Diagnosis and management of ureteral fibroepithelial polyps in children: a new treatment algorithm.

INTRODUCTION: Fibroepithelial polyps are benign mesenchymal tumors arising from the urinary tract. With the advent of endoscopy in the pediatric population, more reports of endoscopic diagnosis and treatment have appeared. OBJECTIVE: The present study reports experience with the diagnosis and treatment of fibroepithelial polyps of the upper urinary tract in the pediatric population. Incorporating past experience from literature, we propose an algorithm to guide the clinical diagnosis and treatment plan. STUDY DESIGN: Four pediatric patients undergoing pyeloplasty for ureteropelvic junction (UPJ) obstruction were diagnosed with ureteral polyps. Their demographics, radiologic, surgical and pathologic information were reviewed. In addition, a comprehensive literature search using the MEDLINE database yielded 37 reports containing 126 cases of ureteral polyps, including 5 series with 57 cases and 9 cases of synchronous bilateral ureteral polyps. RESULTS: Of 123 pediatric patients undergoing pyeloplasty from 2008 to 2013, four (3.3%) were found to have fibroepithelial polyps of the upper urinary tract. All patients were male and the mean age of presentation was 12 years. Ureteral polyps predominantly occurred unilaterally in the left ureter (75%) and one case of bilateral ureteral polyps was encountered. Along with three other recent case series [1-3], the combined incidence of ureteral polyps in patients undergoing evaluation for ureteral obstruction was 5.2%. Intraoperative retrograde pyelogram was used to identify filling defects in 4 of 5 affected ureters (see Figure). Ureterorenoscopy was performed in all three patients with filling defects for polyp mapping along the ureter and evaluation of the macroscopic polyp appearance. Based on ureteroscopic findings, Holmium laser polypectomy was performed in two patients with single, pedunculated polyps. Anderson-Hynes dismembered pyeloplasty was performed in three patients with broad based, multilobulated polyps too large for endoscopic treatment and in one patient for undiagnosed polyp prior to pyeloplasty. DISCUSSION: The present study finds that the 5.2% combined incidence of ureteral polyps in contemporary reports may be higher than previously described [4]. Retrograde pyelogram was an effective tool in diagnosing ureteral polyp and ureteroscopy can be employed if ureteral polyps are suspected for both diagnostic and therapeutic purposes. Although clinical experience is limited, endoscopic laser treatment seems to be effective for the single, pedunculated ureteral polyps, while dismembered pyeloplasty is required for the broad based, multilobulated polyps. The study was limited by the rarity of ureteral polyps. Future multi-institutional collaborative studies are required to validate the diagnostic and treatment algorithm proposed. CONCLUSION: Ureteral polyps cause approximately 5% of UPJ obstruction in the pediatric population. Diagnosis can be made in certain cases by intraoperative retrograde pyelogram. If a filling defect is encountered, ureteroscopy is indicated for polyp mapping. The treatment modality is dictated by the endoscopic appearance of the ureteral polyp.

It's not just what you say: relationships of HIV dislosure and risk reduction among MSM in the post-HAART era.

In the post-HAART era, critical questions arise as to what factors affect disclosure decisions and how these decisions are associated with factors such as high-risk behaviors and partner variables. We interviewed 1,828 HIV-positive men who have sex with men (MSM), of whom 46% disclosed to all partners. Among men with casual partners, 41.8% disclosed to all of these partners and 21.5% to none. Disclosure was associated with relationship type, perceived partner HIV status and sexual behaviors. Overall, 36.5% of respondents had unprotected anal sex (UAS) with partners of negative/unknown HIV status. Of those with only casual partners, 80.4% had >1 act of UAS and 58% of these did not disclose to all partners. This 58% were more likely to self-identify as gay (versus bisexual), be aware of their status for <5 years and have more partners. Being on HAART, viral load and number of symptoms were not associated with disclosure. This study - the largest conducted to date of disclosure among MSM and one of the few conducted post-HAART - indicates that almost 1/5th reported UAS with casual partners without disclosure, highlighting a public health challenge. Disclosure needs to be addressed in the context of relationship type, partner status and broader risk-reduction strategies.

Self-monitoring of behaviour as a risk reduction strategy for persons living with HIV.

To reduce the HIV-related transmission behaviours of persons living with HIV (PLH), a few efficacious interventions have been designed and evaluated. However, these interventions were delivered at relatively high cost, both in terms of time and resources. Given the challenges for health providers and community agencies in delivering these interventions, alternatives are needed. One possible intervention is allowing PLH to self-monitor their HIV transmission risk behaviour. Previous research suggests that self-monitoring of HIV-risk related behaviours may be a useful risk reduction strategy. This paper examines the impact of repeated risk assessments for behavioural self-monitoring as an intervention strategy for reducing sexual and substance use risk behaviours. A total of 365 PLH, recruited from community clinics, health management organizations, and health departments, completed self-assessments over time. Increased self-monitoring resulted in increases in protected sex with sexual partners of HIV-negative or unknown serostatus, and changes in attitudes conducive to reducing risk. Self-monitoring is a relatively low cost and easily implementable strategy for reducing the HIV-related transmission risk of PLH.

Intricacies and inter-relationships between HIV disclosure and HAART: a qualitative study.

This study aimed to understand whether and how highly active antiretroviral treatment (HAART) affects views and patterns of disclosure and how disclosure interacts with treatment decisions. One hundred and fifty-two HIV-positive adults (52 MSM, 56 women and 44 IDU men) from four US cities participated in two to three-hour, semi-structured interviews in 1998-99. Results indicate that HAART interacts with and shapes HIV disclosure issues in several ways. Medications may 'out' people living with HIV. Thus, in different settings (e.g. work, prisons, drug rehabs and public situations), some try to hide medications or modify dosing schedules, which can contribute to non-adherence, and affect sexual behaviours. Disclosure of HIV and/or HAART may also result in antagonism from others who hold negative attitudes and beliefs about HAART, potentially impeding adherence. Observable side effects of medications can also 'out' individuals. Conversely, medications may improve appearance, delaying or impeding disclosure. Some wait until they are on HAART and look 'well' before disclosing; some who look healthy as a result of medication deny being HIV-positive. Alternatively, HIV disclosure can lead to support that facilitates initiation of, and adherence to, treatment. HIV disclosure and adherence can shape one another in critical ways. Yet these interactions have been under-studied and need to be further examined. Interventions and studies concerning each of these domains have generally been separate, but need to be integrated, and the importance of relationships between these two areas needs to be recognized.

A quantitative study of adipokinetic hormone of the firebug, Pyrrhocoris apterus.

The development of an enzyme-linked immunoassay (ELISA) for the adipokinetic neuropeptide hormone, Pya-AKH, from the firebug Pyrrhocoris apterus L. is described. The ELISA measures as little as 20 fmol of Pya-AKH. Tested against a range of synthetic peptides, the assay has a high sensitivity for peptides containing the C-terminal motif FTPNWamide. The amounts of Pya-AKH in the brain, corpora cardiaca, suboesophageal ganglia, and fused thoracic and abdominal ganglionic mass are very small, with only the corpora cardiaca containing appreciable levels of the hormone (ca. 4 pmol per bug). Preliminary estimates of the persistence of the hormone in the haemolymph are consistent with values determined for AKHs in other insects, and suggest that Pya-AKH has a rapid turnover with a half-life of ca. 18 min. Measurements of circulating titres of AKH in Pyrrhocoris are only possible in the ELISA described here by using pooled samples of haemolymph, and after preliminary clean-up of the haemolymph samples. The titre of Pya-AKH in resting reproductive female Pyrrhocoris is ca. 1 fmol/&mgr;l.

The Rumel technique for lateral thoracotomy closure.

The closure of the commonly used lateral thoracotomy incision usually includes pericostal sutures which encircle the ribs. Risks of these pericostal sutures include the injury and/or the entrapment of the intercostal neurovascular bundle located along the inferior underedge of each rib. The simple adaptation of the Rumel tourniquet technique is described as an aid for the primary closure of a lateral thoracotomy which may avoid some of the potential complications inherent to thoracotomy incisions.

Preliminary evaluation of calcium hydroxylapatite as a transurethral bulking agent for stress urinary incontinence.

OBJECTIVES: To evaluate the potential of calcium hydroxylapatite particles as a bulking material for the treatment of stress incontinence. METHODS: Ten women (mean age 68 years, range 60 to 82) with stress incontinence associated with intrinsic sphincter deficiency and limited hypermobility were treated with one (3 patients) or two (7 patients) injections of calcium hydroxylapatite particles and were followed up for 1 year subsequent to the last injection. RESULTS: The mean total volume injected was 3.9 mL. No significant safety issues were identified with regard to local pain, infection, induration, or obstruction. Seven women reported substantial improvement using many fewer pads or none at all (3 patients) at 1 year, 2 women reported fewer pads, and 1 patient reported no change. The daily mean pad use declined from 2.59 to 1.64 and the mean 24-hour pad weight declined by more than 90% (104.9 versus 1.5 g). The mean Valsalva leak point pressure (VLPP) increased from 39 to 46 cm H(2)O at 12 months, with 2 patients dry on testing. CONCLUSIONS: The results of this small initial study suggest that calcium hydroxylapatite particles have potential as a bulking agent for the treatment of stress incontinence.

Efficacy of a preventive intervention for youths living with HIV.

OBJECTIVES: HIV transmission behaviors and health practices of HIV-infected youths were examined over a period of 15 months after they received a preventive intervention. METHODS: HIV-infected youths aged 13 to 24 years (n = 310; 27% African American, 37% Latino) were assigned by small cohort to (1) a 2-module ("Stay Healthy" and "Act Safe") intervention totaling 23 sessions or (2) a control condition. Among those in the intervention condition, 73% attended at least 1 session. RESULTS: Subsequent to the "Stay Healthy" module, number of positive lifestyle changes and active coping styles increased more often among females who attended the intervention condition than among those in the control condition. Social support coping also increased significantly among males and females attending the intervention condition compared with those attending the control condition. Following the "Act Safe" module, youths who attended the intervention condition reported 82% fewer unprotected sexual acts, 45% fewer sexual partners, 50% fewer HIV-negative sexual partners, and 31% less substance use, on a weighted index, than those in the control condition. CONCLUSIONS: Prevention programs can effectively reduce risk acts among HIV-infected youths. Alternative formats need to be identified for delivering interventions (e.g., telephone groups, individual sessions).

Pretransplant evaluation of a patient with acute intermittent porphyria.

The pretransplant evaluation of a patient with a rare diagnosis requires knowledge of the pathophysiology and the transplant literature. A 55-year-old man presented with hypertensive kidney failure and the clinical diagnosis of acute intermittent porphyria. Complications of acute intermittent porphyria, which is a defect of heme production, are due to the accumulation of heme intermediates often precipitated by medications. Based on animal data, cyclosporine is considered unsafe in patients with acute intermittent porphyria. As part of the pretransplant evaluation, the patient received separate trials of tacrolimus and cyclosporine, which did not stimulate his acute intermittent porphyria. Four months after a kidney transplant, the patient still had no signs of rejection or symptoms of acute intermittent porphyria. This is the first documented patient with acute intermittent porphyria who successfully received a kidney transplant using tacrolimus. Because of individual variations, pretransplant testing of calcineurin inhibitors should be continued in patients with acute intermittent porphyria.

St John's wort: a hidden risk for transplant patients.

Herbal medications may cause prescription drug interactions in transplant recipients. After 2 of our kidney transplant recipients started self-medicating with St John's wort, their cyclosporine concentrations were consistently documented to be subtherapeutic. While on St John's wort, one patient developed acute rejection possibly due to low cyclosporine concentrations. Termination of St John's wort returned both patients' cyclosporine concentrations to therapeutic values. Based on the Naranjo Adverse Drug Reaction Probability Scale, our report would achieve a "probable" score, which supports the existence of a St John's wort-cyclosporine adverse drug interaction. St John's wort may induce cytochrome P-450 3A4 activity and/or P-glycoprotein expression, which are both involved in the metabolism and absorption of cyclosporine. Patients using St John's wort concomitantly with cyclosporine or other medications with similar absorption and/or metabolism to cyclosporine need close monitoring. Transplant coordinators are in a critical position to educate transplant recipients about the potential risks of herbal medication usage.

Drug interaction between St. John's wort and cyclosporine.

OBJECTIVE: To report a probable drug interaction between the herbal dietary supplement St. John's wort and cyclosporine. CASE REPORT: A 29-year-old white woman who received a cadaveric kidney and pancreas transplant, with stable organ function and stable cyclosporine concentrations began self-medicating with St. John's wort. After taking St. John's wort supplements for four to eight weeks, her cyclosporine concentrations became subtherapeutic; this was associated with organ rejection. Four weeks after stopping St. John's wort, her cyclosporine concentrations again became therapeutic. Subsequent to this rejection episode, she has developed chronic rejection and now has returned to dialysis. DISCUSSION: St. John's wort is suspected to be a significant inducer of CYP3A4 isoenzyme activity and of P-glycoprotein (P-gp) expression, both of which are important in the metabolism and absorption of cyclosporine. Cyclosporine exhibits a relatively small therapeutic window and is sensitive to medications that can modulate the CYP3A4 isoenzyme and P-gp in both the liver and small intestines. CONCLUSIONS: Patients taking St. John's wort concomitant with other prescription medications whose absorption and metabolism are mediated by the CYP3A4 isoenzyme and P-gp require close monitoring. Patient medication histories should include inquiries into the use of herbal dietary supplements.

Negotiating behavior change with HIV-positive adolescent girls.

A demonstrative case of an HIV-positive adolescent girl is presented in order to illustrate the stages of adaptation that HIV-positive youth undergo. Also discussed is the process by which this individual changes her behavior and the integral role and contributions the service provider can make in the behavior-change process for HIV-positive youth. Finally, this case illustrates some of the unique issues encountered by HIV-positive young women and how those issues can be incorporated into a comprehensive, coordinated, and continuous system of care.

Dynamics of progesterone metabolism in the pseudopregnant rat.

The characteristics of the disappearance of progesterone and 20 alpha-dihydroprogesterone from blood were examined in rats made pseudopregnant by administration of gonadotrophins. Measurement of the disappearance of [3H]progesterone from blood indicated that progesterone metabolism can be represented by a two-compartment model in this animal preparation. The disappearance of [3H]progesterone from blood was described by two half-lives of 0.5 and 11.7 min. The metabolic clearance rate for this steroid was 2.9 litre/day, equivalent to a production rate of 3.9 mumol/day. The initial volume of distribution of the injected [3H]progesterone was 5.0 ml, a volume similar in size to the expected plasma volume. The total volume of distribution of [3H]progesterone (i.e. 'inner' and 'outer' pools) was in the range 24.8-35.4 ml. The disappearance of endogenous progesterone from the blood of pseudopregnant rats after vascular isolation of the ovaries showed two half-lives of 1.1 and 11.4 min respectively. The disappearance of a product of reductive metabolism of progesterone, 20 alpha-dihydroprogesterone, was apparently uniphasic, with a half-life of 41.3 min.