The biomechanical and functional relationships of the proximal radioulnar joint, distal radioulnar joint, and interosseous ligament.

This biomechanical study assessed integrated function of the proximal radioulnar joint (PRUJ), interosseous ligament (IOL), and distal radioulnar joint (DRUJ). Tekscan™ pressure sensors were inserted into the DRUJ and PRUJ of 15 cadaveric specimens. MicroStrain(®) sensors were mounted onto the IOL on nine of these specimens. A customized biomechanical jig was used to apply axial loads and take measurements through pronosupination. The PRUJ, IOL, and DRUJ were shown to function as an integrated osseoligamentous system distributing applied load. The PRUJ has transmitted pressure profiles similar to those of the DRUJ. Different IOL components support loading at different stages of pronosupination. The IOL is lax during pronation. Mid-IOL tension peaks in the midrange of forearm rotation; distal-IOL tension peaks in supination. Axial loading consistently increases IOL strain in a non-linear fashion. There are clinical implications of this work: disease or surgical modification of any of these structures may compromise normal biomechanics and function.

Intravesical botulinum type-A toxin (Dysport®) in the treatment of idiopathic detrusor overactivity in children.

OBJECTIVE: Botulinum type-A toxin is increasingly used for refractory idiopathic detrusor overactivity (IDO) in children. We reviewed our experience and sought to ascertain the influence of dose and functional bladder capacity on outcome. PATIENTS AND METHODS: Thirty patients, aged 6-16 years, with urodynamically proven IDO, had intravesical injections of 400-500 iu of Dysport(®). Outcome was assessed clinically at least 5 months after the injection. RESULTS: Data were available for 27 patients. Urinary frequency was improved in 10; nocturia was improved in 7. Urgency resolved in 10 patients and urge incontinence in 12 (44%). Complications reported were UTI (7), urinary retention (1) and bladder pain (1). The dose of Dysport(®) used was not significantly higher (14 iu/kg v 13 iu/kg) in patients dry at follow up than in those who remained wet (p = 0.45). Functional bladder capacity was not significantly different in patients dry after treatment (p = 0.82). CONCLUSION: This retrospective study demonstrates similar response to a single treatment with intravesical Botulinum type-A toxin to previous series. We did not demonstrate a correlation between dose or functional bladder capacity and resolution of incontinence. A multi-centre study is required to further investigate this promising treatment.

The anatomical assessment of disorders of sex development (DSD).

The assessment of abnormal anatomy in cases of DSD is important to aid diagnosis, understand the aetiology and severity of the condition, guide management and assess the outcomes of treatment. In this paper we present a systematic approach to this assessment which will provide a means by which the multiple disciplines who manage patients with these rare and complex conditions can communicate and thus improve overall care.

Outcome of the Lima periurethral constrictor in children and adolescents: a European perspective.

PURPOSE: The Lima constrictor was described in 1996 as a less complex and less expensive alternative to the artificial urinary sphincter for use in cases of pediatric neuropathic sphincter incontinence. The device provides a fixed periurethral resistance which creates continence, yet allows urethral catheterization without the need to deflate the cuff. We report our multicenter experience, and continence, revision and erosion rates. MATERIALS AND METHODS: We performed a retrospective review of 14 consecutive patients who underwent insertion of the periurethral constrictor (Silimed, Rio de Janeiro, Brazil) between 2005 and 2011. Data are presented as medians (range). RESULTS: A total of 14 patients (13 male, 1 female) with spina bifida (10), sacral agenesis (3) and Hirschsprung disease (1) underwent insertion of the constrictor at a median age of 12 years (range 8 to 20). All patients were wet despite clean intermittent catheterization, medical therapy and/or previous surgery. Eleven patients underwent simultaneous bladder augmentation and/or Mitrofanoff formation. The constrictor was activated a median of 8 weeks (range 2 to 99) after the procedure in 11 patients whereas 3 became dry without activation. Complications occurred in 4 patients (29%), including spontaneous bladder perforation and constrictor erosion (1), tubing disconnection requiring revision (2) and wound infection (1). At a median of 23 months of followup (range 7 to 77) 13 patients were dry and 1 was damp. All patients performed urethral or Mitrofanoff clean intermittent catheterization. The continence rate with the device in situ was 92%. CONCLUSIONS: At a median followup of 23 months the Lima constrictor provided a 92% continence rate with erosion and revision rates of 7% and 14%, respectively. Interim results suggest that the constrictor provides a safe and effective surgical option, particularly in patients who are unable to void to completion.

Introduction, availability and role of simulation in surgical education and training: review of current evidence and recommendations from the Association of Surgeons in Training.

The utility of simulation in surgical training is now well-established, with proven validity and demonstrable transfer of skills to the clinical setting. Through a reduction in the technical learning curve, simulation can prepare surgeons for actual practice and in doing so it has the potential to improve both patient safety and service efficiency. More broadly, multi-disciplinary simulation of the theatre environment can aid development of non-technical skills and assist in preparing theatre teams for infrequently encountered scenarios such as surgical emergencies. The role of simulation in the formal training curriculum is less well-established, and availability of facilities for this is currently unknown. This paper reviews the contemporary evidence supporting simulation in surgical training and reports trainee access to such capabilities. Our national surgical trainee survey with 1130 complete responses indicated only 41.2% had access to skills simulator facilities. Of those with access, 16.3% had availability out-of-hours and only 54.0% had local access (i.e. current work place). These results highlight the paucity in current provision of surgical skills simulator facilities, and availability (or awareness of availability) varies widely between region, grade and specialty. Based on these findings and current best-evidence, the Association of Surgeons in Training propose 22 action-points for the introduction, availability and role of simulation in surgical training. Adoption of these should guide trainers, trainees and training bodies alike to ensure equitable provision of appropriate equipment, time and resources to allow the full integration of simulation into the surgical curriculum.

Subluxation-related ulnar neuropathy (SUN) syndrome related to distal radioulnar joint instability.

Ulnar neuropathy coexistent with distal radioulnar joint (DRUJ) instability has previously been observed in our practice. The aim of this study was to define this phenomenon and investigate the hypothesis that the cause of this intermittent, positional ulnar neuropathy is related to kinking of the ulnar nerve about the DRUJ. Ulna neuropathy was present in 10/51 (19.6%) of a historical cohort of patients who presented with DRUJ instability. Nine subsequent patients with DRUJ instability and coexistent ulnar neuropathy underwent 3-T magnetic resonance imaging to better understand the mechanism of the observed syndrome. Both 3D qualitative and quantitative analyses were used to assess the presence of nerve 'kinking', displacing the nerve from its normal course and causing nerve compression/distraction in the distal forearm and Guyon's canal. Results of the quantitative analysis were statistically significant (p < 0.05). The clinical features of the condition have been delineated and termed subluxation-related ulnar neuropathy or SUN syndrome. The imaging study was a level II diagnostic study.

Fibre bundles in the human extensor carpi ulnaris tendon are arranged in a spiral.

The extensor carpi ulnaris musculotendinous unit has important agonist and antagonist action in wrist motion, including the dart-throwing action, and is a dynamic stabilizer of the distal radioulnar joint during forearm rotation. Despite its functional and clinical importance, little is known about its internal structure. Investigation of the ultrastructure of the human extensor carpi ulnaris (ECU) tendon was undertaken using plane polarized light microscopy and microcomputer tomography with 3D reconstruction. The study demonstrates that the tendon comprises fibre bundles (fascicles) approximately 0.1 mm in diameter that are arranged in a gradual spiral. The spiralling fibres make an angle of 8º to the longitudinal axis of the tendon. The spiral structure of the human ECU tendon has important biomechanical implications, allowing fascicular sliding during forearm rotation. The observed features may prevent injury.

Heavy drinking in early adulthood and outcomes at mid life.

BACKGROUND: Heavy drinking in early adulthood among Blacks, but not Whites, has been found to be associated with more deleterious health outcomes, lower labor market success and lower educational attainment at mid-life. This study analysed psychosocial pathways underlying racial differences in the impact of early heavy alcohol use on occupational and educational attainment at mid-life. METHODS: Outcomes in labor market participation, occupational prestige and educational attainment were measured in early and mid-adulthood. A mixture model was used to identify psychosocial classes that explain how race-specific differences in the relationship between drinking in early adulthood and occupational outcomes in mid-life operate. Data came from Coronary Artery Risk Development in Young Adults, a longitudinal epidemiologic study. RESULTS: Especially for Blacks, heavy drinking in early adulthood was associated with a lower probability of being employed in mid-life. Among employed persons, there was a link between heavy drinking for both Whites and Blacks and decreased occupational attainment at mid-life. We grouped individuals into three distinct distress classes based on external stressors and indicators of internally generated stress. Blacks were more likely to belong to the higher distressed classes as were heavy drinkers in early adulthood. Stratifying the data by distress class, relationships between heavy drinking, race and heavy drinking-race interactions were overall weaker than in the pooled analysis. CONCLUSIONS: Disproportionate intensification of life stresses in Blacks renders them more vulnerable to long-term effects of heavy drinking.

Evaluation of terminology used to describe disorders of sex development.

OBJECTIVE: The terminology used to describe abnormalities of sex determination and sex differentiation was revised in 2006. It was anticipated that new terms, such as 'disorders of sex development' (DSD), would improve communication between health professionals, aid parental understanding and be acceptable to affected individuals. The purpose of this study was to evaluate the success of the new terminology. SUBJECTS AND METHODS: Using a questionnaire, we evaluated the acceptance of these new terms by parents of children with a DSD (n = 19), health professionals (n = 15) and parents of unaffected children (n = 25). RESULTS: Comparing the term 'DSD' to 'intersex', overall 86.4% of participants preferred the term 'DSD', and parents of a child with a DSD had an even higher preference (94.7%). Parents of an affected child considered the new term to improve their understanding of their child's condition (83.3%), and to aid explanation by parent to affected child (82.4%) and to wider family and friends (84.2%). Health professionals preferred the genotype-based terms, whereas parents considered these terms confusing. Overall, 59.3% of participants agreed DSD was an acceptable new term. CONCLUSIONS: There was broad support for the new terminology by parents and health professionals. The description 'disorder of sex development' may be helpful to parents at the time when it is not possible to assign gender, after which aetiologically based diagnoses should be used where possible.

A critical appraisal of the evidence for improved fertility indices in undescended testes after gonadotrophin-releasing hormone therapy and orchidopexy.

Male fertility depends on the transformation of gonocytes into dark adult spermatogonia, during the first 3 months of postnatal life, and this is an androgen-dependent process. This essential developmental step appears to be defective in undescended testes, and in many patients orchidopexy alone (at the age it is currently performed) does not improve fertility indices, either because it does not address the underlying pathophysiology or the surgery is performed too late. Hormone therapy with gonadotrophin-releasing hormone creates a rise in testosterone levels, copying the postnatal gonadotrophin surge. This can improve germ cell numbers, with the implication of enhanced longer-term fertility. The role of hormone therapy has been controversial, and although favoured at the European Society of Paediatric Urologists' workshops in 2008 and 2009, it is not routine clinical practice in the UK or other countries. We performed a critical appraisal of the key papers in the world literature to evaluate the level of evidence for improved fertility indices, semen analysis and paternity rates following hormone therapy in undescended testes. We suggest that the evidence is sufficiently strong to recommend a change in clinical practice.

Aetiology and treatment of symptomatic idiopathic urethral strictures in children.

OBJECTIVE: To report the presentation and treatment outcomes on a series of 12 paediatric bulbar or posterior urethral strictures that were possibly congenital in origin, identified in a 9-year period. METHODS: A retrospective case-note review of all cases of urethral strictures thought to be congenital in origin, prospectively collected into the departmental database. RESULTS: The age at presentation had a bimodal distribution with 6/12 presenting in the first year of life of which four had antenatal hydronephrosis and 5/12 presenting after the age of 11 years. All six patients under 1-year old had a successful outcome following urethrotomy and urethral dilatation. Four of five over 11 years of age ultimately required an urethroplasty and one 3-year-old may well require an urethroplasty in the future. CONCLUSION: This outcome, in conjunction with the bimodal age distribution at presentation, would suggest a different aetiology in older children, and we would urge caution in classifying strictures in ambulant children as genuinely congenital, as this population may represent the long-term manifestation of unrecorded bulbar urethral trauma or asymptomatic inflammation. Optical urethrotomy or dilatation is durable when treated in infancy, but older patients do not experience prolonged resolution and we would recommend treatment along adult lines for these.

Bowel management for paediatric patients with faecal incontinence.

This review assesses the incidence and aetiology of faecal incontinence in childhood. We then systematically address the presentation, clinical assessment, investigation and management of these children. Under management, both medical and surgical approaches and their complications are discussed.

Plastic surgery in the press.

The media play a vital role in public education. The predominant image they portray of plastic and reconstructive surgery is that of cosmetic surgery, whilst the specialty's true scope is often misrepresented. The aim was to evaluate portrayal of plastic surgery in the national newspapers. LexisNexis Professional search engine was used to retrieve articles from all UK newspapers published in 2006 that contained the term 'plastic surgery' and each article was analysed. Of 1191 articles, 89% used the term 'plastic surgery' in the context of cosmetic surgery and only 10% referred to reconstructive work. There were 197 feature articles on cosmetic surgery and 52% of them included a quote from the medical profession. If the quoted doctor was on the UK General Medical Council (GMC) specialist register for plastic surgery, it was significantly more likely that a potential problem or complication associated with cosmetic surgery would be mentioned (p= 0.015). The vast majority of newspaper articles refer only to the cosmetic component of plastic surgery. When quoted, doctors on the GMC specialist register for plastic surgery provide a more balanced view of cosmetic surgery. Further initiative is needed to portray the full scope of plastic and reconstructive surgery to the general public.

A review of the S100 proteins in cancer.

AIM: In the quest to reduce mortality and morbidity from cancer, there is continued effort to identify novel biomarkers to aid in the early detection and the accurate prediction of tumour behaviour. One group of proteins that is emerging as a potentially important group of markers in multiple tumour types is the S100 family. This review summarises the biological and clinical relevance of these proteins in relation to different tumour types. METHODS: A literature search was performed using the PubMed database and the reference lists of relevant articles. Single case studies were excluded and only reports with a clinical relevance from 1961 to 2007 were included. RESULTS: The search yielded over 1000 published articles and reports. Important reports and studies were reviewed, screened and tracked for further relevant publications. Only the most relevant publications are discussed with relation to individual members of the S100 family. CONCLUSION: There is increasing evidence that altered expression of S100 family members is seen in many cancers including breast, lung, bladder, kidney, thyroid, gastric, prostate and oral cancers. S100 proteins are commonly up-regulated in tumours and this is often associated with tumour progression. In contrast S100A2, S100A11 and S100A9 have been documented as tumour suppressors in some cancers but as tumour promoters in others. This demonstrates the complexity of the family and variability of their functions. Although the precise roles of these proteins in cancer is still to be discovered many of the family are associated with promoting metastases through interactions with matrix metalloproteinases or by acting as chemoattractants. There is also evidence that some members can regulate transcription factors such as p53. S100B already has a role in a clinical setting in the diagnosis and therapeutic monitoring of malignant melanoma. As our understanding of this family develops it is likely that many more members will aid the diagnosis, monitoring and potential treatment of cancers in the future.

Femoral nerve neuropathy following the psoas hitch procedure.

OBJECTIVE: To present two cases of femoral nerve neuropathy following a psoas hitch procedure performed during Leadbetter-Politano ureteric reimplantation, and emphasize the importance of this rare complication. PATIENTS: Two 2-year-old boys with complex urological histories underwent Leadbetter-Politano ureteric reimplantations with a psoas hitch using non-absorbable sutures independently in Turkey and the UK. Postoperatively both developed a femoral nerve palsy, which required re-exploration and removal of the sutures. In the first case the femoral nerve was not identified, but in the second case re-exploration revealed the femoral nerve stretched by the nearby suture. Both boys made a full recovery from their neuropraxia. CONCLUSION: These two cases illustrate the potential for nerve involvement with the psoas hitch manoeuvre, and the importance of early recognition of this complication. It is recommended that if a psoas hitch procedure is performed great care should be taken to identify the nerves, and if none are seen then the sutures are placed superficially into the belly of the muscle as the nerves may be sited deeper within it.

Is there an association between functional bladder outlet obstruction and Down's syndrome?

OBJECTIVE: The incidence of urinary tract abnormalities in patients with Down's syndrome (DS) is estimated to be 3-7%. Abnormalities included are renal hypoplasia, renal cysts, ureterovesical and ureteropelvic junction obstruction and, more recently, an association between males with DS and the non-neurogenic neurogenic bladder has been reported. Based on clinical experience, the hypothesis is tested that patients with DS have functional bladder outflow obstruction secondary to detrusor sphincter dyssynergia. METHODS: This study comprised three parts: an initial retrospective review of case notes of existing patients, followed by a prospective community-based study of all patients with DS to assess the incidence and types of bladder dysfunction, and a final hospital-based assessment where a problem was identified following return of the questionnaire. RESULTS: The retrospective study identified a high potential for renal injury with three out of seven patients requiring urinary diversion for dilated upper tracts secondary to bladder outflow obstruction. The prospective study identified a high incidence (77%) of bladder dysfunction with 68% having a history of wetting. CONCLUSION: There is a potentially serious problem in children with DS that is not widely appreciated. We recommend that, at the very least, such children have a detailed history of bladder function taken, and where a problem is detected a urinary tract ultrasound scan should be performed.