Differential renal length index: useful measure in management of isolated unilateral hydronephrosis?

OBJECTIVE: To explore the usefulness of the 'differential renal length index' (iDRL) before and after pyeloplasty, as the anteroposterior diameter is commonly used to quantify hydronephrosis but inaccuracies arise due to interobserver variability, hydration status and pure intra-renal dilatation. PATIENTS AND METHODS: Prospectively collected data, from two centres, of all children undergoing pyeloplasty for isolated unilateral pelvi-ureteric junction obstruction (PUJO) (2015-2021) were analysed. Subgroup analysis was undertaken: Group A - differential renal function (DRF) ≥40%, Group B - subnormal DRF (20-39%), and Group C - symptomatic. Children with structural anomalies of upper and lower urinary tract, bilateral involvement, and subnormal DRF (<20%) were excluded. All the children had a pre- and postoperative ultrasound scan and Tc99m mercapto-acetyltriglycine (MAG3) renograms. The iDRL was calculated as follows: iDRL = ([a - b]/b) × 100, where 'a' is the length of hydronephrotic kidney (cm) and 'b' is the length of contralateral normal kidney (cm). The mean difference and standard error of mean (SEM) between the pre- and postoperative iDRL was evaluated using the paired Student's t-test, with P < 0.05 considered statistically significant. RESULTS: A total of 119 children with 1-year follow-up were included. For the entire cohort, the mean (SEM) preoperative iDRL was 27.7 (1.4) and postoperatively was 12.5 (1.1), with a mean (range) DRF improvement of 54% (44-66%) (P < 0.001). In Group A (n = 97), the mean (SEM) preoperative iDRL was 26.6 (1.5) and postoperatively was 13.1 (1.2), with a mean (range) DRF improvement of 50% (38-63%) (P < 0.001). In Group B (n = 22), the mean (SEM) preoperative iDRL was 32.6 (3.5) and postoperatively was 10.0 (2.8), with a mean (range) DRF improvement of 69% (49-89%) (P < 0.001). In Group C (n = 28), the mean (SEM) preoperative iDRL was 19.9 (2.3) and postoperatively was 7.7 (1.9), with a mean (range) DRF improvement of 61% (38-85%) (P < 0.001). CONCLUSION: Our study identifies the iDRL as a useful measure of improvement following successful pyeloplasty. In the subgroup with DRF of >39% minimum improvement was >37%. Similar minimum DRF improvement was also noted (>37%) in hypo-functioning kidneys and symptomatic PUJO.

Fetal ascites in cloacal malformations-a red flag.

INTRODUCTION: Cloacal malformation is a rare anomaly that remains a diagnostic challenge prenatally, despite the current advances in ultrasonography and MRI. This condition can in some, present with isolated ascites or with other findings, such as a pelvic cyst or upper urinary tract dilatation. In a minority, the ascites may be progressive, questioning the role of antenatal intervention. METHODS: We report on ten patients that have been identified from our Cloaca database between 2010 and 2022. RESULTS: The presence of ascites was associated with extensive bowel adhesions and matting, leading to a challenging initial laparotomy and peri-operative course. CONCLUSIONS: Antenatal finding of ascites in newborns with cloacal malformations should raise a red flag. The surgeon and anaesthetist should be prepared for the operative difficulties secondary to bowel adhesions and the higher risk of haemodynamic instability at the initial surgery. An experienced team at initial laparotomy in such patients is vital. LEVEL OF EVIDENCE: II.

Bladder function after conservative surgery and high-dose rate brachytherapy for bladder-prostate rhabdomyosarcoma.

BACKGROUND: Conservative surgery (CS) brachytherapy (BT) techniques for local therapy in bladder-prostate rhabdomyosarcoma (BP-RMS) seek to retain organ function. We report bladder function after high-dose rate (HDR) BT combined with targeted CS for any vesical component of BP-RMS. PROCEDURE: Prospective cohort of all BP-RMS patients between 2014 and 2019 receiving HDR-BT (iridium-192, 27.5 Gy in five fractions) with/without percutaneous endoscopic polypectomy (PEP) or partial cystectomy (PC). Functional assessment included frequency-volume chart, voided volumes, post-void residual, flow studies, continence status and ultrasound scanning; abnormalities triggered video urodynamics. RESULTS: Thirteen patients (10 male), aged 9 months to 4 years (median 23 months), presented with localised fusion-negative embryonal BP-RMS measuring 23-140 mm (median 43 mm) in cranio-caudal extent. After induction chemotherapy, local treatment consisted of PC+BT in three, PEP+BT in four and BT alone in six. At a median 3.5 years (range 21 months to 7 years) follow-up, all were alive without relapse. At a median age of 6 years (4-9 years), the median bladder capacity was 86% (47%-144%) of that expected for age, including 75% (74%-114%) after PC. Radiation dose to the bladder was associated with urinary urgency, but not bladder capacity or nocturnal enuresis. Complications occurred in two: one urethral stricture and one vesical decompensation in a patient with pre-existing high-grade vesico-ureteric reflux (VUR). The remaining patients were dry by day; five with anticholinergic medication for urinary urgency. Three patients are enuretic. CONCLUSIONS: Day-time dryness at a median 3.5 years after CS-HDR-BT was achieved in 92%, with 85% voiding urethrally, and 62% attaining day-and-night continence aged 4-9 years. We report reduced open surgery with minimally invasive percutaneous surgery, with HDR-BT or BT alone being suitable for many.

Donor's graft ex vivo T-cell depletion with fludarabine reduces graft-versus-host disease signs and improves survival after intestinal transplantation - an experimental study.

Intestinal passenger T leukocytes are responsible for graft-versus-host disease (GvHD) in intestinal transplantation (ITx). We hypothesized that ex vivo fludarabine treatment of the bowel graft would diminish the risk of GvHD and improve overall survival post-transplant. We performed isolated heterotopic small bowel transplantations from Lewis (LEW) to Brown Norway (BN) rat strains, which generated GvHD signs from the fourth day post-transplant. These symptoms included rash, weight loss, piloerection, and diarrhea. The grafts of one of the experimental groups were immersed and sealed in cold Celsior preservation solution with 1000 µm fludarabine for 1 h, prior to its implantation into recipient animals. No histological signs of intestinal tissue alterations were observed after fludarabine treatment. Fludarabine-treated bowel recipients showed significantly later and milder clinical signs of GvHD and reduced total donor cell chimerism, as determined by flow cytometry using strain-specific anti-HLA antibodies. Additionally, fludarabine treatment prolonged recipients' overall survival (13.5 days ± 0.3 days vs. 9.2 days ± 0.5). We conclude that active modification of the intestinal leukocyte composition is advantageous in our ITx animal model. Immunosuppression with fludarabine during the surgical procedure, which could be translated directly to the clinic, protects bowel recipients from GvHD and improves overall post-transplant survival.

The appendix conduit with a conflict of interests - An alternate strategy.

INTRODUCTION: Conventionally the split appendix has been used to address the need for dual conduits such as the Mitrofanoff and the ACE, however limited by its length. We present a video demonstration of an alternate solution. MATERIAL AND METHODS: Size-12 Nelaton catheter introduced via appendicular stump and skirted along the lateral wall of the caecum. Ethicon Endopath 35 mm Linear Stapler was used to create a caecal tube of about 3 cm based on the appendicular stump. RESULTS: From September 2019-January 2023, 6-patients, aged 5-18 years with a diagnoses of 4-spinal dysraphisms, 1-cloacal anomaly, and 1-urogenital sinus were included. FOLLOW UP: 5-45 months. Two patients had ACE site infection which resolved with antibiotics. One developed a stomal granuloma treated effectively with silver nitrate. All are clean with no stomal leaks and experience easy intubation. DISCUSSION: Alternatives to the split appendix include the Monti ACE, and Caecostomy tube/caecal flap when limited by appendicular length. The technique described is easy and quick however care must be taken to keep away from the ileo-caecal junction and to keep the tube length as short as possible or needed to preserve vascularity. CONCLUSIONS: The stapled caecal tube ACE is easy, quick, and safe especially when limited by appendicular length.

The Effect of Gynostemma pentaphyllum Extract on Mouse Dermal Fibroblasts.

Background. The objective of this paper is to demonstrate the effect of Gynostemma pentaphyllum extract on mouse dermal fibroblasts. Recent studies have shown that this plant may possess great antioxidant properties, which can be very beneficial in combating oxidative stress. Methods. Gynostemma pentaphyllum extract was prepared and mouse dermal fibroblasts were obtained and cultured as per our laboratory protocols. Twelve samples of cells were cultured under the same conditions and both negative and positive controls were established. Induction of oxidative stress was carried out using ultraviolet C (UVC) light. Viable cell count was carried out, using microscopy. The analysis of the overall results was processed using SPSS version 16.0. Results. Statistical analysis showed strong positive correlation between the concentration of Gynostemma pentaphyllum and the mean duration of cell viability (rs = 1), with a high level of statistical significance (P < 0.01). Likewise, strong positive correlation existed between trials of cell viability (rs = 0.988-1), with statistical significance (P < 0.01). Conclusion. Gynostemma pentaphyllum extract prolongs viability of mouse dermal fibroblasts damaged by UVC light-induced oxidative stress. The results show the potential benefits of this extract on dermal cell aging.

Sarampo: ameaça real ou virtual? Promovendo a imunidade de grupo / Measles: real or virtual threat? Promoting herd immunity

Em Portugal, o sarampo está eliminado desde outubro de 2015, contudo os elevados fluxos migratórios no nosso país a juntar aos movimentos anti vacinação que se iniciaram na América, e que têm ganho adeptos em vários países da Europa, a par dos vários casos recentemente documentados de Sarampo gera preocupação e pode comprometer a saúde pública. A vacinação contribui para a imunidade individual, assim como para a imunidade da comunidade; quando numa comunidade existe um n.º suficiente de pessoas imunes a determinada doença, impede que essa doença se propague, e confere à população "imunidade de grupo" (ECDC, 2015). O nosso projeto foi implementado na UCSP Linda-a-Velha e dirigido às crianças nascidas em 2010 e 2011 com a 2ª inoculação da VASPR em atraso. Tem como finalidade: contribuir para o aumento da taxa de cobertura vacinal da VASPR2 nas crianças nascidas em 2010 e 2011 inscritas nesta unidade de saúde. O projeto segue a Metodologia de Planeamento em Saúde, ancorado no referencial teórico do Modelo de Promoção de Saúde de Nola Pender. Utilizou-se como instrumento de colheita de dados uma versão traduzida do questionário da OMS "Immunization Coverage Cluster Survey", aplicado aos pais das crianças. Os problemas de saúde identificados, foram priorizados com recurso à grelha de análise, e daí emerge o diagnóstico de Enfermagem: Adesão ao regime de imunização comprometido, relacionado com o défice de informação. A principal estratégia de intervenção utilizada foi a educação para a saúde, através da qual se conseguiu aumentar a taxa de cobertura vacinal da VASPR2 de 79,9% para 98,4% (o que corresponde a um aumento de 18,5%) atingindo-se a imunidade de grupo.

In Portugal, measles has been eliminated since October 2015, however, the high migratory flows in our country in addition to the anti-vaccination movements that began in America, and which have gained followers in several European countries, along with the several recently documented cases Measles causes concern and can compromise public health. Vaccination contributes to individual immunity as well as community immunity; When in a community there is a sufficient number of people immune to a certain disease, it prevents that disease from spreading, and gives the population "group immunity" (ECDC, 2015). Our project was implemented at UCSP Linda-a-Velha and aimed at children born in 2010 and 2011 with the 2nd VASPR inoculation delayed. Its purpose is to: contribute to increasing the VASPR2 vaccination coverage rate in children born in 2010 and 2011 enrolled in this health unit. The project follows the Health Planning Methodology, anchored in the theoretical framework of Nola Pender's Health Promotion Model. A translated version of the WHO questionnaire "Immunization Coverage Cluster Survey", applied to the children's parents, was used as a data collection instrument. The health problems identified were prioritized using the analysis grid, and from this emerges the Nursing diagnosis: Adherence to the immunization regime compromised, related to the information deficit. The main intervention strategy used was health education, through which it was possible to increase the VASPR2 vaccination coverage rate from 79.9% to 98.4% (which corresponds to an increase of 18.5%) reaching group immunity.

Prática da episiotomia e fatores maternos e neonatais relacionados / Practice of episiotomy and related maternal and neonatal factors / Práctica de la episiotomía y factores maternos y neonatales relacionados

A episiotomia trata-se de uma incisão cirúrgica realizada no momento da expulsão do concepto. O objetivo deste estudo foi avaliar o uso da episiotomia e sua associação com as alterações maternas e neonatais em duas maternidades públicas. Apopulação constituiu-se de parturientes submetidas ao parto normal, no período de junho de 2009 a maio de 2010, mediante revisão dos prontuários. Foram analisados 1.129 prontuários. A episiotomia foi utilizada em 57,55% (n=636) de todos os partos normais e em 83,7% (n=325) dos partos de primíparas. A associação entre o uso da episiotomia e a primiparidade é estatisticamente significante (p<0,001). Os dados sugerem a associação da episiotomia e aumento do risco de lacerações graves (p<0,001). O emprego da episiotomia mostrou-se semelhante nas duas maternidades. Os resultados deste estudo ratificam o uso indiscriminado da episiotomia e apontam para a necessidade de propor estratégias para reduzir o emprego dessa técnica...

Episiotomy consists of a surgical incision performed at the moment the infant is expelled. The purpose of this study was to assess the use of episiotomy and its association with maternal and neonatal factors at two public maternity hospitals. The study population consisted of parturients who experienced natural childbirth in the period between June 2009 and May 2010, through the review of medical records. Analysis included 1,129 medical records. Episiotomy was used in 57.55% (n=636) of all natural childbirths and in 83.7% (n=325) of the deliveries involving primiparous women. The association between the use of episiotomy and primiparity is statistically significant (p<0.001). Data suggest the association of episiotomy with an increase in the risk of severe lacerations (p<0.001). The use of episiotomy was found to be similar in the two maternity hospitals. The results of this study confirm the indiscriminate use of episiotomy and point out the need for proposal strategies aimed at reducing the use of this technique...

La episiotomía es una incisión quirúrgica realizada en el momento de la expulsión del feto. Se objetivó evaluar el uso de la episiotomía y su asociación con las alteraciones maternas y neonatales en dos maternidades públicas. La población se constituyó de parturientas sometidas a parto normal, de junio 2009 a mayo 2010, mediante revisión de historias clínicas. Fueron analizadas 1.129 historias. La episiotomía fue utilizada en el 57.55% (n=636) de los partos normales y en 83,7% (n=325) de los partos de primerizas. La asociación entre el uso de la episiotomía y la primiparidad es estadísticamente significativa (p<0,001). Los datos sugieren asociación de la episiotomía y aumento de riesgo de laceraciones graves (p<0,001). El empleo de la episiotomía se mostró semejante en ambas maternidades. Los resultados de este estudio ratifican el uso indiscriminado de la episiotomía y expresan la necesidad de proponer estrategias para reducir el empleo de esta técnica...

Fatores maternos e neonatais associados à prematuridade / Maternal and neonatal factors associated with prematurity / Factores maternos y neonatales asociados a prematuridad

A prematuridade representa a causa mais freqüente de morbidade neonatal. O objetivo desse estudo foi realizar um levantamento dos nascimentos de recém-nascidos vivos com menos de 37 semanas completas de gestação e relacionar com as alterações patológicas encontradas. Foram coletados dados referentes à história clínica materna e do neonato. A média da idade gestacional dos 104 RNs estudados foi de 31 semanas ± 4 dias. A média de peso dos prematuros foi de 2350 gramas. Os grupos de doenças de base maternas encontradas foram: hipertensão materna 51 casos (49%), alterações útero-placentárias 21 casos (20,1%), doenças infecciosas 12 casos (11,5%), cardiopatias 9 casos (5,7 %), diabetes 2 casos (1,9%), Síndrome da Imunodeficiência Adquirida 1 caso (0,9%) ainda 8 casos (7,6%) em que não havia registro de doença de base. Entre os grupos de doenças de base fetais o mais frequente foi o grupo de doenças do aparelho respiratório, com 81 casos (78%). Em nosso estudo, houve diferença estatisticamente significante entre idade gestacional e doença de base materna (p=0,038). A prematuridade continua sendo a principal causa de morbidade e mortalidade neonatal, representando um dos maiores desafios para o fornecimento de uma assistência profissional de qualidade.

The prematurity is the most frequent cause of neonatal morbidity. The aim of this search was to perform a survey of thenewborns with less than 37 completed weeks of gestation and related with the pathological alterations found. The data wascollected from the maternal and neonatal medical record. The mean gestational age of the 104 newborns studied was 31weeks ± 4 days. The mean weight of the premature infants in our study was 2350 grams. The groups with maternal baselinediseases were: maternal hypertension 51 cases (49%), uterus-placental disorders 21 cases (20.1%), infectious diseases 12cases (11.5%), heart diseases 9 cases (5.7 %), diabetes 2 cases (1.9%), Acquired Immune Deficiency Syndrome 1 case(0.9%) and 8 cases (7.6%) with no record of the baseline disease. Among the groups with fetal baseline diseases the mostfrequent diseases were of the respiratory tract, with 81 cases (78%). In our study, there was statistically significantdifference between gestational age and maternal baseline disease (p=0038). The prematurity remains the main cause ofneonatal morbidity and mortality, being one of the biggest challenges for the provision of professional high quality assistance.

El nacimiento prematuro representa la causa más frecuente de morbilidad neonatal. Objetivo: realizar un levantamiento delos nacimientos de recién nacidos vivos con menos de 37 semanas completas de gestación y relaciona con las modificacionespatológicas encontradas. Se recolectaron los datos referentes a historia clínica materna y del neonato. La media de la edadgestacional de los 104 recién nacidos estudiados fue de 31 semanas±4 días. De los 104 casos estudiados, 82 casos (78,8 %)habían sido acompañados durante el prenatal. La media de peso de los prematuros fue de 2350 gramos. Los grupos deenfermedades de base maternas encontradas fueron: hipertensión materna 51 casos (49%), alteraciones útero-placentarias21 casos (20,1%), enfermedades infecciosas 12 casos (11,5%), cardiopatías 9 casos (5,7 %), diabetes 2 casos (1,9%),Síndrome de Inmunodeficiencia Adquirida 1 caso (0,9%) además de 8 casos (7,6%) en que no habían registros deenfermedades de base. Entre los grupos de enfermedades de base fetales las más frecuentes fueron las del grupo deenfermedades del sistema respiratorio, con 81 casos (78%). En nuestro estudio, hubo diferencias estadísticamentesignificativas entre edad gestacional y enfermedad de base materna (p=0,038). La prematuridad continúa siendo la principalcausa de morbilidad y mortalidad neonatal.