Surgical Management of Extravaginal Testicular Torsion in a 16-Year-Old Male: A Case Report.

Extravaginal torsion (EVT) is a rare type of testicular torsion that usually occurs in neonates. The primary type of testicular torsion that occurs in adolescents is intravaginal torsion. In this case report, we describe the first case of EVT reported in a 16-year-old male with a contralateral bell clapper deformity and subsequent surgical management using a tunica vaginalis flap and bilateral orchiopexy. In discussion of this case, we examine possible anatomical causes of EVT and suggestions for appropriate surgical management.

Parental perception of bladder spasms and hematuria after surgery for vesicoureteral reflux: A prospective multicenter study.

INTRODUCTION: Anti-reflux surgery success has been well-documented in the literature. Little data exists about the characterization of the child's symptoms regarding pain, bladder spasms, and hematuria following these procedures. These symptoms may affect the choice of surgery for families and providers. OBJECTIVE: To characterize parent's perception of recovery from surgery and preparedness for recovery from surgery. We hypothesized that parents of children undergoing open intravesical reimplantation (Open) would report a higher incidence of bladder spasms and hematuria compared to children undergoing robotic extravesical reimplantation (RALR) or endoscopic treatment (DxHA). STUDY DESIGN: A 20-question survey was developed to assess perception of recovery preparedness, pain, and symptoms. Parents completed the survey at a follow-up visit occurring 3-6 weeks post-discharge. Chi-square and t-test or their non-parametric equivalents were used for between-group comparisons. RESULTS: Participating were three institutions and eleven surgeons. Eighty-four parents completed the survey a median of 33 days (IQR 27-40) post-surgery. More parents reported bladder spasms and hematuria in the Open group vs RALR and DxHA. Although there was no difference in maximum bladder spasm pain, duration of pain medication for spasms was longer with Open vs RALR. Most parents (87%) reported they were prepared for their child's symptoms after surgery. Approximately one-quarter of parents whose child underwent Open (33%) or RALR (36%) reported the bladder spasms were more painful than expected, and almost half of parents whose child underwent Open (49%) reported hematuria was worse than expected. DISCUSSION: We found that Open had significantly worse parental reports of bladder spasms, pain medication usage, and severity of hematuria than RALR and DxHA. Although most parents said they were prepared for their child's recovery, many reported the symptoms were worse than expected. These contradictions may reflect a need for improved physician to parent communication when discussing anti-reflux surgery.

Occurrence of halogenated transformation products of selected pharmaceuticals and personal care products in secondary and tertiary treated wastewaters from southern California.

Final effluent samples from 10 southern California (United States) wastewater treatment facilities, employing four distinct treatment schemes, were surveyed for selected pharmaceuticals, personal care products (PPCPs), alkylphenols, and 21 of their halogenated disinfection byproducts. Chlorinated and brominated standards and isotopically labeled internal standards were synthesized and purified to confirm and more accurately quantify selected disinfection byproducts of salicylic acid, bisphenol A, gemfibrozil, naproxen, diclofenac, technical 4-nonylphenol, and 4-tert-octylphenol using high-performance liquid chromatography and tandem mass spectrometry. Concentrations of parent compounds ranged from <10 to 3830 ng/L (gemfibrozil), and those of chloro/bromo byproducts ranged from <4 to 370 ng/L (dibromo nonylphenol). The highest concentrations of parent compounds were measured in effluent that was not subjected to tertiary treatment. The chlorinated and brominated byproduct concentration may be affected by the influent concentration of parent compounds, hydraulic retention times, and chlorine contact times. Salicylic acid was readily halogenated, which is evident from the ratio of halogenated to nonhalogenated species. There were no measured chlorinated byproducts of bisphenol A despite occasionally high concentrations of the parent compound. Not surprisingly, higher concentrations of most brominated species were measured in the treatment plant with the highest bromide concentrations. These results demonstrate the occurrence of novel halogenated byproducts of PPCPs that have limited toxicological data and significant uncertainty with regard to their risk to ecological systems.

Use of a vascularized tunica vaginalis flap for repair of testicular rupture in a pediatric patient.

The management of testicular rupture in children with a large tunical defect is challenging. We describe a technique suitable when primary closure cannot be achieved. A 16-year-old boy presented with right testicular rupture. Owing to the large tunical separation and excessive edema, primary closure could not be achieved. A tunica vaginalis flap was then fashioned with a broad-based pedicle to complete closure. The patient had an uneventful recovery. At 4 months postoperatively, the testis was of normal size and position, and the ultrasound findings were normal. The vascularized tunica vaginalis flap provides an excellent alternative method for closure of pediatric testicular rupture.

The impact of surgical approach and urinary diversion on patient outcomes in pediatric pyeloplasty.

PURPOSE: Recent comparisons of the impact of the surgical approach on pediatric pyeloplasty outcomes have generally incorporated a form of internal ureteral drainage. We hypothesized that the surgical approach does not affect outcomes in children who undergo unstented pyeloplasty and stenting offers no long-term benefit in those with pediatric pyeloplasty. MATERIALS AND METHODS: After receiving institutional review board approval we examined the records of all children who underwent initial pyeloplasty from December 2001 to December 2009. We compared unstented and stented pyeloplasties, and each surgical approach in the unstented group. RESULTS: During the study period 367 pyeloplasties were performed, including 231 unstented and 136 stented procedures. When comparing unstented to stented pyeloplasties, there was no difference in the complication or failure rate. Of unstented pyeloplasties 71, 67 and 93 were done using a transperitoneal laparoscopic approach, a flank approach and dorsal lumbotomy, respectively. There were 5 failures, of which 2 were laparoscopic, 2 used a flank approach and 1 used dorsal lumbotomy (p = 0.51). A total of 31 patients, including 10 treated with a laparoscopic approach, 3 with a flank approach and 18 with dorsal lumbotomy (p = 0.02), required second procedures, of which 24 were temporary drainage for a urine leak. Univariate analysis of factors associated with secondary procedures in the unstented pyeloplasty group showed that only surgical approach was significant (p = 0.05). CONCLUSIONS: In pediatric pyeloplasty there is no significant difference in outcome between stented and unstented repairs. In unstented repairs complications may vary by surgical approach. Regardless of the approach unstented pyeloplasty is safe and effective in the pediatric population.

Practical considerations in the measurement of the internal relative humidity of pharmaceutical packages with data loggers.

The utility of temperature/humidity data loggers are evaluated as a low-cost approach to enrich practical understanding of the actual time dependent humidity that a pharmaceutical product is exposed to. While this approach is found to have significant utility in general, small systematic biases in the measurements due to the presence of the data logger are observed. Taking these biases into account enables more productive extrapolation of measured time/humidity profiles.

Diurnal variability of pharmaceutical, personal care product, estrogen and alkylphenol concentrations in effluent from a tertiary wastewater treatment facility.

Hourly samples of tertiary wastewater effluent were analyzed for 30 pharmaceuticals, personal care products, estrogenic steroids, and alkylphenols in order to better understand the rate at which these compounds enter the environment. Several distinct patterns of daily cycling were observed, and were characterized as three separate categories. The concentrations of compounds such as trimethoprim, sulfamethoxazole, naproxen, estrone, and triclosan varied greatly during a daily cycle, with relative standard deviations exceeding 100% of their daily mean. Less extreme daily cycles were seen for other compounds such as azithromycin, atenolol, tert-octylphenol, iopromide and gemfibrozil. Peak concentrations for most compounds occurred in the early evening (5-8 pm). However, some compounds including carbamazepine, primidone, fluoxetine, and triclocarban exhibited little or no variability.

Solvent effects on the AIBN forced degradation of cumene: Implications for forced degradation practices.

Solvent effects on the AIBN and ACVA forced degradation of cumene are explored. The degradant formation rates of the three cumene oxidative degradants, cumene hydroperoxide, acetophenone, and 2-phenyl-2-propanol are reported. The relative abundance and ratios of these three degradants provide insight into the fate of the peroxy radical oxidants generated by the forced stress system, and suggest that alkoxy radicals are actually a significant source of the observed reactivity. The presence of even 1% methanol in the forced stress solvent significantly quenches this alkoxy radical reactivity, dramatically reducing the overall degradation rate and leaving cumene hydroperoxide as the major product of the oxidation reaction. The origin of this significant solvent effect on the oxidation product distribution is shown to be related to the preferential H-atom abstraction from methanol and its trace impurities by any alkoxy radicals present in the reaction solution. The implications for these observations are explored with the intent of producing more predictive oxidative forced stress experiments.

Targeted biopsy of the prostate: the impact of color Doppler imaging and elastography on prostate cancer detection and Gleason score.

OBJECTIVES: To compare detection of prostate cancer and distribution of Gleason scores with gray-scale, color Doppler, and elastographic imaging. METHODS: Prostate biopsy patients were evaluated with gray-scale, color Doppler, and elastographic imaging. Targeted biopsy cores were obtained along with six laterally directed systematic sextant cores. Pathologic results were correlated with imaging findings. RESULTS: Prostate cancer was detected in 60 of 137 patients (43.8%). Cancer was detected in 241 (14%) of 1703 biopsy cores, including 90 (20%) of 448 targeted cores, 106 (13%) of 818 sextant cores, and 45 (10%) of 437 transition zone cores. Sonographic abnormality was associated with cancer: gray-scale odds ratio (OR) = 3.19, P = 0.011; color Doppler OR = 1.86, P = 0.041; elastography OR = 2.53; P = 0.007. Although targeted cores were more likely than sextant cores to detect cancer (OR = 1.82, P = 0.004), no sonographic abnormality was found in 57 (53.8%) of 106 of positive sextant sites. A linear trend for increasing Gleason score was present with gray-scale (P <0.001) imaging, color Doppler imaging (P <0.005), and elastography (P <0.001). Abnormal color flow was strongly associated with Gleason score 8 to 10 lesions but not with lower-grade lesions. Elastography demonstrated a positive association with Gleason scores of 5 to 10. CONCLUSIONS: Targeted cores based on gray-scale, color Doppler, and elastographic imaging are more likely to return positive biopsy results as compared with systematic biopsy cores. Although color Doppler imaging and elastography are encouraging adjuncts to improve cancer detection, targeted biopsy alone is not sufficient to replace the traditional sextant biopsy technique.

Degradation of vitamin D3 in a stressed formulation: the identification of esters of vitamin D3 formed by a transesterification with triglycerides.

Four unknown degradants in the LC-UV profile of a stressed experimental tablet formulation that contains vitamin D3 have been identified by a combination of Ag+-cationization electrospray ionization (ESI) LC/MS and atmospheric pressure chemical ionization (APCI) LC/MS/MS. The peaks elute in the method chromatography in two pairs of two peaks. The first pair of peaks has m/z 511 while the second pair has m/z 539. The major, first peak of each set of peaks corresponds to the octanoate and decanoate ester of vitamin D3, respectively. These are formed by a transesterification with the two major fatty acid components (octanoate and decanoate) of the triglycerides present in the formulation. The formation of two degradation products with each fatty acid is due to the presence of both vitamin D3 (major component) and the isomeric pre-vitamin D3 (minor component) in the stressed formulation.

Development and validation of a high-throughput GC measurement for water activity.

The development and validation of a headspace GC method to measure the water activity of pharmaceutical samples is presented. Thermal and moisture transfer equilibration rates are shown to be critical variables in the measurement. Several different calibration schemes are discussed with their advantages and disadvantages. The high-throughput applications and experimental considerations of this approach are discussed. The method is shown to be a useful tool to measure a high throughput of water activity samples.

Use of thermal desorption mass spectrometry for the detection of free acid impurities in pharmaceutical products.

A method utilizing thermal desorption mass spectrometry (TDMS) for the detection and quantitation of free acid forms in pharmaceutical drug products formulated as salts is presented. Selective detection of neutral drug forms is possible because the volatility of a drug present in its free acid form is typically much higher than that of its corresponding salt forms, which have negligible volatility even at high temperatures. Tandem mass spectrometric detection allows selective quantitation of the desired free acid drug forms without significant interferences from formulation excipients. The application of the TDMS approach is demonstrated for a sodium salt of a representative, carboxylated drug molecule. Excellent sensitivity, specificity, and adequate linearity of detector signal as a function of micrograms of free acid added were demonstrated in the presence of the sodium salt of the drug and formulation excipients. The sensitivity of the method was demonstrated at free acid levels of 0.6% w/w (6 microg absolute mass). Tablet samples were analyzed by thermal desorption EI-MS/MS with reference to external standards using a commercially available quadrupole ion trap mass spectrometer. The relative drug form stabilities in three different tablet formulations were differentiated using this method; the salt-to-free acid form conversion ranged between less than the limit of detection to near complete conversion during the stability study.

Nucleophilic group transfer reactivity for fibric acid derived drug molecules.

A novel group transfer reaction is reported in which a drug molecule undergoes a thermally induced 2-methyl-2-yl-propionic acid group transfer from one drug molecule to the carboxylic acid functional group of another. The resulting product, the 2-carboxy isopropyl ester of the parent compound, can itself participate in further reactions to yield a series of homologous products. The structural requirements and solvent dependence of this reactivity were investigated, and the resulting implications for the reaction mechanism were discussed. The experimental data is consistent with solvent-assisted nucleophilic substitution reaction mechanism, where the solvent is a small molecule or a second drug molecule. Hydrogen bonding appears to play an important role in both intramolecular activation of the leaving group, as well as intermolecular interaction with the attacking nucleophile. The reactivity is found to be intrinsic to the 2-arenoxy-2-methylpropionic acid structure, which is common to the extended class of fibrate PPAR drug molecules, suggesting that the potential for this reactivity exists for many of these drug molecules as well.

Evaluation of solution oxygenation requirements for azonitrile-based oxidative forced degradation studies of pharmaceutical compounds.

AIBN and ACVA oxidative forced degradation models are examined for two drug molecules whose predominant oxidation chemistries arise from different reaction mechanisms (i.e., free radical vs. nucleophilic). Stress was conducted under a variety of initiator concentrations, and under ambient and pressurized oxygen atmospheres. In each case examined, the azonitrile initiator solutions served as a good predictive model of the major oxidative degradation products observed in pharmaceutical formulations. At low to moderate inititator concentrations, the degradation product distributions and degree of reactivity were similar for samples stored in ambient and pressurized oxygen environments. These results are rationalized with reference to the oxygen consumption kinetics of AIBN and ACVA solutions as a function of initiator concentration. The data suggests that ambient air provides sufficient oxygen to enable chain propagation of peroxy radicals in azonitrile solutions of concentrations appropriate to the forced degradation of pharmaceutical compounds.

Atmospheric concentrations and deposition of polycyclic aromatic hydrocarbons to the Mid-Atlantic East Coast region.

Atmospheric concentrations of polycyclic aromatic hydrocarbons (PAHs) were measured at urban/industrial, suburban, coastal, and rural areas in New Jersey as part of the New Jersey Atmospheric Deposition Network. Concentrations of 36 PAH compounds were measured in the gas and particle phases in air and in precipitation at nine sites at regular intervals from October 1997 through May 2001. Gas-phase and particle-phase sigma36PAH concentrations ranged from 0.45 to 118 ng m(-3) and from 0.046 to 172 ng m(-3), respectively, and precipitation concentrations ranged from 11 to 16200 ng L(-1). PAH concentrations vary spatially across the region, with the highest concentrations occurring at the most heavily urban and industrial locations. Average gas absorption deposition ranged from 0.004 (naphthacene) to 5040 (methylphenanthrenes) ng m(-2) d(-1), and dry particle deposition PAH fluxes ranged from 0.11 (naphthacene) to 300 (benzo[b+k]fluoranthene) ng m(-2) d(-1) at the nine sites. Average atmospheric wet deposition PAH fluxes at the seven sites ranged from 0.40 (cyclopenta[cd]pyrene) to 140 (methylphenanthrenes) ng m(-2) d(-1). These represent the first comprehensive estimates of PAH deposition to New Jersey and the Mid-Atlantic East Coast.

Coan promotions and the authorship of the Presbeutikos.

This article argues that the Presbeutikos Thessalou (Ambassadorial Oration of Thessalus), a seminal text of the Hippocratic pseudepigrapha, is an excerpt of the lost third century BCE historical work Ta Kôaka (History of Cos) of Macareus. It further argues that the rhetoric of the speech derives from ambassadorial speeches delivered by Coan embassies, of which Macareus was a member, on behalf of the Coan Asclepieion. It also suggests that the Presbeutikos' companion in the pseudepigrapha, the Epibomios (Speech from the Altar), may have a similar origin in Macareus' historical work.

Gas-phase reactivity of charged pi-type biradicals.

Four pi,pi-biradicals, 2,6-dimethylenepyridinium and the novel isomers N-(3-methylenephenyl)-3-methylenepyridinium, N-phenyl-3,5-dimethylenepyridinium, and N-(3,5-dimethylenephenyl)pyridinium ions, were generated and structurally characterized in a Fourier transform ion cyclotron resonance mass spectrometer. Their gas-phase reactivity toward various reagents was compared to that of the corresponding monoradicals, 2-methylenepyridinium, N-phenyl-3-methylenepyridinium, and N-(3-methylenephenyl)pyridinium ions. The biradicals reactivity was found to reflect their predicted multiplicity. The 2,6-dimethylenepyridinium ion, the only biradical in this study predicted to have a closed-shell singlet ground state, reacts significantly faster than the other biradicals, which are predicted to have triplet ground states. In fact, this biradical reacts at a higher rate than the analogous monoradical, which suggests that to avoid the costly uncoupling of its unpaired electrons, the biradical favors ionic mechanisms over barriered radical pathways. In contrast, the second-order reaction rate constants of the isomeric biradicals with triplet ground states are well approximated by those of the analogous monoradicals, although the final reaction products are sometimes different. This difference arises from rapid radical-radical recombination of the initial monoradical reaction products. The overall reactivity toward the hydrogen-atom donors benzeneselenol and tributylgermanium hydride is significantly greater for the radicals with the charged site in the same ring system as the radical site. This finding indicates that polar effects play an important role in controlling the reactivity of pi,pi-biradicals, just as has been demonstrated for sigma,sigma-biradicals.

Chlordanes in the mid-Atlantic atmosphere: New Jersey 1997-1999.

To characterize the atmospheric dynamics and behavior of chlordane compounds in the mid-Atlantic region of the United States, atmospheric concentrations were measured in 1997-1999 at three New Jersey locations as part of the New Jersey Atmospheric Deposition Network (NJADN) project. Observed concentrations of sigma-chlordanes (cischlordane + trans-chlordane + cis-nonachlor + transnonachlor) are log-normally distributed, with a geometric mean concentration of 77.1 pg m(-3) and range from 6.1 to 481 pg m(-3). Gas-phase species comprised 83% (+/-23%) of the sigma-chlordanes species across all samples at all location. Gas-phase sigma-chlordane concentrations are inversely proportional to temperature, with higher concentrations during periods of warmer air temperatures. Observed concentrations do not correlate with wind direction or air mass history, which suggests that observed concentrations in the New Jersey atmosphere are due to volatilization from soils and surfaces on the regional scale.

Atmospheric concentrations and deposition of polychorinated biphenyls to the Hudson River Estuary.

The first estimates of atmospheric deposition fluxes of polychlorinated biphenyls (PCBs) to the Hudson River Estuary are presented. Concentrations of PCBs were measured in air, aerosol, and precipitation at nine sites representing a variety of land-use regimes at regular intervals from October 1997 through May 2001. Highest concentrations in the gas phase were observed at urban sites such as Camden and Jersey City (sigmaPCB concentrations averaged 3250 and 1260 pg m(-3), respectively). In great portions of the state encompassing forested, coastal, and suburban environments, gas-phase sigmaPCB concentrations were essentially the same (averaging 150-220 pg m(-3)). This spatial trend suggests that atmospheric PCBs arise from highly localized, urban sources which influence atmospheric concentrations and deposition fluxes over a distance of a few tens of kilometers. Atmospheric sigmaPCB deposition fluxes (gas absorption + dry particle deposition + wet deposition) ranged from 7.3 to 340 microg m(-2) yr(-1) and increased with proximity to urban areas. While the magnitude of the fluxes increased with urbanization,the relative proportions of wet, dry, and gaseous deposition remained largely constant. Because the Hudson River Estuary is adjacent to urban areas such as Jersey City, it is subject to higher depositional fluxes of PCBs. These depositional fluxes are at least 2-10 times those estimated for the Chesapeake Bay and Lake Michigan. Inputs of PCBs to the Hudson River Estuary from the upper Hudson River and from wastewater treatment plants are 8-18 times atmospheric inputs, and volatilization of PCBs from the estuary exceeds atmospheric deposition of low molecular weight PCBs.

Wet deposition of polychlorinated biphenyls in urban and background areas of the Mid-Atlantic States.

Spatial and temporal trends of polychlorinated biphenyl (PCB) concentrations in precipitation were measured at urban and background sites as part of the New Jersey Atmospheric Deposition Network (NJADN). The volume weighted mean concentration (VWM) of sigmaPCBs (sum of PCBs) based on precipitation measurements at three background sites was in the range of 0.30-0.50 ng/L. Concentrations in precipitation at two urban-industrial sites were on average 7-43 times higher than background concentrations. Wet deposition fluxes of sigmaPCBs at the two urbanized sites were 16 +/- 3.4 and 3.9 +/- 0.72 microg/m2-yr, while the background flux was approximately 0.30 microg/m2-yr. On average, 97% of the total atmospheric washout (WT) of PCBs resulted from particle scavenging. The fraction of atmospheric PCBs on particles was the best predictor of atmospheric washout in both urban (log WT = 0.71 (+/- 0.049) log psi + 4.9 (+/- 0.11); r2 = 0.81) and nonurban areas (log W(T) = 0.77 (+/- 0.083) log psi + 5.6 (+/- 0.16); r2 = 0.64). Wet deposition fluxes of sigmaPCBs are of the same order of magnitude as dry-particle deposition fluxes in all land-use regimes.