De novo, deleterious sequence variants that alter the transcriptional activity of the homeoprotein PBX1 are associated with intellectual disability and pleiotropic developmental defects.

We present eight patients with de novo, deleterious sequence variants in the PBX1 gene. PBX1 encodes a three amino acid loop extension (TALE) homeodomain transcription factor that forms multimeric complexes with TALE and HOX proteins to regulate target gene transcription during development. As previously reported, Pbx1 homozygous mutant mice (Pbx1-/-) develop malformations and hypoplasia or aplasia of multiple organs, including the craniofacial skeleton, ear, branchial arches, heart, lungs, diaphragm, gut, kidneys, and gonads. Clinical findings similar to those in Pbx mutant mice were observed in all patients with varying expressivity and severity, including external ear anomalies, abnormal branchial arch derivatives, heart malformations, diaphragmatic hernia, renal hypoplasia and ambiguous genitalia. All patients but one had developmental delays. Previously reported patients with congenital anomalies affecting the kidney and urinary tract exhibited deletions and loss of function variants in PBX1. The sequence variants in our cases included missense substitutions adjacent to the PBX1 homeodomain (p.Arg184Pro, p.Met224Lys, and p.Arg227Pro) or within the homeodomain (p.Arg234Pro, and p.Arg235Gln), whereas p.Ser262Glnfs*2, and p.Arg288* yielded truncated PBX1 proteins. Functional studies on five PBX1 sequence variants revealed perturbation of intrinsic, PBX-dependent transactivation ability and altered nuclear translocation, suggesting abnormal interactions between mutant PBX1 proteins and wild-type TALE or HOX cofactors. It is likely that the mutations directly affect the transcription of PBX1 target genes to impact embryonic development. We conclude that deleterious sequence variants in PBX1 cause intellectual disability and pleiotropic malformations resembling those in Pbx1 mutant mice, arguing for strong conservation of gene function between these two species.

Society for fetal urology recommendations for postnatal evaluation of prenatal hydronephrosis--will fewer voiding cystourethrograms lead to more urinary tract infections?

PURPOSE: There is no consensus on the extent and mode of postnatal imaging after a diagnosis of prenatal hydronephrosis. We validated the protocol of our practice, which parallels current Society for Fetal Urology (SFU) recommendations, in limiting voiding cystourethrogram, while examining its impact on the incidence of febrile urinary tract infections. A secondary goal was to examine predictors of postnatal intervention. MATERIALS AND METHODS: We evaluated a cohort of 117 infants with prenatal hydronephrosis and retrospectively reviewed outcomes. Excluded from study were 30 infants with anatomical abnormalities. Third trimester prenatal ultrasound was done to evaluate SFU grade, laterality and anteroposterior diameter. Cox proportional hazard model and chi-square analysis were used to assess predictors of resolution and surgical intervention. RESULTS: A total of 87 infants with a median followup of 33.5 months were included in analysis. Postnatal voiding cystourethrogram was done in 52 patients, of whom 7 had vesicoureteral reflux. In 6 infants (6.9%) a febrile urinary tract infection developed, which was diagnosed with a catheter specimen during followup. In 3 infants a urinary tract infection developed immediately after catheterization. Anteroposterior diameter 9 mm or greater and SFU grade 3 or greater independently predicted the need for postnatal intervention (p = 0.0014 and 0.001, respectively). CONCLUSIONS: With adherence to our protocol, voiding cystourethrogram was avoided in almost half of evaluated infants. No infant diagnosed with vesicoureteral reflux had a urinary tract infection. Catheterization was associated with a urinary tract infection in 50% of cases. An anteroposterior diameter of 9 mm or greater and a SFU grade of 3 or greater were associated with postnatal progression to surgery. Patients with a SFU grade of 4 progressed to surgical intervention at a faster rate than those with a grade of greater than 3.

Intractable hemorrhagic cystitis after hematopoietic stem cell tranplantation--is there a role for early urinary diversion in children?

PURPOSE: Severe hemorrhagic cystitis is a major complication in the pediatric population undergoing hematopoietic stem cell transplantation. Percutaneous nephrostomy tube drainage as a treatment for severe hemorrhagic cystitis has rarely been investigated. We examined children undergoing hematopoietic stem cell transplantation for risk factors associated with severe hemorrhagic cystitis, as well as our experience with percutaneous nephrostomy tube placement as an adjunctive management strategy. MATERIALS AND METHODS: Using prospectively collected data from the Blood and Marrow Transplant Database at the University of Minnesota, we reviewed 40 pediatric patients with severe hemorrhagic cystitis from 1996 to 2010. Specific treatment for each patient was administered at the discretion of the attending physician and generally included bladder irrigation before bladder fulguration or percutaneous nephrostomy tube placement. A percutaneous nephrostomy tube was placed in 11 patients due to the intractable nature of the hemorrhagic cystitis. RESULTS: Of the 11 patients who underwent percutaneous nephrostomy tube drainage 5 (45%) had improvement of the hemorrhagic cystitis within 30 days and the same number had long-term resolution. Among the patients with long-term resolution hemorrhagic cystitis resolved an average of 12.4 days after percutaneous nephrostomy tube placement, and the tubes were removed an average of 8.8 weeks after placement. Through September 2011 mortality among patients with percutaneous nephrostomy tubes was 55% (6 of 11 patients), which was identical to the overall mortality in the severe hemorrhagic cystitis group (22 of 40). No death could be directly attributed to hemorrhagic cystitis or percutaneous nephrostomy tube placement. CONCLUSIONS: Placement of percutaneous nephrostomy tubes for treatment of severe hemorrhagic cystitis results in long-term improvement in intractable hemorrhagic cystitis, and is a safe and viable option for the majority of patients.

Spectrum of urodynamic abnormalities and renal function changes in adult men with non-neurogenic urinary retention.

INTRODUCTION: The purpose of this study was to identify abnormalities in bladder and renal function in men with urinary retention presumed to be due to BPH. METHODS: In this retrospective analysis, urodynamic studies (UDS) and renal function were evaluated. Bladder contractility and compliance and the severity of bladder outlet obstruction (BOO) were determined from urodynamics. Renal function (BUN, creatine, eGFR) was assessed prior to retention, at the time of presentation and after urodynamic evaluation. RESULTS: Of 87 patients with evaluable UDS, 48% did not demonstrate detrusor activity during testing while 52% showed some detrusor contractile activity. Of these, 23% did not have BOO. Diminished bladder compliance was detected in 56%. In the entire cohort, BUN, serum creatinine, and eGFR were significantly changed during retention but were restored after catheterization. In older patients (>75 years), BUN and creatinine during retention were significantly higher, and eGFR was significantly lower compared to younger patients, but renal function after catheterization was not different between age groups. No significant correlations were found between renal function measurements and bladder compliance or age. CONCLUSION: The urodynamic spectrum in men with urinary retention ranged from detrusor acontractility to varied degrees of contractility associated with outlet obstruction spanning from equivocal to severe. Moreover, prompt relief of retention restores renal function to baseline levels, regardless of age. This study indicates that prostatic obstruction may not be the only cause of urinary retention in adult men presumed to have BPH and illustrates the value of urodynamic assessment prior to potentially failure-prone surgical interventions.

The value of toxin profiles in the chemotaxonomic analysis of paralytic shellfish toxins in determining the relationship between British Alexandrium spp. and experimentally contaminated Mytilus sp.

Although phytoplankton is ubiquitous in the world's oceans some species can produce compounds that cause damaging effects in other organisms. These include the toxins responsible for paralytic shellfish poisoning, which, in UK waters, are produced by dinoflagellates from the Alexandrium genus. Within Great Britain (GB) a monitoring programme exists to detect this harmful genus as well as the Paralytic Shellfish Poisoning (PSP) toxins in the flesh of shellfish from classified production areas. The techniques used for toxin analysis allow for detailed analysis of the toxin profiles present in contaminated shellfish. It is possible to compare the toxin profiles of contaminated shellfish with the profiles from toxin producing algae and use this information to infer the causative microalgal species responsible for the contamination. This study sought to evaluate the potential for this process within the GB monitoring framework. Two species of toxic Alexandrium, A. catenella from Scotland and A. minutum from Southern England, were fed to mussels (Mytilus sp.) under controlled conditions. The toxin profile in mussels derived from feeding on each species independently, when mixed and when introduced sequentially was analysed and compared to the source algal cultures using K means cluster analysis. Toxin profiles in contaminated shellfish clustered with those of the causative algae and separately from one another during toxin accumulation and, where A. catenella was the sole toxin source, during depuration. During depuration after feeding with A. minutum and where mixed or sequential feeding was undertaken deviant toxin profiles were observed. Finally, data generated within this experimental study were compared to monitoring data from the GB official control programme. These data indicated that the causative algal species in sole source contaminations could be inferred from toxin profile analysis. This technique will be of benefit within monitoring programmes to enhance the value of data with minimal additional expense, where the toxin profiles of causative microalgae have been well described.

Non-traditional management of the neurogenic bladder: tissue engineering and neuromodulation.

Patients with spina bifida and a neurogenic bladder have traditionally been managed with clean intermittent catheterization and pharmacotherapy in order to treat abnormal bladder wall dynamics, protect the upper urinary tract from damage, and achieve urinary continence. However, some patients will fail this therapy and require surgical reconstruction in the form of bladder augmentation surgery using reconfigured intestine or stomach to increase the bladder capacity while reducing the internal storage pressure. Despite functional success of bladder augmentation in achieving a low pressure reservoir, there are several associated complications of this operation and patients do not have the ability to volitionally void. For these reasons, alternative treatments have been sought. Two exciting alternative approaches that are currently being investigated are tissue engineering and neuromodulation. Tissue engineering aims to create new bladder tissue for replacement purposes with both "seeded" and "unseeded" technology. Advances in the fields of nanotechnology and stem cell biology have further enhanced these tissue engineering technologies. Neuromodulation therapies directly address the root of the problem in patients with spina bifida and a neurogenic bladder, namely the abnormal relationship between the nerves and the bladder wall. These therapies include transurethral bladder electrostimulation, sacral neuromodulation, and neurosurgical techniques such as selective sacral rhizotomy and artificial somatic-autonomic reflex pathway construction. This review will discuss both tissue engineering techniques and neuromodulation therapies in more detail including rationale, experimental data, current status of clinical application, and future direction.

Distribution, occurrence and biotoxin composition of the main shellfish toxin producing microalgae within European waters: A comparison of methods of analysis.

Harmful algal blooms (HABs) are a natural global phenomena emerging in severity and extent. Incidents have many economic, ecological and human health impacts. Monitoring and providing early warning of toxic HABs are critical for protecting public health. Current monitoring programmes include measuring the number of toxic phytoplankton cells in the water and biotoxin levels in shellfish tissue. As these efforts are demanding and labour intensive, methods which improve the efficiency are essential. This study compares the utilisation of a multitoxin surface plasmon resonance (multitoxin SPR) biosensor with enzyme-linked immunosorbent assay (ELISA) and analytical methods such as high performance liquid chromatography with fluorescence detection (HPLC-FLD) and liquid chromatography-tandem mass spectrometry (LC-MS/MS) for toxic HAB monitoring efforts in Europe. Seawater samples (n=256) from European waters, collected 2009-2011, were analysed for biotoxins: saxitoxin and analogues, okadaic acid and dinophysistoxins 1/2 (DTX1/DTX2) and domoic acid responsible for paralytic shellfish poisoning (PSP), diarrheic shellfish poisoning (DSP) and amnesic shellfish poisoning (ASP), respectively. Biotoxins were detected mainly in samples from Spain and Ireland. France and Norway appeared to have the lowest number of toxic samples. Both the multitoxin SPR biosensor and the RNA microarray were more sensitive at detecting toxic HABs than standard light microscopy phytoplankton monitoring. Correlations between each of the detection methods were performed with the overall agreement, based on statistical 2×2 comparison tables, between each testing platform ranging between 32% and 74% for all three toxin families illustrating that one individual testing method may not be an ideal solution. An efficient early warning monitoring system for the detection of toxic HABs could therefore be achieved by combining both the multitoxin SPR biosensor and RNA microarray.

Erectile dysfunction.

In this era of increased awareness of sexual health, male erectile dysfunction has become a primary care issue. Since erectile dysfunction can be either a physiologic or psychological problem, the general practitioner needs to be prepared for how to approach the evaluation, treatment and overall management for their patients. This manuscript will review the epidemiology, definition, evaluation, and various treatment modalities for erectile dysfunction, including a review of the pharmacologic mechanism of PDE-5 inhibitors such as sildenafil, vardenafil, and tadalafil.

Secondary vaginoplasty for disorders for sexual differentiation: is there a right time? Challenges with compliance and follow-up at a multidisciplinary center.

PURPOSE: We present the experience of a multidisciplinary center for disorders of sexual differentiation (DSD) in treating females requiring vaginoplasty. Specifically, we evaluate outcomes and compliance with follow-up protocols in patients undergoing secondary vaginoplasties. MATERIALS/METHODS: We retrospectively reviewed consecutive DSD patients who underwent feminizing genitoplasties in 2006-2010. A subset of patients were instructed in vaginal self-dilation at time of secondary vaginoplasty. Through follow-up visits and administered questionnaires we assessed outcomes, compliance and overall satisfaction. RESULTS: Twenty-two feminizing genitoplasties were completed during the study interval. There were no postoperative complications; average blood loss was 74 ml and mean length of stay was 3 days. Ten females underwent secondary vaginoplasty. The response rate to questionnaires was 5 of 9. Age of initiation for self-dilation ranged from 8 to 24 years. Initial compliance two months postoperatively was good, but diminished 12-24 months after surgery. Responses to the quality-of-life questionnaire were diverse, reflecting a range of patient ages and varied experiences. CONCLUSION: A multidisciplinary, comprehensive approach is necessary to care for patients with DSD due to psychosexual, medical and reconstructive concerns. A secondary vaginoplasty to facilitate menarche and psychosocial concerns is feasible with minimal complications, though compliance and toleration with regard to post-surgical dilation regimens is variable.

Pseudodistal ureteral stone resulting from calcified Deflux implantation.

Vesicoureteral reflux (VUR) is a common clinical problem affecting 1% of pediatric patients. Subureteral endoscopic injection of dextranomer/hyaluronic acid (Deflux) is a minimally invasive treatment option for VUR that is rapidly gaining popularity. Histologic studies have demonstrated that in a minority of patients, the Deflux injection site can be associated with microcalcification. We report the case of a 12-year-old girl with a history of VUR who had previously been treated with Deflux and presented with abdominal pain and was noted to have a small hyperdense mass in the bladder wall on imaging. The presumptive diagnosis of a distal ureteral stone was ultimately ruled out by cystoscopy and retrograde pyelography, which revealed that the lesion seen on imaging represented the intramural Deflux deposit. This is the second reported case in which a calcified Deflux implant was mistaken for a distal ureteral stone in a patient presenting with abdominal pain.

Chronic periglandular inflammation on prostate needle biopsy does not increase the likelihood of cancer on subsequent biopsy.

PURPOSE: Recent literature suggests a role for chronic inflammation in the development of prostate cancer. We investigated the association of chronic periglandular inflammation on prostate needle biopsy with subsequent prostate cancer development and clinical disease features at presentation. METHODS: Six hundred fifty-five patients were abstracted from a prostate/needle biopsy registry from Brigham and Women's Hospital presenting with prostate-specific antigen (PSA) > 4 ng/mL or abnormal digital rectal examination (DRE) between the years 1990 and 2004. DRE, PSA, PSA density, prostate volume, histology, and age were analyzed to identify clinical and pathologic associations with inflammation. Chronic inflammation was defined as an inflammatory cell infiltrate composed predominately of lymphocytes in a periglandular distribution. A subset of patients (n = 308) with follow-up biopsy results were used to identify if prostate inflammation predicted development of prostate cancer. RESULTS: Modeling performed based on 4 biopsy samples revealed prostate volume (P < .001) and DRE (P = .02) as significant predictors of inflammation; DRE lost significance in models accounting for volume. Kaplan-Meier analysis demonstrated inflammation does not predict subsequent prostate cancer (P = .2). Cox models with the same endpoint show inflammation at initial biopsy (P = .3), inflammation at last biopsy (P = .4), and inflammation on any previous biopsy (P = .08) are not associated with time-to-positive biopsy. CONCLUSIONS: Although inflammation on initial and subsequent biopsy does not predict prostate cancer in this cohort, we cannot dismiss its role in prostate cancer pathogenesis. Additional research is necessary to explore the relationship between prostate inflammation and prostate cancer development.