Mixed reality for teaching catheter placement to medical students: a randomized single-blinded, prospective trial.

BACKGROUND: Cost-effective methods to facilitate practical medical education are in high demand and the "mixed-reality" (MR) technology seems suitable to provide students with instructions when learning a new practical task. To evaluate a step-by-step mixed reality (MR) guidance system for instructing a practical medical procedure, we conducted a randomized, single-blinded prospective trial on medical students learning bladder catheter placement. METHODS: We enrolled 164 medical students. Students were randomized into 2 groups and received instructions on how to perform bladder catheter placement on a male catheterization training model. One group (107 students) were given their instructions by an instructor, while the other group (57 students) were instructed via an MR guidance system using a Microsoft HoloLens. Both groups did hands on training. A standardized questionnaire covering previous knowledge, interest in modern technologies and a self-evaluation was filled out. In addition, students were asked to evaluate the system's usability. We assessed both groups's learning outcome via a standardized OSCE (objective structured clinical examination). RESULTS: Our evaluation of the learning outcome revealed an average point value of 19.96 ± 2,42 for the control group and 21.49 ± 2.27 for the MR group - the MR group's result was significantly better (p = 0.00). The self-evaluations revealed no difference between groups, however, the control group gave higher ratings when evaluating the quality of instructions. The MR system's assessment showed less usability, with a cumulative SUS (system usability scale) score of 56.6 (lower half) as well as a cumulative score of 24.2 ± 7.3 (n = 52) out of 100 in the NASA task load index. CONCLUSIONS: MR is a promising tool for instructing practical skills, and has the potential to enable superior learning outcomes. Advances in MR technology are necessary to improve the usability of current systems. TRIAL REGISTRATION: German Clinical Trial Register ID: DRKS00013186.

Adipose-Derived Stem Cells Support Lymphangiogenic Parameters In Vitro.

It is a common complication to develop a secondary lymphedema after surgery or radiation, for example, after axillary lymph node dissection due to breast cancer and current therapies are mainly symptomatic. Since these surgical procedures result in both, loss of adipose tissue and loss of lymphatic nodes and vessels, tissue engineering could be a new promising approach, to create an adipose tissue substitute comprised with a lymphatic network. We have conducted co-culture experiments to investigate the effects of human adipose-derived stem cells (ASCs) on human lymphatic endothelial cells (LECs) in terms of gene expression profile, proliferation, migration, and tube formation in vitro. In this respect, both cell types were co-cultured either indirectly or directly with or without the recombinant growth factor VEGF-C. Indirect co-cultures were performed with the aid of a transwell chamber. In case of direct co-culture, immunomagnetic separation by CD31 magnetic beads allowed examination of the LEC population. Direct and indirect co-culture of ASCs induced mRNA expression of lymphatic marker genes, proliferation, and migration by LECs without affecting tube formation. Thus, we have shown that co-culture of ASCs with LECs might be a feasible approach that could be used in cell-based tissue engineering therapies to heal or improve a secondary lymphedema. J. Cell. Biochem. 117: 2620-2629, 2016. © 2016 Wiley Periodicals, Inc.

Ureteric avulsion caused by lumbar exostosis.

A 72-year-old woman sustained a ureteric avulsion following circulatory collapse at home. Urosonographic imaging revealed hydronephrosis at the left kidney, and abdominal emergency computed tomography showed some fluid around it. Left retrograde pyelography proved ureteral disruption at the level of the ureteropelvic junction (UPJ). Immediate open surgery was performed to restore ureteropelvic continuity. Correct and early diagnosis of UPJ transsection is difficult under emergency service conditions and lack of symptoms. With the rapid increase in the aging population, the presence of degenerative exostoses will increase, and its exclusive pathomechanism and pattern of injury might be seen more frequently in emergency care. Trauma specialists should be aware of this pathology.

Complete removal of the foreskin--why?

Partial circumcision techniques frequently lead, on account of the remaining foreskin, to functional complications and unsatisfactory cosmetic results requiring re-operation. A series of pictures taken from our own sample of patients illustrates the problem. Review of the literature also attests to higher complication rates after partial circumcision. From a medical point of view, complete circumcision is preferable.

Sonographic long-term study: paediatric growth charts for single kidneys.

AIMS: To explore the clinical course of children with "single kidney" (defined as either a solitary or single functioning kidney) with reference to renal function (glomerular filtration rate (GFR) and proteinuria), body height and particularly sonomorphological features. PATIENTS AND METHODS: This retrospective monocentric study evaluated 119 children with a solitary or single functioning kidney (>90% unilateral function on isotope scan) between 1997 and 2007. Patients were followed for 6.3 years (median, range 1-17) and had at least three renal ultrasound examinations (median 8). During recruitment six children were identified with chronic kidney disease (CKD) stage III or worse. These patients were analysed separately. RESULTS: The aetiology of "single kidney" was attributed to contralateral multicystic dysplastic kidney (26%), tumournephrectomy (24%), renal agenesis (18%), hypo/dysplasia (11%) and obstructive or refluxive uropathy (18%). Irrespective of aetiology, the sonographic dimensions of "single kidneys" were in the upper range of normal paired kidneys and showed adequate growth. Compensatory renal hypertrophy (defined as >95% CI on two or more recent measurements) occurred in a third of patients. All six patients with CKD and GFR less than 60 ml/minute per 1.73 m(2) had pathological sonomorphology of their "single kidney" with inadequate renal growth (6/6), abnormal echogenicity (5/6), hypo/dysplasia (5/6). In addition, proteinuria (5/6) and short stature (3/6) were found. CONCLUSIONS: New reference centiles were generated to assess renal size of "single kidneys" in paediatric patients. These charts will facilitate counselling of patients and parents. Further evidence for a benign clinical course of children with "single kidney" and absent additional pathology of the remnant kidney is presented.

[Polyhydramnios, prematurity, dystrophy, polyuria, constipation, nephrocalcinosis and renal tumor: presentation of a classic tubulopathy]. / Polyhydramnion, Frühgeburtlichkeit, Dystrophie, Polyurie, Obstipation, Nephrokalzinose und renale Raumforderung: Präsentation einer klassischen Tubulopathie.

BACKGROUND: A diagnostic workup of a renal mass will rarely lead to the diagnosis of a tubulopathy. We would like to stress the importance of taking a detailed history and of evaluating these findings in the context of the clinical symptoms. CASE REPORT: A 3 year old boy with a renal mass, diagnosed due to urinary tract infection, was referred to exclude renal malignancy. Detailed history revealed polyuria and polydipsia in a child with preterm delivery due to polyhydramnios. These symptoms, together with poor thriving are highly suggestive of a neonatal form of Bartter syndrome. This diagnosis was substantiated by ultrasound findings of nephrocalcinosis and urolithiasis due to hypercalciuria and a renal abscess. Detection of mutations in the KCNJ1-gene confirmed the diagnosis. After unilateral nephrectomy for acute destructive nephritis and under medication with indomethacin and potassium citrate the patient is now thriving well. CONCLUSION: Renal masses suspicious of malignancy may distract from a hereditary tubulopathy. Typical clinical history and presentation with prematurity, polyhydramnios, polyuria, poor thriving and urolithiasis requires diagnostic evaluation of tubular function since routine laboratory tests and urinary dip stick may be normal. Unrecognized, neonatal Bartter syndrome may lead to severe complications including loss of kidney function.

[Left flank tumor of fluctuating size in a 5-week-old boy: perirenal urinoma caused by urethral valves]. / Perirenales Urinom durch Urethralklappen bei einem Säugling mit fluktuierender Flankenschwellung.

BACKGROUND: Flank swelling and pseudotumors of the kidney are unusual manifestations of obstructive uropathies in small children. Our case illustrates typical problems and briefly reviews management options. CASE REPORT: A 5-week-old boy presented with a large, palpable urinoma due to posterior urethral valves. Sonography and voiding cystourethrogram led to the diagnosis and immediate suprapubic transcutaneous urinary diversion was performed. However, the urinoma did not resolve. Thus, in addition to suprapubic urinary diversion, indirect drainage - instead of percutaneous puncture - was performed by retrograde insertion of a double-J catheter. Urethral valves were resected 4 weeks later and follow-up demonstrated an uneventful further development with normal renal function as assessed by regular ultrasound studies, a repeat cystourethrogram and a renal scan. CONCLUSION: Perirenal urinomas may be the first symptom in patients with posterior urethral valves. Drainage via double-J stenting offers a promising alternative to percutaneous puncture. A renoprotective "pop-off" mechanism by which intrarenal pressure may be relieved is discussed.

Intraoral wound closure with tissue-engineered mucosa: new perspectives for urethra reconstruction with buccal mucosa grafts.

In urethra reconstruction, the creation of a new urethra from a free oral mucosa graft is an established surgical technique. The oral mucosa is removed at the same time that the urethra reconstruction procedure is performed. Depending on the size of graft required, the intraoral wound is closed primarily or left to heal secondarily. The latter method limits this technique by leading to scars or strictures, which have a negative impact on the condition of the intraoral soft tissue. Therefore, in this study, a pilot study involving 12 patients, tissue-engineered mucosa was tested for covering intraoral defects to avoid the drawbacks mentioned above. For mucosa tissue-graft engineering, a biopsy sample 2 to 4 mm in diameter was removed from the hard palate approximately 4 weeks before the urethra reconstruction procedure was to be performed. In addition, 30 ml of autogenous serum was extracted from a venous whole-blood sample. The primary cultures were incubated in Dulbecco modified Eagle's medium and nutrient factor F 12 (Gibco Co., Eggenstein, Germany), containing the usual additives and autogenous serum. After a period of 3 weeks, subcultivation was performed to engineer mucosa transplants consisting of several layers of keratinocytes on a support foil. After thorough intraoperative blood coagulation had occurred, the cultured mucosa graft on the carrier foil was applied on the wound surface and fixed by single sutures. Additionally, the cultured mucosa graft was covered for 8 to 10 days by an intraoral dressing, which was also fixed onto the wound surface by single suture loops. It is possible to perform primary intraoral wound closure with tissue-engineered mucosa to cover defect sizes as large as 11.0 x 4.0 cm. This new method provides a better prospect for both urethra reconstruction and the reconstruction of intraoral tissue defects. The number and size of intraoral scars and strictures are diminished. This is of special interest for the reconstruction of the functional unit oral cavity, including soft tissue and cosmetic conditions (e.g., in case of prosthetic rehabilitation). In comparison to primary wound closure with local tissue, the technique presented in this study reduces the severity of postoperative pain and allows faster rehabilitation in patients because of a better wound-healing process. Furthermore, better mobility of intraoral soft tissue structures is achieved.

Fetotoxicity and teratogenesis of SWL treatment in the rabbit.

The potential effects of extracorporeal application of shockwaves on an embryo or fetus were explored in an animal model. In experimental Series A, the fetuses of 30 gravid rabbits were exposed to piezoelectrically induced and sonographically guided shockwaves on Day 25 or 20 of gestation under technical conditions corresponding to extracorporeal lithotripsy in humans. Fetotoxicity was examined by abdominal section 24 hours or 9 days later, and immediate/intermediate damage was assessed (resorptions, viability, gross injuries, and microscopic lesions of the target and neighboring fetuses). In series B, the kidneys of an additional 28 gravid rabbits (including a control group) were exposed to the same shockwave treatment on Day 11 of gestation in order to investigate indirect embryotoxic effects, including teratogenic potency. One day before the expected birth, the maternal kidneys, uteri, and adjacent organs were examined for lesions, and the 156 offspring were assessed for embryolethal, embryonoxious, or teratogenic sequelae. Shockwave targeting of the cranium, thorax, abdomen, or placenta was usually lethal to the fetuses. When the uterine wall or the space between two fetuses was targeted, the fetuses suffered from superficial hematoma, as was found in the surrounding soft tissues within a radius of 1.5 cm. Fetuses outside this region were vital and free of lesions. Shockwave treatment of the maternal kidney resulted in renal petechial hemorrhage or subcapsular hematoma. However, statistically significant embryotoxic or teratogenetic effects could be demonstrated neither from maternal data (resorptions) nor from fetal findings (body measurements, vitality test, inner organs, skeletal deformities). When using a piezoelectric lithotripter with a small focus of high energy, lesions of a fetus are to be expected only when it is located in or close to the focus. It seems that embryotoxic or teratogenic sequelae do not occur when shockwaves are focused outside the uterus. Nonetheless, this preliminary research does not justify clinical use of extracorporeal shockwave lithotripsy in pregnant humans.

Endoscopic treatment of reflux by subureteric collagen injection: critical review of 5 years' experience.

In the past decade, subureteric endoscopic injection of Teflon or collagen has been propagated as a safe and successful treatment for vesicoureteral reflux. In our center, from 1990 through 1995, 118 children and 5 adults with reflux and recurrent urinary tract infections were injected with cross-linked bovine collagen in an open, prospective study. Efficacy and safety were assessed 6 and 12 months after injection, and long-term (> or =3 years) results were available in 78 cases. The overall success rate was 58% (64% of ureteral units) free from reflux at 12 months and 54% (58%) after 3 years. Analysis of anatomic, urodynamic, and technical features showed the grade of reflux to be the best predictor of success or failure. When only primary low- and middle-grade reflux, without concomitant anatomic disorders, is considered, the long-term success rate rose to 69% (74% of ureteral units). In conclusion, subureteric collagen injection cannot ultimately replace the highly effective surgical reimplantation. However, the procedure offers a minimally invasive alternative in selected cases of mild reflux when conservative management is inadequate.

Once-daily fleroxacin versus twice-daily ciprofloxacin in the treatment of complicated urinary tract infections.

PURPOSE: We compared the efficacy and safety of once-daily fleroxacin and twice-daily ciprofloxacin in patients with complicated urinary tract infections. MATERIALS AND METHODS: Using a prospective, open, randomized, multicenter study design, 133 patients (67 fleroxacin, 66 ciprofloxacin) were treated with doses of either 200 mg. of fleroxacin once daily or 250 mg. of ciprofloxacin twice daily in phase 1. In phase 2, 211 patients (103 fleroxacin, 108 ciprofloxacin) received 400 mg. of fleroxacin once daily or 500 mg. of ciprofloxacin twice a day. RESULTS: In phase 1, bacteriological efficacy was excellent only against sensitive pathogens, such as Escherichia coli (84% with fleroxacin, 88% with ciprofloxacin), but high failure rates were observed in infections caused by Pseudomonas species (56% with fleroxacin, 67% with ciprofloxacin) and gram-positive organisms (52% with fleroxacin, 67% with ciprofloxacin). In phase 2, bacteriological overall success rate was 88% in the fleroxacin group and 84% in the ciprofloxacin group. Clinical overall success was observed in more than 90% of patients in both groups (94% with fleroxacin, 93% with ciprofloxacin). No statistically significant differences between the drugs were observed in efficacy during phase 2, including a 4 to-6-week followup. Tolerance was also similar for fleroxacin and ciprofloxacin, with about 20% of patients reporting adverse events. CONCLUSIONS: The results suggest that both fleroxacin and ciprofloxacin are safe and effective for the treatment of complicated urinary tract infections at the higher doses used in phase 2, with fleroxacin offering the advantage of a once-daily dosing regimen. Lower doses of fleroxacin (200 mg. once daily) should only be used to treat urinary tract infections caused by gram-negative organisms with minimum inhibiting concentrations of less than 0.5 mg./l.

Ureteral xanthine calculus and aberrant umbilical artery causing ureteral obstruction.

A 30-month-old girl presented with gastrointestinal symptoms and a febrile urinary tract infection. Sonographic and radiographic imaging demonstrated left hydronephrosis due to a radiolucent ureteral stone. Surgical exploration identified an aberrant, patent left umbilical artery causing ureteral obstruction. Stone and urine analyses revealed hereditary xanthinuria that had not previously been recognized in this child and her family.

Subureteral collagen injection versus antireflux surgery in primary vesico-ureteral reflux grade III.

UNLABELLED: Endoscopic subureteral collagen injection (SCIN) was performed in 24 girls and 5 boys (mean/range: 3.2/0.7-12.2 years) with primary grade III vesicoureteral reflux. Clinical outcome was compared to 20 girls and 6 boys treated by antireflux surgery (mean/range: 3.0/0.2-9.4 years). forty-one ureters were treated by endoscopy, 37 by surgery. Patients were followed for 12 months. SCIN was not associated with severe persistent complications. No reflux was detected immediately after SCIN. After 6 months recurrent grade II reflux was present in 1 (4%) surgically treated patient and in 12/29 (41%) patients treated by collagen injection. This corresponded to a recurrence rate of 1/37 (3%) of ureters following surgery and 15/41 (37%) following SCIN. 8/15 refluxing ureters after collagen showed decreased reflux grade (two grade I, six grade II). After 12 months 24/26 (92%) patients with antireflux surgery remained free of urinary tract infections as compared to 25/29 (86%) children following endoscopy. Following SCIN, 4/29 (14%) patients required secondary antireflux surgery because of recurrent urinary tract infections. CONCLUSION: On the basis of this study endoscopic SCIN appears to be safe in children. It is less effective than surgery with regard to elimination of primary grade II reflux. However, clinical success rate is comparable to surgery with regard to the frequency of recurrent urinary tract infections after the procedure. This may be due to the reduction of refluxing urine volume in those patients who showed recurrence of reflux after collagen injection.

Salmonella enteritidis orchitis in a 10-week-old boy.

Extraintestinal manifestations of salmonellosis in paediatric patients are found predominantly in infants less than three months of age. Genital involvement is a rare complication. We present a short review of the literature and describe the case of a 10-week-old boy suffering from severe diarrhoea, who presented with a swelling of the right testicle after six days of illness. He underwent surgery on suspicion of testicular torsion, whereby orchitis was diagnosed. Salmonella enteritidis was cultured from the intraoperative swab. All cultures from blood, CSF and urine remained sterile. We conclude that orchitis must be taken into consideration as an extraintestinal complication of enteric salmonellosis and as a differential diagnosis of testicular torsion. In addition, we wish to emphasize that any infant less than three months of age with suspected or proven salmonellosis, should receive early antibiotic treatment.

Correlation of ultrasound and renal scintigraphy in children with unilateral hydronephrosis in primary workup.

Ultrasound accurately detects hydronephrosis in infants and children, while nuclear medicine techniques quantify relative renal function in addition to characterizing the urodynamic relevance of hydronephrosis. This prospective study was undertaken to examine the relationship between ultrasound morphological findings and relative renal function, quantified with dynamic 99mtechnetium mercaptotriacetylglycine imaging, in the initial diagnostic workup of children with unilateral hydronephrosis. The ultrasound grade of hydronephrosis and relative renal function ipsilateral to the hydronephrosis were inversely related, indicating that with more severe hydronephrosis ultrasound fails to estimate the potential reduction of relative kidney function. Because renal function is not necessarily affected by hydronephrosis, renal scintigraphy is indicated to assess the functional status of hydronephrotic kidneys.