Do repeat ultrasounds affect orchiectomy rate in patients with testicular torsion treated at a pediatric institution?

INTRODUCTION: Testicular torsion is a urological emergency; as the testicular salvage rate decreases with time, prompt intervention is required to restore the blood flow. Interhospital transfers and ultrasound examinations, while clinically essential to proper treatment and diagnosis, may adversely affect outcomes by delaying surgical intervention. Patients transferred to another institution for treatment of testicular torsion may experience a further time delay by undergoing two ultrasound examinations: one at the initial admitting institution and one at the receiving institution. To the knowledge of the authors, no study has yet explored the time delays and outcomes associated with these repeat ultrasounds. OBJECTIVE: The objective was to investigate the impact of repeat ultrasound imaging on time to treatment and patient outcomes in patients with testicular torsion. STUDY DESIGN: A retrospective chart review of 133 patients, aged 0-20 years, treated at the authors' institution for testicular torsion was conducted. Neonate patients and patients who did not receive ultrasound were excluded. Demographic and clinical variables were collected from the electronic medical record. Pearson Chi-squared and t-tests were used for univariate comparisons, and multivariate logistic regression analysis was performed to measure the relationships between variables. RESULTS: Forty-nine percent of patients were primary patients, and 51% were transfer patients. Fifty-two percent of transfer patients received repeat ultrasounds. In comparison to salvaged patients, those who underwent orchiectomy experienced a greater delay between presentation at the institution and surgical intervention (229 min vs 177 min, p = 0.048). The transfer status does not appear to be related to the outcome, i.e. orchiectomy versus salvage. Patients who underwent orchiectomy were more likely than salvaged patients to have received repeat ultrasounds (p = 0.008). Repeat ultrasound patients had three times the likelihood of orchiectomy of single ultrasound patients. In a subset analysis of transfer patients, repeat ultrasound patients were more likely than single ultrasound patients to receive an orchiectomy (p = 0.03). DISCUSSION: In agreement with previous studies, patients who underwent orchiectomy were found to experience greater treatment delays and trend toward transfer. Specifically, repeat ultrasound and time between presentation and intervention appear to influence patient outcomes. The effect of repeat ultrasound on outcomes appears to be independent of the transfer status. The study was limited by its retrospective nature and small sample size. CONCLUSION: The analysis suggests that efforts to prevent repeat ultrasounds and minimize the time between presentation and intervention would improve patient outcomes. It is proposed that standardized clinical decision-making procedures, such as the TWIST scoring system, be incorporated into hospital protocols.

Interdisciplinary pain management is beneficial for refractory orchialgia in children.

INTRODUCTION: Idiopathic testicular/groin pain can be a difficult entity for children, their families, and caregivers. The role of interdisciplinary pain management has previously been demonstrated in treating chronic orchialgia at the present pediatric pain clinic. OBJECTIVE: To evaluate the role of interdisciplinary pain management in managing refractory orchialgia. It was hypothesized that children with refractory orchialgia might respond well. Interdisciplinary care was defined as that which crosses two medical disciplines such as a surgical specialty and specialist in analgesia. SUBJECTS AND METHODS: Pediatric patients were identified who were: ≥ 10 years old; evaluated in the pediatric urology clinic between 2002 and 2012; were diagnosed wtih ICD code 608.9 or had the diagnosis of male genital disorder NOS. Children were included if they presented with orchialgia without an identifiable cause and failed conservative management (rest, scrotal support, Sitz bath, timed voiding, constipation avoidance) including conventional anti-nociceptive analgesics (acetaminophen, non-steroidal anti-inflammatory drugs, opioids). Patient electronic medical records were reviewed retrospectively. RESULTS: Twenty-two children met inclusion criteria. Mean age was 13.7 years (range 10-17). Nearly half (45%) of the children had chronic medical conditions such as asthma, allergies, and obesity. Twenty-one of the 22 children were referred to the pediatric pain clinic; 15 were evaluated, and one refused treatment. All children evaluated in the pediatric pain clinic were initially offered an empiric anti-neuropathic anti-convulsant (i.e. gabapentin) and/or an anti-depressant (i.e. amitriptyline) before being offered a nerve block. Of the 14 children accepting treatment in the pediatric pain clinic, six were treated solely with an empiric anti-neuropathic anti-convulsant and/or anti-depressant; eight received medications followed by nerve block (seven ilioinguinal-iliohypogastric blocks, one spinal and ilioinguinal-iliohypogastric block) (see Fig. 1). A total of eight of the 14 children (57%) treated by the pain clinic had resolution of pain, with 50% of those treated with medications alone (three out of six children) responding (two responding to gabapentin and a tricyclic antidepressant, one to gabapentin alone); and five out of eight (63%) treated with medications and then nerve block (ilioinguinal-iliohypogastric block) responding. Of the eight children undergoing nerve block, five required more than one block. The time between each block ranged from 4 to 22.6 weeks. Response to nerve block required an average of 1.4 procedures (range 1-2); mean follow-up after nerve block was 2.4 months (range 0.1-4.8). DISCUSSION: Children with refractory orchialgia often have comorbidities that suggest a multidisciplinary approach would be useful for treating them. The present study found that the majority of children with refractory orchialgia treated in the pediatric pain clinic responded to management. Major limitations, however, included small cohort size and short follow-up, particularly in those children undergoing nerve block. There was also no objective assessment of pain improvement or improvement in quality of life, which could be rectified with a prospective study. CONCLUSION: Collaboration and early referral for interdisciplinary pain management as one of these multidisciplinary approaches may help to coordinate care and ease patient suffering.

Microfiltration: Effect of channel diameter on limiting flux and serum protein removal.

Our objective was to determine the limiting flux and serum protein (SP) removal at 8, 9 and 10% true protein (TP) in the retentate recirculation loop using 0.1-µm ceramic graded permeability (GP) microfiltration (MF) membranes with 3mm channel diameters (CD). An additional objective was to compare the limiting flux and SP removal between 0.1-µm ceramic GP membranes with 3mm CD and previous research using 4-mm CD membranes. The MF system was operated at 50°C, using a diluted milk protein concentrate with 85% protein on a total solids basis (MPC85) as the MF feed. The limiting flux for the MF of diluted MPC85 was determined at 8, 9, and 10% TP concentration in the recirculation loop. The experiment using the 3-mm CD membranes was replicated 3 times for a total of 9 runs. On the morning of each run MPC85 was diluted with reverse osmosis water to a MF feed TP concentration of 5.4%. In all runs the starting flux was 55 kg/m2 per hour, the flux was then increased in steps until the limiting flux was reached. For the 3-mm CD membranes, the limiting flux was 128±0.3, 109±4, and 97±0.5 kg/m2 per hour at recirculation loop TP concentrations of 8.1±0.07, 9.2±0.04, and 10.2±0.03%, respectively. For the 3-mm CD membranes, increasing the flux from the starting to the limiting flux decreased the SP removal factor from 0.72±0.02 to 0.67±0.01; however, no difference in SP removal factor among the target recirculation loop TP concentrations was detected. The limiting flux at each recirculation loop target TP concentration was lower for the 3- compared with the 4-mm CD membranes. The differences in limiting fluxes between the 3- and 4-mm CD membranes were explained in part by the difference in cross-flow velocity (5.5±0.03 and 7.0±0.03 m/s for the 3- and 4-mm CD membranes, respectively). The SP removal factor was also lower for the 3- compared with the 4-mm CD membranes, indicating that more membrane fouling may have occurred in the 3- versus 4-mm CD membranes.

Microfiltration: Effect of retentate protein concentration on limiting flux and serum protein removal with 4-mm-channel ceramic microfiltration membranes.

The objective of our study was to determine if the limiting flux and serum protein (SP) removal were different at 8, 9, or 10% true protein (TP) in the microfiltration (MF) retentate recirculation loop using 0.1-µm ceramic graded permeability membranes with 4-mm-channel diameters operated at 50 °C using a diluted milk protein concentrate with 85% protein on a total solids basis (MPC85) as the MF feed. The limiting flux for the MF of diluted MPC85 was determined at 3 TP concentrations in the recirculation loop (8, 9, and 10%). The experiment was replicated 3 times for a total of 9 runs. On the morning of each run, MPC85 was diluted with reverse osmosis water to an MF feed TP concentration of 5.4%. In all runs, the starting flux was 55 kg/m(2) per hour, the flux was increased in steps until the limiting flux was reached. The minimum flux increase was 10 kg/m(2) per hour. The limiting flux decreased as TP concentration in the recirculation loop increased. The limiting flux was 154 ± 0.3, 133 ± 0.7, and 117 ± 3.3 kg/m(2) per hour at recirculation loop TP concentrations of 8.2 ± 0.07, 9.2 ± 0.04, and 10.2 ± 0.09%, respectively. No effect of recirculation loop TP concentration on the SP removal factor was detected. However, the SP removal factor decreased from 0.80 ± 0.02 to 0.75 ± 0.02 as flux was increased from the starting flux of 55 kg/m(2) per hour to the limiting flux, with a similar decrease seen at all recirculation loop TP concentrations.

Microfiltration of skim milk and modified skim milk using a 0.1-µm ceramic uniform transmembrane pressure system at temperatures of 50, 55, 60, and 65°C.

Increasing the temperature of microfiltration (MF) to >50°C may allow for operation at higher fluxes and reduce the bacterial growth during MF. However, there is a concern that operating at higher temperatures could cause calcium phosphate precipitation that would lead to membrane fouling. Our objective was to determine the effect of operating a 0.1-µm ceramic uniform transmembrane pressure MF unit at temperatures of 50, 55, 60, and 65°C on membrane fouling and serum protein (SP) removal from skim milk with and without removal of low-molecular-weight soluble milk components by ultrafiltration (UF) before MF at a flux of 54kg/m(2) per hour. For each replicate, 1,000kg of pasteurized skim milk was split into 2 batches. One batch was ultrafiltered (with diafiltration) to remove an average of 89±2% of the lactose and a percentage of the soluble calcium and phosphorus. The retentate from UF was diluted back to the protein concentration of skim milk, creating the diluted UF retentate (DUR). On subsequent days, both the DUR and skim milk were run on the MF unit with the flux maintained at 54kg/m(2) per hour and a concentration factor of 3× and the system run in recycle mode. The temperature of MF was increased in 5°C steps from 50 to 65°C, with a 1-h stabilization period after each increase. During the run, transmembrane pressure was monitored and permeate and retentate samples were taken and analyzed to determine if any changes in SP, calcium, or phosphorus passage through the membrane occurred. Increasing temperature of MF from 50 to 65°C at a flux of 54kg/m(2) per hour did not produce a large increase in membrane fouling when using either skim milk or a DUR as the MF feed type as measured by changes in transmembrane pressure. Increasing the temperature to 65°C only caused a slight reduction in calcium concentration in the permeate (11±3%) that was similar between the 2MF feed types. Increasing processing temperature reduced the percentage of SP removal by the process, but the increased temperature also caused a decrease in casein contamination in the permeate with no evidence of membrane fouling.

Probiotic viability and physico-chemical and sensory properties of plain and stirred fruit yogurts made from goat's milk.

Probiotic plain and stirred fruit yogurts were made from goat's milk using bacterial cultures comprising, Lactobacillus acidophilus LA-5, Bifidobacterium animalis subsp. lactis BB-12 and Propionibacterium jensenii 702. The products were stored at 4°C for 4weeks, during which time the viability of the yogurt starter culture and probiotic bacteria was analysed weekly. P. jensenii 702 demonstrated the highest viability (10(8)cfu/g) in all types of yogurt throughout the storage period, while the viability of the bifidobacteria (∼10(7)cfu/g) also remained above the minimum therapeutic level. The viability of L. acidophilus LA-5 fell below 10(6)cfu/g in yogurts, however, the addition of fruit juice appeared to support the viability of lactobacilli, with higher microorganism numbers observed in fruit yogurts than in plain yogurt throughout the shelf life. Addition of fruit juice significantly increased the syneresis, and decreased viscosity and water holding capacity of yogurts (p<0.05), and also enhanced their sensory acceptability.

Effect of probiotic Propionibacterium jensenii 702 supplementation on layer chicken performance.

The effects of the probiotic, Propionibacterium jensenii 702 (PJ 702), supplementation on egg productivity, egg shell thickness, fatty acid profile of eggs, and body weight in early layer hens were investigated. Twenty eight twenty-week-old starter pullets were evenly divided into a treatment and a control group for an eight week experiment. Each bird in the treatment group received 107 cfu PJ 702 daily in a total volume of 1 ml by oral administration. No adverse effect was observed due to administration of PJ 702, and successful gastrointestinal transit in the bird was demonstrated by recovery of PJ 702 from faeces of the treatment group. Layer production was significantly improved by the supplementation of PJ 702. Total egg weight in the treatment group was significantly higher than the control (P<0.001). Average egg weight for the treatment group was 55.26 g, 4.2% higher than the control which averaged 53.02 g. Moreover, the fatty acid profile was significantly altered by the supplementation of PJ 702. Myristic acid (P<0.001), palmitoleic acid (P=0.001) and all-cis-11,14-eicosadienoic acid (P=0.02) were significantly lower in the treatment group compared to the control group. No difference in egg shell thickness was observed between the treatment and control group (P=0.23). In conclusion, the application of novel probiotic PJ 702 in the early layer hen is safe and effective to promote production and the quality of products in layer husbandry.

Lactobacilli and dairy propionibacterium with potential as biopreservatives against food fungi and yeast contamination.

Naturally fermented and raw foods contain a range of organisms that may have benefit as additives in some foods and food processing. In particular, potential anti-fungal properties of these organisms may be potentially utilised as natural alternatives to chemical additives used to delay and prevent spoilage by fungi and yeast. This study examined 12 novel bacteria previously isolated from food as possible biopreservatives. The bacteria from the lactobacilli and dairy propionibacterium groups were tested by agar overlay method for their ability to inhibit the growth of 10 fungi and one yeast commonly associated with food contamination. Eight among eleven tested lactic acid bacteria demonstrated broad spectrum of antifungal activity. Strong fungi inhibition was also demonstrated by the dairy propionibacterium, but efficacy was growth medium dependant. Only one fungi, Geotrichum candidum was highly resistant to the bacteria. Variation between the inhibition results for different bacteria identifies the importance of careful strain selection, and the benefits of strain combinations when selecting biopreservatives for foods.

Prophylactic role of maternal administration of probiotics in the prevention of irritable bowel syndrome.

Neonatal stress is a common early life event which alters the development of the endocrine and immune systems. Specifically, exposure to neonatal stress results in alterations to the hypothalamic-pituitary-adrenal (HPA) axis resulting in offspring who hyper-respond to stress in adulthood. Recently, this concept has been applied to the ontogeny of functional gastrointestinal (GI) disturbances such as irritable bowel syndrome (IBS). The high prevalence of this disorder and the ineffectiveness of current treatments results in high direct and indirect costs to the society. Recently, administration of probiotics to neonates has been used as a safe and cost-effective preventative strategy to revoke the long term unfavourable imprinting induced on the gastrointestinal system by early life stressors in animal models of human IBS. It is not as yet known however, whether maternal supplementary probiotics may also contribute to improved GI integrity and gut-associated immune functioning in stressed neonates, if these possible improvements persist into adulthood, or how this protective effect may be mediated. Our hypothesis is an attempt to link this proposed nutritional approach and its possible preventive effects against GI dysfunctions provoked by neonatal stress.

A comparative evaluation of the sensitivity of Salmonella detection on processed chicken carcasses using Australian and US methodologies.

AIM: To confirm the reliability and sensitivity of Salmonella testing of processed poultry in Australia. METHODS AND RESULTS: The detection of Salmonella in a whole carcass wash of 90 randomly selected processed broilers was compared using the Australian Standard method, an Australian industry method used by a major processor and the United States Department of Agriculture method published in the Federal Register. The sensitivity of each method was determined using a carcass wash containing a known number of Salmonella Typhimurium to determine the minimum concentration to be able to be identified as positive. The two Australian methods were found to be comparable with both the Australian methods detecting more positive carcasses than the United States Department of Agriculture (USDA) method. The Australian methods were sensitive at the level of 1-3 CFU ml(-1) and the USDA method was sensitive at 10-30 CFU ml(-1). CONCLUSIONS: The Australian Standard method and the Australian industry method were both able to detect Salmonella reliably even at a low level of contamination. SIGNIFICANCE AND IMPACT OF THE STUDY: This study gives a high level of confidence both to the operators of poultry-processing plants and to regulators dependent upon the outcome of Salmonella testing for process control in Australia.

First stage approximation of the exstrophic bladder in patients with cloacal exstrophy--should this be the initial surgical approach in all patients?

PURPOSE: Cloacal exstrophy is rare and it represents a reconstructive challenge. Options for managing the urinary tract include primary closure or approximation of the bladder halves in the midline with later closure. We present our observations and evolving thoughts concerning optimal treatment in these patients. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with cloacal exstrophy seen in the last 5 years. Initial management was examined, including complete primary closure vs a staged approach. We noted midline defects, spinal cord abnormalities or other anatomical reasons that precluded primary closure. RESULTS: Seven patients, including 5 females and 2 males, were identified. An omphalocele noted in all 7 patients was closed in 5 at initial operation. All underwent preservation of the hindgut in the fecal stream. Spinal cord tethering was noted in 7 of 7 cases. Complete primary bladder closure was performed in 3 of the 7 patients, while the size of the bladder plates or a large abdominal wall defect precluded closure in the remainder. Continence was not achieved in the 3 cases closed primarily. All patients achieving urinary continence underwent bladder neck closure and augmentation cystoplasty with a continent catheterizable channel. CONCLUSIONS: Patients with cloacal exstrophy have anatomical issues that can prevent complete primary bladder closure or preclude the achievement of urinary continence. The high incidence of tethered cord places these patients at risk for upper tract changes and bladder decompensation during followup. Despite successful primary closure in 3 of 7 patients all have a tiny bladder and require secondary procedures to become continent. Extensive dissection during the first operation can contribute to more difficult dissection with potential increased morbidity during subsequent surgeries. Therefore, the best initial approach for the typical patient may be closure of the abdominal wall and approximation of the exstrophied bladder halves in the midline. Secondary closure with continent diversion and reconstruction of the external genitalia can be performed at ages 18 to 24 months.

Continent catheterizable channels and the timing of their complications.

PURPOSE: We reviewed our experience with continent catheterizable channels with interest in the timing of conduit related complications. MATERIALS AND METHODS: A retrospective review was performed of the outcome of continent catheterizable channels in all patients between 1998 and 2003 who had undergone construction of an antegrade continence enema and/or a Mitrofanoff procedure using appendix, small bowel or continent cutaneous vesicostomy. We performed a total of 117 such stomas in 37 male and 41 female patients 2.5 to 20 years old (mean age 8.9). For the antegrade continence enema we used appendix in 92% of cases, an ileal Yang-Monti tube in 6% and a cecal tube in 2%. For the continent catheterizable channel we used appendix in 43% of cases, a Yang-Monti tube in 38% and continent cutaneous vesicostomy in 19%. RESULTS: Continence was achieved in 98% of patients. Followup was 6 to 71 months (mean 28.4). There were 27 channel related complications (23%). Stomal stenosis occurred in 7 antegrade continence enema procedures (14%) within 1 to 10 months (mean 6.2) and in 9 continent bladder channels (13%), including 5 continent cutaneous vesicostomies, within 1 to 24 months (mean 9.4) after surgery. False passages occurred in 5 antegrade continence enema procedures (10%) within 1 to 13 months (mean 3.6) and in 4 continent catheterizable channels (6%) within 1 to 13 months (mean 6.5) after surgery. Of patients with stomal stenosis 50% were treated with surgical revision, while the remainder was successfully treated with dilation. Most false passages were managed by catheter drainage alone. Reasons for revision were contained perforation, colovesical fistula and inability to catheterize. Patient noncompliance appeared to have a role in stomal stenosis. CONCLUSIONS: Continent catheterizable stomas help patients achieve bowel and bladder continence. Stomal incontinence after reconstruction is rare. In our experience most stoma related complications occurred in the first year after reconstruction. Experience with more patients and longer followup will help determine whether such problems continue to accumulate with time or whether continent stomas function well with time, particularly after the initial period of healing.

Management of the failed pyeloplasty: a contemporary review.

PURPOSE: We reviewed our experience with open dismembered pyeloplasty, with specific focus on the presentation and management of failed pyeloplasty in the pediatric population. MATERIALS AND METHODS: We performed a retrospective review of patients who had undergone open dismembered pyeloplasty between 1998 and 2003. All patients with less than 6 months of followup were excluded from analysis. The patients were followed postoperatively with serial ultrasounds, with renograms reserved for those patients with prolonged, persistent or worsening hydronephrosis, or recurrent symptoms during followup. RESULTS: A total of 105 pyeloplasties were performed in 103 patients (71 males and 32 females) 1 to 204 months old (mean 60), with an overall success rate of 93.3%. Followup ranged from 6 to 69 months (mean 23). The 7 patients with treatment failure were males 1 to 204 months old (mean 125), who presented most commonly with pain within 3 to 38 months (mean 13.1) after initial surgery. Subsequent ultrasound revealed worsening hydronephrosis, and renography in these patients showed a pattern consistent with obstruction. Five patients underwent initial balloon dilation, in which 1 was successful. In addition, 1 of these patients underwent an unsuccessful antegrade laser endopyelotomy. Six patients (86%) underwent open surgery, consisting of ureterocalicostomy in 3 and reoperative dismembered pyeloplasty in 3. Dense scarring was seen in all patients, 2 patients had a redundant pelvis causing kinking and 2 patients had unrecognized crossing vessels. Overall salvage rate was 100% with continued followup of 3 to 50 months (mean 18). CONCLUSIONS: Dismembered pyeloplasty was successful in the vast majority of patients. In our series failures occurred as late as 3 years postoperatively, although most presented within 12 months of followup. Excluding routine postoperative nuclear renography did not seem to affect our ability to identify these cases. Although anatomical features such as renal pelvic size may have a role, failure is most likely secondary to technical issues, including missed crossing vessels and dependency of the anastomosis. In this series failed pyeloplasties did not respond well to balloon dilation, likely due to scar formation. Our current practice is to manage failures by open surgery, although endoscopic management by an incision may be an option.

Signal analysis of total internal reflection fluorescent speckle microscopy (TIR-FSM) and wide-field epi-fluorescence FSM of the actin cytoskeleton and focal adhesions in living cells.

Fluorescent speckle microscopy (FSM) uses low levels of fluorescent proteins to create fluorescent speckles on cytoskeletal polymers in high-resolution fluorescence images of living cells. The dynamics of speckles over time encode subunit turnover and motion of the cytoskeletal polymers. We sought to improve on current FSM technology by first expanding it to study the dynamics of a non-polymeric macromolecular assembly, using focal adhesions as a test case, and second, to exploit for FSM the high contrast afforded by total internal reflection fluorescence microscopy (TIR-FM). Here, we first demonstrate that low levels of expression of a green fluorescent protein (GFP) conjugate of the focal adhesion protein, vinculin, results in clusters of fluorescent vinculin speckles on the ventral cell surface, which by immunofluorescence labelling of total vinculin correspond to sparse labelling of dense focal adhesion structures. This demonstrates that the FSM principle can be applied to study focal adhesions. We then use both GFP-vinculin expression and microinjected fluorescently labelled purified actin to compare quantitatively the speckle signal in FSM images of focal adhesions and the actin cytoskeleton in living cells by TIR-FM and wide-field epifluorescence microscopy. We use quantitative FSM image analysis software to define two new parameters for analysing FSM signal features that we can extract automatically: speckle modulation and speckle detectability. Our analysis shows that TIR-FSM affords major improvements in these parameters compared with wide-field epifluorescence FSM. Finally, we find that use of a crippled eukaryotic expression promoter for driving low-level GFP-fusion protein expression is a useful tool for FSM imaging. When used in time-lapse mode, TIR-FSM of actin and GFP-conjugated focal adhesion proteins will allow quantification of molecular dynamics within interesting macromolecular assemblies at the ventral surface of living cells.

An in vitro model for investigating intestinal adhesion of potential dairy propionibacteria probiotic strains using cell line C2BBe1.

AIMS: The purposes of this study were to screen the adhesion properties of dairy propionibacteria strains and evaluate whether C2BBe1 could be used in the screening of potential probiotic strains. METHODS AND RESULTS: Thirteen dairy propionibacteria strains and two control strains, Lactobacillus acidophilus MJLA1 and Bifidobacterium lactis BDBB2, were tested for adhesion to C2BBe1. Electron microscopic observations demonstrated that the control strains, L. acidophilus MJLA1 and B. lactis BDBB2, had similar adhesive ability to C2BBe1 as had been previously shown to Caco-2. Only one of the 13 strains of dairy propionibacteria, strain P. jensenii 702, demonstrated adhesion to C2BBe1. CONCLUSIONS: C2BBe1 can provide an alternative to Caco-2 for assessing in vitro adhesion properties of probiotic strains. Adhesion properties of dairy propionibacteria were strain-dependent. SIGNIFICANCE AND IMPACT OF THE STUDY: C2BBe1 is highly suitable for application in bacterial adhesion studies, and was used successfully to select a new potential probiotic.

Is postoperative cystography necessary after ureteral reimplantation?

OBJECTIVES: To evaluate the patients in our practice to determine whether postoperative cystography was useful in monitoring the outcome after ureteroneocystostomy. Surgical repair of vesicoureteral reflux is the treatment of choice after medical therapy failure. Radiographic evaluation by ultrasonography or voiding cystourethrography (VCUG) is commonly used postoperatively to evaluate for urinary tract obstruction or persistent reflux. However, imaging modalities are not without cost, both in monetary terms and in terms of radiation exposure and trauma to the child. METHODS: We reviewed the records of all patients who underwent ureteroneocystostomy without ureteral tapering at our institution between January 1, 1996 and December 31, 1999 for primary vesicoureteral reflux. These records were evaluated with respect to the type of surgical procedure, preoperative and postoperative clinical course, and radiographic studies performed. RESULTS: We performed reimplantation on 267 renal units in 153 patients. The surgical technique was the Cohen cross-trigonal in 120 renal units (45%), Glenn-Anderson ureteral advancement in 92 (35%), and modified Leadbetter-Politano ureteral advancement in 55 (20%). All patients underwent imaging with ultrasonography within 6 weeks of surgery. The follow-up ranged from 4 to 42 months (average 14.2). Between 3 and 8 months postoperatively, 61 patients underwent imaging with VCUG. We identified persistent reflux in six renal units. Four of six had marked improvement in their reflux. All the patients with persistent reflux were asymptomatic, including 2 patients who were no longer receiving antibiotics. Four patients developed febrile urinary tract infections postoperatively. Three of the four underwent imaging with VCUG after treatment; all three had no evidence of reflux. CONCLUSIONS: In our population, the addition of VCUG to the postoperative evaluation did not allow us to identify those patients at risk of febrile urinary tract infections. Patients in whom persistent reflux was identified were all asymptomatic. We continue to monitor patients with ultrasonography, but believe that VCUG often provides little benefit to these children.

Early evolution of bladder emptying after myelomeningocele closure.

OBJECTIVES: To analyze bladder emptying in newborns with spina bifida after closure of the myelomeningocele defect. Manipulation of the spinal cord and nerve roots results in temporary changes in bladder function in many settings. METHODS: We reviewed 62 consecutive newborn patients who underwent closure of a myelomeningocele defect at our institution from January 1990 to December 1997. We examined the catheterized urine volumes obtained before and after closure, radiographic and urodynamic studies, and the subsequent need for intermittent catheterization. Poor bladder emptying was defined as most catheterized urine volumes greater than 10 mL (20% of expected bladder capacity). Adequate follow-up was available for 54 patients for a period of 4 to 96 months (mean 42). One patient with posterior urethral valves was excluded from the study, leaving 53 for evaluation. RESULTS: Of the 53 patients, 4 with high outflow resistance and dyssynergy never emptied the bladder adequately before or after closure. Of the remaining 49 patients, 6 (12%) emptied well immediately after the myelomeningocele repair. In the other 43 (88%), the bladder did not empty as well after closure. The mean volume obtained with catheterization after closure was 20 mL, significantly higher (P <0.001) than the mean volume obtained before repair (6.5 mL) or after resumption of better spontaneous emptying (4 mL). Intermittent catheterization done for poor emptying was required for an average duration of 11 days (range 2 to 42). Of the 43 patients with poor emptying immediately after closure, 32 (74%) required catheterization for 2 weeks or less; the remaining 11 (26%) required catheterization for 2 to 6 weeks. Despite the relatively early resumption of good emptying, numerous patients (19 of 49) required additional intervention (clean intermittent catheterization or vesicostomy) before attempts to toilet train. CONCLUSIONS: A clinical pattern similar to spinal shock does occur in most newborns after closure of a myelomeningocele defect. Resumption of near-complete emptying usually occurs less than 2 weeks after repair but may require up to 6 weeks.

Angiotensin type II receptor expression and ureteral budding.

PURPOSE: Deletion of the angiotensin type II receptor gene (Agtr2) in mice results in a spectrum of urinary tract anomalies similar to that in humans. The mechanism behind this anomalous development is poorly understood. We evaluated Agtr2 expression as it relates to normal and abnormal ureteral budding. MATERIALS AND METHODS: A total of 400 wild type mice were inspected at birth for gross evidence of a urinary tract anomaly. In addition, the urinary tracts of 30 wild type embryos were evaluated at 11.0/11.5 and 13.5 weeks of gestation. These embryos were examined for ureteral budding site via section and whole mount in situ hybridization with c-ret probe and Agtr2 expression via in situ hybridization with Agtr2 riboprobe. There were 740 newborn mice homozygous for the null mutation of Agtr2 also evaluated along with 55 angiotensin type II knockout embryos at the aforementioned gestational ages. RESULTS: All wild type newborn animals were grossly normal. Of the angiotensin type II knockout newborns 23 (3.1%) had gross abnormalities of the urinary tract at birth. The predominant finding was a duplicated collecting system associated with a hydronephrotic upper pole moiety. These duplicated collecting systems fulfilled the Meyer-Weigert law. Interestingly, 25 (59.5%) of the knockout embryos showed abnormal ureteral budding. However, in wild type embryos Agtr2 was expressed at this "ectopic" cranial site between the wolffian duct and metanephric mesenchyme. CONCLUSIONS: Although not the sole regulator, angiotensin type II receptor expression may have a role in the embryological development of the urinary tract by inhibiting aberrant ureteral budding. A defect in this inhibitory process appears to cause ectopic ureteral budding, and may subsequently lead to renal dysplasia and other congenital anomalies of the kidney and urinary tract.

Small intestinal submucosa as a urethral coverage layer.

PURPOSE: Urethrocutaneous fistula is the most common complication of hypospadias surgery. Numerous techniques have been used to decrease the incidence of this complication and the use of biocompatible materials in surgery has expanded the options in difficult situations. We hypothesized that porcine small intestinal submucosa may be used as a coverage layer after urethral surgery. We evaluated the histological changes associated with small intestinal submucosa when used as a coverage layer over the urethra in a rabbit model. METHODS AND METHODS: We performed urethral surgery in 16 New Zealand White rabbits divided into 4 animals each in groups 1-sham operation with penile degloving only, 2-penile degloving and small intestinal submucosa patch placement, 3-urethrotomy without a patch and 4-urethrotomy with a small intestinal submucosa patch. The graft edges were marked with permanent suture at surgery for later identification. All rabbits were maintained for 6 weeks before sacrifice. The urethra of each animal was then serially sectioned and examined histologically. RESULTS: Histological examination of animals with an small intestinal submucosa patch revealed a foreign body tissue reaction with an infiltrate of histiocytes, giant cells and lymphocytes in the area of graft placement. There was no histological evidence of remaining small intestinal submucosa patch in any sections. The urethral mucosa healed normally in all cases in which it was disrupted. There was no evidence of acute or chronic inflammation in any group 1 or 2 nonsmall intestinal submucosa animals and none in the animals with a small intestinal submucosa graft in areas other than the former graft site. There were also no urethrocutaneous fistulas in any of the 8 rabbits that underwent urethrotomy. CONCLUSIONS: Small intestine submucosa provides an adequate coverage layer in the rabbit penis after urethrotomy. Histologically the foreign material did not alter normal healing of the urethral mucosa, although it did appear to cause an infiltration of histiocytes, giant cells and lymphocytes. Small intestinal submucosa has previously been studied as a scaffold on which tissue may be remodeled or may regenerate. Our study shows that small intestinal submucosa did not interfere with normal tissue healing in this animal model. When used as a urethral coverage layer, it appears to provide extra tissue between the urethra and skin. Small intestinal submucosa may potentially decrease the incidence of urethrocutaneous fistula after urethral surgery.

Determination of the efficacy of preservation of non-eye area water-miscible cosmetic and toiletry formulations: collaborative study.

A collaborative study was conducted to test a method developed to distinguish between adequately and inadequately preserved cosmetic formulations. Nineteen laboratories participated in the study. Samples tested included shampoos, hair conditioners, oil-in-water emulsions, and water-in-oil-emulsions. Triplicate samples of 4 adequately preserved and 4 inadequately preserved cosmetic products were tested by each collaborative laboratory. Results showed that all inadequately preserved shampoo and conditioner samples failed to meet the acceptance criteria for adequately preserved formulations. Of the 51 preserved samples, 49 shampoos and 48 conditioners met the criteria for adequate preservation. All samples of inadequately preserved water-in-oil emulsions and oil-in-water emulsions failed to meet the acceptance criteria, whereas all adequately preserved emulsion formulations met the acceptance criteria.