Group A (n = 33) and group B (n = 35) patients were treated by HMU and TIPU, respectively. All patients had a small glans. In group A, the patients underwent Mathieu urethroplasty plus a deep incision of the urethral plate. In group B, the patients underwent TIPU. Urethral stents were used in all cases. Hypospadias objective score evaluation (HOSE) was used to assess the results. Results: Urethrocutaneous fistulae developed in two cases in group A and six cases in group B. Meatal stenosis was significantly lower (one case in group A vs. eight cases in group B). Glanular dehiscence occurred in two cases in group A and five cases in group B. The small glans strongly correlated with the development of both urethrocutaneous fistulae and meatal stenosis where the odd ratios were 3.500 (1.383-7.879) and 9.481 (1.114-12.669), respectively. Conclusion: Both techniques showed efficacy during management of patients with a small glans. HMU had better outcomes, shorter duration of stent and lesser incidence of complications than TIPU. Small glans was significantly related to urethrocutaneous fistulae and meatal stenosis in group B.

Delayed vs. early enteral feeding after repair of congenital recto-vestibular fistula: The effect on perineal wound healing.

Introduction: congenital Recto vestibular fistula represents the commonest type of anorectal malformation in females. The treatment of this anomaly is mainly approached either through anterior or posterior sagittal ano-rectoplasty approach. Several perioperative factors may affect the outcome. One of major postoperative complications is the occurrence of wound infection. We aimed to study the effect of delayed vs. early enteral feeding on the occurrence of perineal wound infection (PWI) after repair of congenital recto vestibular fistula. Patients and methods: Fifty-five infants with recto-vestibular fistula were included. They were managed by single stage anterior sagittal anorectoplasty (ASARP) at an age ≥3 months. Groups A and B included infants who started oral intake on the 6th and 2nd postoperative days respectively. Group A infants were kept on peripheral parenteral nutrition (PPN) during the fasting period. Results: Superficial wound infection occurred in three cases in group A while it developed in seven cases in group B. Deep perineal infection occurred in two and five cases in group A and group B respectively. The mean hospital stay was 8 days in group A vs. 13 days in group B when PWI developed. Conclusion: Delayed enteral feeding with PPN keeps the perineal wound less contaminated with stool. This promoted proper and fast healing with lower incidence of PWI. Also, PPN compensates the catabolic effects of both surgical trauma and fasting during the postoperative period and ensures maintenance of normal levels of essential nutrients that allow for proper healing.