Ureteral stricture after pediatric kidney transplantation: Is there a role for percutaneous antegrade ureteroplasty?

INTRODUCTION: Ureteral obstruction following pediatric kidney transplantation occurs in 5-8% of cases. We describe our experience with percutaneous antegrade ureteroplasty for the treatment of ureteral stricture in pediatric kidney transplant patients. METHODS: We retrospectively reviewed all pediatric kidney transplantation patients who presented with ureteral stricture and underwent percutaneous antegrade ureteroplasty at our institution from July 2009 to July 2021. Variables included patient demographics, timing of presentation, location and extent of stricture, ureteroplasty technique and clinical outcomes. Our primary outcome was persistent obstruction of the kidney transplant. RESULTS: Twelve patients met inclusion criteria (4.2% of all transplants). Median age at time of ureteroplasty was 11.5 years (range: 3-17.5 years). Median time from kidney transplantation to ureteroplasty was 3 months. Patency was maintained in 50% of patients. Seven patients (58.3%) required additional surgery. Four patients developed vesicoureteral reflux. Patients with persistent obstruction had a longer time from transplant to ureteroplasty compared to those who achieved patency (19.3 vs 1.3 months, p = 0.0163). Of those treated within 6 months after transplantation, two patients (25%) required surgery for persistent obstruction (p = 0.06). All patients treated >1 year after transplantation had persistent obstruction following ureteroplasty (p = 0.06). CONCLUSION: Percutaneous antegrade ureteroplasty can be considered a viable minimally invasive treatment option for pediatric patients who develop early ureteral obstruction (<6 months) following kidney transplantation. In patients who are successfully treated with ureteroplasty, 67% can develop vesicoureteral reflux into the transplant kidney. Patients who fail early percutaneous ureteroplasty or develop obstruction >1 year after transplantation are best managed with surgical intervention.

A randomized controlled trial of cognitive-behavior therapy plus bright light therapy for adolescent delayed sleep phase disorder.

OBJECTIVE: To evaluate cognitive-behavior therapy plus bright light therapy (CBT plus BLT) for adolescents diagnosed with delayed sleep phase disorder (DSPD). DESIGN: Randomized controlled trial of CBT plus BLT vs. waitlist (WL) control with comparisons at pre- and post-treatment. There was 6-month follow-up for the CBT plus BLT group only. SETTING: Flinders University Child & Adolescent Sleep Clinic, Adelaide, South Australia. PATIENTS: 49 adolescents (mean age 14.6 ± 1.0 y, 53% males) diagnosed with DSPD; mean chronicity 4 y 8 months; 16% not attending school. Eighteen percent of adolescents dropped out of the study (CBT plus BLT: N = 23 vs. WL: N = 17). INTERVENTIONS: CBT plus BLT consisted of 6 individual sessions, including morning bright light therapy to advance adolescents' circadian rhythms, and cognitive restructuring and sleep education to target associated insomnia and sleep hygiene. MEASUREMENTS AND RESULTS: DSPD diagnosis was performed via a clinical interview and 7-day sleep diary. Measurements at each time-point included online sleep diaries and scales measuring sleepiness, fatigue, and depression symptoms. Compared to WL, moderate-to-large improvements (d = 0.65-1.24) were found at post-treatment for CBT plus BLT adolescents, including reduced sleep latency, earlier sleep onset and rise times, total sleep time (school nights), wake after sleep onset, sleepiness, and fatigue. At 6-month follow-up (N = 15), small-to-large improvements (d = 0.24-1.53) continued for CBT plus BLT adolescents, with effects found for all measures. Significantly fewer adolescents receiving CBT plus BLT met DPSD criteria at post-treatment (WL = 82% vs. CBT plus BLT = 13%, P < 0.0001), yet 13% still met DSPD criteria at the 6-month follow-up. CONCLUSIONS: CBT plus BLT for adolescent DSPD is effective for improving multiple sleep and daytime impairments in the immediate and long-term. Studies evaluating the treatment effectiveness of each treatment component are needed. CLINICAL TRIAL INFORMATION: Australia-New Zealand Trials Registry Number: ACTRN12610001041044.

Recent worldwide sleep patterns and problems during adolescence: a review and meta-analysis of age, region, and sleep.

Adolescent sleep health is becoming increasingly recognized internationally as a significant concern, with many countries reporting high incidences of sleep disturbance in our youth. Notwithstanding the value of findings obtained from each large-scale survey of adolescent sleep performed within individual countries, the field lacks synthesis and analysis of adolescent sleep studies into a single review. This review presents findings from a meta-analysis of 41 surveys of worldwide adolescent sleep patterns and problems published in the last decade (1999-2010). Sleep patterns tended to delay with increasing age, restricting school-night sleep. Notably, Asian adolescents' bedtimes were later than peers from North America and Europe, resulting in less total sleep time on school nights and a tendency for higher rates of daytime sleepiness. Weekend sleep data were generally consistent worldwide, with bedtimes 2+ hours later and more total sleep time obtained. We note a worldwide delayed sleep-wake behavior pattern exists consistent with symptoms of Delayed Sleep Phase Disorder, which may be exacerbated by cultural factors. Recommendations for future surveys of adolescent sleep patterns are discussed and provided in light of current methodological limitations and gaps in the literature.

A single-blind placebo run-in study of venlafaxine XR for activity-limiting osteoarthritis pain.

OBJECTIVE: Osteoarthritis pain is a significant problem for our aging population. Non-steroidal anti-inflammatory drugs and opioids are effective treatments, but have significant adverse effects, so there is a need for alternative treatments. Selective norepinephrine-serotonin reuptake inhibitor antidepressants may provide a new treatment option for osteoarthritis pain. METHODS: We performed a single-blind placebo run-in trial of 150-225 mg of venlafaxine in 18 subjects with activity-limiting osteoarthritis pain. Each subject received 2 weeks of placebo followed by 10 weeks of venlafaxine. The primary outcome was reduction in average pain intensity between 2 and 12 weeks. For subjects not completing the trial, their last observation was carried forward as an imputed outcome. RESULTS: Average pain on the Brief Pain Inventory (BPI) was 4.7 at baseline, 4.4 after the 2-week placebo run-in, and 3.3 at 12 weeks (25% decrease, P = 0.03). Nine subjects (50%) reported at least 30% pain reduction between weeks 2 and 12. The Western Ontario and McMasters University Osteoarthritis Index (WOMAC) pain score at baseline was 2.0, 1.8 after 2 weeks, and 1.7 after 12 weeks. This represented a 6% decrease in pain between weeks 2 and 12 (P = 0.42), with two subjects (11%) reported at least 30% pain relief between weeks 2 and 12 on the WOMAC. Effects on self-reported physical and role function and depression were marginal or non-significant, and observed physical function did not improve. CONCLUSION: Venlafaxine significantly reduced pain intensity on the BPI and marginally improved self-reported function. Venlafaxine should be investigated further in a larger randomized trial for the treatment of osteoarthritis pain.

A single-blind, placebo run-in study of duloxetine for activity-limiting osteoarthritis pain.

UNLABELLED: Osteoarthritis pain is a significant problem for our aging population. Antidepressants that are serotonin-norepinephrine reuptake inhibitors are effective for other forms of chronic pain and may provide a new treatment option for osteoarthritis pain. We performed a single-blind, placebo run-in trial of 60 to 90 mg of duloxetine in 25 subjects with activity-limiting osteoarthritis pain. Each subject received 2 weeks of placebo followed by 10 weeks of duloxetine. The primary outcome was reduction in average pain intensity between 2 and 12 weeks for subjects completing the trial. Average pain on the Brief Pain Inventory (BPI) was 5.7 at baseline, 4.8 after the 2-week placebo run-in, and 3.5 at 12 weeks for the 17 patients completing the trial (28% decrease between 2 and 12 weeks, P = .122). Eight of 15 study completers who had nonmissing BPI results (53%) reported at least 30% pain reduction between weeks 2 and 12. The Western Ontario McMaster Osteoarthritis Index (WOMAC) pain score at baseline was 2.3, 1.8 after 2 weeks, and 1.3 after 12 weeks (30% decrease between 2 and 12 weeks, P = .018). Ten of 17 patients (59%) reported at least 30% pain relief between weeks 2 and 12 on the WOMAC. Significant improvements in self-reported physical and role function were reported but observed physical function did not improve. PERSPECTIVE: Duloxetine did not significantly reduce pain intensity on the BPI but did improve pain intensity and self-reported function on the WOMAC. Duloxetine warrants further investigation as a novel treatment for osteoarthritis pain.

Unique histopathologic findings in a patient with adult-onset Still disease.

Adult-onset Still disease (AOSD) is an uncommon disorder characterized by fever, polyarthralgia, elevated white blood cell count, and a maculopapular rash, the histologic features of which have not been well-known. A 55-year-old Asian woman presented initially with a "burning" and severely pruritic eruption on her face, hands, and arms, thought clinically to be urticaria. Within 1 month, she began spiking high fevers, developed diffuse joint pain, and had marked elevations of ferritin, C-reactive protein, and erythrocyte sedimentation rate, characteristic of AOSD. The cutaneous eruption became more widespread, involving the trunk, scalp, and remainder of the extremities, with diffuse thickening of the skin with papular and linear hyperpigmentation and accentuation. Biopsies from several locations showed focal hyperkeratosis associated with dyskeratotic keratinocytes with a peculiar, distinctive distribution in the upper epidermis and cornified layers. In addition, increased dermal mucin was present, with minimal fibroblast proliferation and inflammation. This unusual combination of diffuse dermal mucinosis and a unique pattern of dyskeratosis can present a challenge in generating an accurate differential diagnosis, and may represent an unusual response to chronic scratching or be a distinctive histologic manifestation of AOSD.