Molecular Detection of Enterotoxigenic Staphylococcus aureus in Ready-to-eat Cowhide (‘Ponmo’) Collected from Lagos Metropolis, Nigeria

Aims: Ready-to-eat [RTE] animal products like ponmo are preferred by consumers due to its palatability and quality. However, foodborne pathogens particularly Staphylococcus aureus are sources of concern due to cross-contamination of raw and cooked cowhide. This study aimed to investigate the incidence of enterotoxigenic S. aureus in ready-to-eat locally processed cowhide. Methodology: Sixty (60) RTE cowhide samples were collected from different locations in Lagos, Nigeria and analyzed using conventional microbiological and molecular techniques for the detection of toxigenic S. aureus contamination. Suspected S. aureus isolates were confirmed by the presence of thermostable endonuclease [nuc] gene in their genome. Results: Result showed that 25 (41.67%) and 20 (33.50%) samples harbored coagulase-positive S. aureus and 20 other bacterial species different from S. aureus, respectively while 15 (24.83%) of the tested ponmo samples yielded no bacterial growth. Thirteen of the 15 randomly selected from the 25 suspected isolates were confirmed as S. aureus by the presence of thermostable endonuclease [nuc] gene in their genome. Enterotoxigenic genes were confirmed in all the 13 PCR detected S. aureus. Enterotoxin B gene is most prevalent in ponmo. Multiplex PCR detection of S. aureus enterotoxins [SE] genes revealed the molecular detection of different isolates carrying staphylococcal enterotoxin types A and B, mixed strain carrying both staphylococcal enterotoxins type A and type D. Antibiotic susceptibility of 20 S. aureus isolates revealed varying degrees of susceptibility patterns against the antimicrobial agents. Generally, gentamicin 70% (14/20), azithromycin 75% (15/20), co-trimoxazole 85% (17/20), levofloxacin 95% (19/20) were the most effective antibiotics to S. aureus. A low, ?50% susceptibility was recorded to chloramphenicol 55% (11/20) and nitrofurantoin 65% (13/20). A higher resistance to streptomycin (90%; 18/20) and ceftazidime (95%; 19/20) was identified, with resistance to ceftazidime being the highest (95%; 19/20). Conclusion: It can be concluded that RTE ponmo vended in the study sites is of low hygienic quality and may be of health risk to consumers. High level hygiene practice and good manufacturing practices are required during the production, distribution and marketing of ponmo to curb the potential health consequences of eating ponmo.

Myeloperoxidase as a biomarker for intestinal-brain axis dysfunction induced by malnutrition and Cryptosporidium infection in weanling mice

Abstract Cryptosporidiosis is a waterborne protozoal infection that may cause life-threatening diarrhea in undernourished children living in unsanitary environments. The aim of this study is to identify new biomarkers that may be related to gut-brain axis dysfunction in children suffering from the malnutrition/infection vicious cycle is necessary for better intervention strategies. Myeloperoxidase (MPO) is a well-known neutrophil-related tissue factor released during enteropathy that could drive gut-derived brain inflammation. We utilized a model of environmental enteropathy in C57BL/6 weanling mice challenged by Cryptosporidium and undernutrition. Mice were fed a 2%-Protein Diet (dPD) for eight days and orally infected with 107-C. parvum oocysts. C. parvum oocyst shedding was assessed from fecal and ileal-extracted genomic DNA by qRT-PCR. Ileal histopathology scores were assessed for intestinal inflammation. Prefrontal cortex samples were snap-frozen for MPO ELISA assay and NF-kb immunostaining. Blood samples were drawn by cardiac puncture after anesthesia and sera were obtained for serum amyloid A (SAA) and MPO analysis. Brain samples were also obtained for Iba-1 prefrontal cortex immunostaining. C. parvum-infected mice showed sustained stool oocyst shedding for six days post-infection and increased fecal MPO and inflammation scores. dPD and cryptosporidiosis led to impaired growth and weight gain. C. parvum-infected dPD mice showed increased serum MPO and serum amyloid A (SAA) levels, markers of systemic inflammation. dPD-infected mice showed greater MPO, NF-kB expression, and Iba-1 immunolabeling in the prefrontal cortex, an important brain region involved in executive function. Our findings suggest MPO as a potential biomarker for intestinal-brain axis dysfunction due to environmental enteropathy.

Vedolizumab for perianal fistulizing Crohn’s disease: systematic review and meta-analysis

Background/Aims@#Perianal fistulas are a debilitating manifestation of Crohn’s disease (CD). Despite the advent of anti-tumor necrosis factor (anti-TNF) therapy, the medical management of fistulizing CD continues to be challenged by unmet needs. We conducted a systematic review and meta-analysis of the effectiveness of vedolizumab for the management of perianal fistulizing CD. @*Methods@#A search of PubMed, EMBASE and the Cochrane Library was performed from inception to June 2020 for studies reporting rates of perianal fistula healing in CD patients treated with vedolizumab. The primary outcome of interest was complete healing of perianal fistulas and the secondary outcome was partial healing. The pooled fistula healing rates with 95% confidence intervals (CI) were calculated utilizing a random effects model. @*Results@#A total of 74 studies were initially identified, 4 of which met the inclusion criteria. A total of 198 patients with active perianal fistulas were included, 87% of whom had failed previous anti-TNF therapy. The pooled complete healing rate was 27.6% (95% CI, 18.9%–37.3%) with moderate heterogeneity (I2=49.4%) and the pooled partial healing rate was 34.9% (95% CI, 23.2%–47.7%) with high heterogeneity (I2=67.1%). @*Conclusions@#In a meta-analysis of 4 studies that included 198 patients with perianal fistulizing CD, the majority of whom had failed previous anti-TNF therapy, vedolizumab treatment led to healing of perianal fistulas in nearly one-third of the patients. The lack of high-quality data and significant study heterogeneity underscores the need for future prospective studies of fistula healing in patients receiving anti-integrin therapy.

Factors associated with anti-tumor necrosis factor effectiveness to prevent postoperative recurrence in Crohn’s disease

Background/Aims@#We assessed the effectiveness of anti-TNF agents and its associated factors to prevent endoscopic and clinical postoperative recurrence (POR) in Crohn’s disease (CD). @*Methods@#From a prospectively-maintained database, we retrieved 316 CD patients who underwent intestinal resection (2011–2017). Endoscopic (Rutgeerts index ≥ i2 at 6 months) and clinical (recurrence of symptoms leading to hospitalization or therapeutic escalation) POR were assessed. @*Results@#In 117 anti-TNF-naïve patients, anti-TNF therapy was more effective than immunosuppressive agents (odds ratio [OR], 8.8; 95% confidence interval [CI], 1.8–43.9; P= 0.008) and no medication/5-aminosalicylates (OR, 5.2; 95% CI, 1.0–27.9; P= 0.05) to prevent endoscopic POR. In 199 patients exposed to anti-TNF prior to the surgery, combination with anti-TNF and immunosuppressive agents was more effective than anti-TNF monotherapy (OR, 2.32; 95% CI, 1.02–5.31; P= 0.046) to prevent endoscopic POR. Primary failure to anti-TNF agent prior to surgery was predictive of anti-TNF failure to prevent endoscopic POR (OR, 2.41; 95% CI, 1.10–5.32; P= 0.03). When endoscopic POR despite anti-TNF prophylactic medication (n = 55), optimizing anti-TNF and adding an immunosuppressive drug was the most effective option to prevent clinical POR (hazard ratio, 7.38; 95% CI, 1.54–35.30; P= 0.012). Anti-TNF therapy was the best option to prevent clinical POR (hazard ratio, 3.10; 95% CI, 1.09–8.83; P= 0.034) in patients with endoscopic POR who did not receive any biologic to prevent endoscopic POR (n = 55). @*Conclusions@#Anti-TNF was the most effective medication to prevent endoscopic and clinical POR. Combination with anti-TNF and immunosuppressive agents should be considered in patients previously exposed to anti-TNF.

Pouchitis in inflammatory bowel disease: a review of diagnosis, prognosis, and treatment

Patients with inflammatory bowel disease (IBD) occasionally need a restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) because of medically refractory colitis or dysplasia/cancer. However, pouchitis may develop in up to 70% of patients after this procedure and significantly impair quality of life, more so if the inflammation becomes a chronic condition. About 10% of patients with IBD who develop pouchitis require pouch excision, and several risk factors of the failure have been reported. A phenotype that has features similar to Crohn’s disease may develop in a subset of ulcerative colitis patients following proctocolectomy with IPAA and is the most frequent reason for pouch failure. In this review, we discuss the diagnosis and prognosis of pouchitis, risk factors for pouchitis development, and treatment options for pouchitis, including the newer biological agents.

Development of a Non-Invasive Liver Fibrosis Score Based on Transient Elastography for Risk Stratification in Patients with Type 2 Diabetes

Background@#In non-alcoholic fatty liver disease (NAFLD), transient elastography (TE) is an accurate non-invasive method to identify patients at risk of advanced fibrosis (AF). We developed a diabetes-specific, non-invasive liver fibrosis score based on TE to facilitate AF risk stratification, especially for use in diabetes clinics where TE is not readily available. @*Methods@#Seven hundred sixty-six adults with type 2 diabetes and NAFLD were recruited and randomly divided into a training set (n=534) for the development of diabetes fibrosis score (DFS), and a testing set (n=232) for internal validation. DFS identified patients with AF on TE, defined as liver stiffness (LS) ≥9.6 kPa, based on a clinical model comprising significant determinants of LS with the lowest Akaike information criteria. The performance of DFS was compared with conventional liver fibrosis scores (NFS, FIB-4, and APRI), using area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive and negative predictive values (NPV). @*Results@#DFS comprised body mass index, platelet, aspartate aminotransferase, high-density lipoprotein cholesterol, and albuminuria, five routine measurements in standard diabetes care. Derived low and high DFS cut-offs were 0.1 and 0.3, with 90% sensitivity and 90% specificity, respectively. Both cut-offs provided better NPVs of >90% than conventional fibrosis scores. The AUROC of DFS for AF on TE was also higher (P<0.01) than the conventional fibrosis scores, being 0.85 and 0.81 in the training and testing sets, respectively. @*Conclusion@#Compared to conventional fibrosis scores, DFS, with a high NPV, more accurately identified diabetes patients at-risk of AF, who need further evaluation by hepatologists.

Getting to the heart of the issue: senior emergency resident electrocardiogram interpretation and its impact on quality assurance events

Objective@#Electrocardiogram (ECG) interpretation skills are of critical importance for diagnostic accuracy and patient safety. In our emergency department (ED), senior third-year emergency medicine residents (EM3s) are the initial interpreters of all ED ECGs. While this is an integral part of emergency medicine education, the accuracy of ECG interpretation is unknown. We aimed to review the adverse quality assurance (QA) events associated with ECG interpretation by EM3s. @*Methods@#We conducted a retrospective study of all ED ECGs performed between October 2015 and October 2018, which were read primarily by EM3s, at an urban tertiary care medical center treating 56,000 patients per year. All cases referred to the ED QA committee during this time were reviewed. Cases involving a perceived error were referred to a 20-member committee of ED leadership staff, attendings, residents, and nurses for further consensus review. Ninety-five percent confidence intervals (CIs) were calculated. @*Results@#EM3s read 92,928 ECGs during the study period. Of the 3,983 total ED QA cases reviewed, errors were identified in 268 (6.7%; 95% CI, 6.0%–7.6%). Four of the 268 errors involved ECG misinterpretation or failure to act on an ECG abnormality by a resident (1.5%; 95% CI, 0.0%–2.9%). @*Conclusion@#A small percentage of the cases referred to the QA committee were a result of EM3 misinterpretation of ECGs. The majority of emergency medicine residencies do not include the senior resident as a primary interpreter of ECGs. These findings support the use of EM3s as initial ED ECG interpreters to increase their clinical exposure.

Are critical size bone notch defects possible in the rabbit mandible?

OBJECTIVES: Small animal maxillofacial models, such as non-segmental critical size defects (CSDs) in the rabbit mandible, need to be standardized for use as preclinical models of bone regeneration to mimic clinical conditions such as maxillofacial trauma. The objective of this study is the establishment of a mechanically competent CSD model in the rabbit mandible to allow standardized evaluation of bone regeneration therapies. MATERIALS AND METHODS: Three sizes of bony defect were generated in the mandibular body of rabbit hemi-mandibles: 12 mm×5 mm, 12 mm×8 mm, and 15 mm×10 mm. The hemi-mandibles were tested to failure in 3-point flexure. The 12 mm×5 mm defect was then chosen for the defect size created in the mandibles of 26 rabbits with or without cautery of the defect margins and bone regeneration was assessed after 6 and 12 weeks. Regenerated bone density and volume were evaluated using radiography, micro-computed tomography, and histology. RESULTS: Flexural strength of the 12 mm×5 mm defect was similar to its contralateral; whereas the 12 mm×8 mm and 15 mm×10 mm groups carried significantly less load than their respective contralaterals (P<0.05). This demonstrated that the 12 mm×5 mm defect did not significantly compromise mandibular mechanical integrity. Significantly less (P<0.05) bone was regenerated at 6 weeks in cauterized defect margins compared to controls without cautery. After 12 weeks, the bone volume of the group with cautery increased to that of the control without cautery after 6 weeks. CONCLUSION: An empty defect size of 12 mm×5 mm in the rabbit mandibular model maintains sufficient mechanical stability to not require additional stabilization. However, this defect size allows for bone regeneration across the defect. Cautery of the defect only delays regeneration by 6 weeks suggesting that the performance of bone graft materials in mandibular defects of this size should be considered with caution.

Are critical size bone notch defects possible in the rabbit mandible?

OBJECTIVES@#Small animal maxillofacial models, such as non-segmental critical size defects (CSDs) in the rabbit mandible, need to be standardized for use as preclinical models of bone regeneration to mimic clinical conditions such as maxillofacial trauma. The objective of this study is the establishment of a mechanically competent CSD model in the rabbit mandible to allow standardized evaluation of bone regeneration therapies.@*MATERIALS AND METHODS@#Three sizes of bony defect were generated in the mandibular body of rabbit hemi-mandibles: 12 mm×5 mm, 12 mm×8 mm, and 15 mm×10 mm. The hemi-mandibles were tested to failure in 3-point flexure. The 12 mm×5 mm defect was then chosen for the defect size created in the mandibles of 26 rabbits with or without cautery of the defect margins and bone regeneration was assessed after 6 and 12 weeks. Regenerated bone density and volume were evaluated using radiography, micro-computed tomography, and histology.@*RESULTS@#Flexural strength of the 12 mm×5 mm defect was similar to its contralateral; whereas the 12 mm×8 mm and 15 mm×10 mm groups carried significantly less load than their respective contralaterals (P<0.05). This demonstrated that the 12 mm×5 mm defect did not significantly compromise mandibular mechanical integrity. Significantly less (P<0.05) bone was regenerated at 6 weeks in cauterized defect margins compared to controls without cautery. After 12 weeks, the bone volume of the group with cautery increased to that of the control without cautery after 6 weeks.@*CONCLUSION@#An empty defect size of 12 mm×5 mm in the rabbit mandibular model maintains sufficient mechanical stability to not require additional stabilization. However, this defect size allows for bone regeneration across the defect. Cautery of the defect only delays regeneration by 6 weeks suggesting that the performance of bone graft materials in mandibular defects of this size should be considered with caution.

The correlation between PI-RADS score and the detection of prostate cancer using MRI-ultrasound fusion-guided transperineal prostate biopsy: The first Philippine report

OBJECTIVE@#MRI-Ultrasound fusion guided targeted biopsy has revolutionized the diagnosis of prostatecancer through accurate identification, localization and characterization of prostatic lesions utilizingthe prostate imaging reporting and data system (PI-RADS) scoring system by multiparametric MRI(MPMRI). The fusion prostate biopsy system on the other hand, enables accurate targeting and easyaccess of the tumor. The study objective is to determine the detection rate of clinically-significantprostate cancer using fusion biopsy, and to establish the correlation between PI-RADS score andGleason's score.@*PATIENTS AND METHODS@#A retrospective cohort study was conducted to determine the correlation betweenPI-RADS score and the presence of prostate cancer using MRI-Ultrasound fusion guided transperinealprostate biopsy. This was carried out from June 2017 to July 2018 in a single institution. One hundredthirty five (135) men were included in this study. They presented with an elevated PSA, abnormalDRE or a previous negative prostate biopsy, but with a persistent rise in PSA. A total of 220 prostatelesions were identified. The following characteristics were measured: patient age; the size, location,the PI-RADS score of each lesion, the maximum PI-RADS score for select patients; and the Gleasonscore of discovered tumors.@*RESULTS@# Two hundred twenty PI-RADS 3, 4 and 5 lesions were detected in 135 patients by MPMRI.131 of the 220 lesions were scored as PI-RADS 3, 61 as PI-RADS 4 and 28 as PI-RADS 5. Theselesions were biopsied using the MRI-Ultrasound fusion guided transperineal prostate biopsy system.Thirty-three out of the 131 PI-RADS 3 lesions (25.2%), 44 out of the 61 PI-RADS 4 lesions (72.1%)and 24 out of the 28 PI-RADS 5 lesions (85.7%) respectively were positive for malignancy. Overall,there were 101 (45.9%) lesions classified as PI-RADS 3 to 5 that were positive for prostate carcinoma.Seventy four (74) of the 135 patients (54.8%) were diagnosed with prostate adenocarcinoma. Nineteenout of 65 patients with a maximum score of PI-RADS 3 (29.2%), 33 of 44 with a maximum of PI-RADS 4 (75%) and 22 of 26 with a maximum of PI-RADS 5 (84.6%) harbored malignancy. In termsof location, 45 of the 101 (44.6%) malignancies were in the peripheral sector, 31 (30.7%) in theanterior sector, and 25 (24.8%) in the central sector of the prostate. The mean Gleason grade of PI-RADS 3, 4 and 5 lesions were 6.61, 7.73, and 7.38, respectively. Using Spearman correlation, the rhocoefficient was 0.3153 (p-value =.00013) which denotes a significant positive relationship betweenGleason and PI-RADS score.@*CONCLUSION@#This is the first comprehensive Philippine study on Multiparametric MRI-Ultrasoundfusion-guided transperineal prostate biopsy. Present data validate the superiority of MPMRI in theidentification, localization and characterization of prostate cancers. The authors also verified thepositive correlation between PI-RADS score and Gleason score. Finally, they demonstrated theaccuracy of the MRI- ultrasound fusion-guided transperineal prostate biopsy system in targetingprostate lesions.

24-hour urinary citrate determination among Filipino urinary stone formers after potassium citrate therapy: A prospective, cohort study

OBJECTIVE@#Urolithiasis, a common problem in medicine, poses a significant burden with prevalenceof 1-15%. Potassium citrate therapy has become one of the cornerstones of medical stone managementwith hypocitraturia being the most common metabolic problem in stone formers. The authorsdetermined the effects of potassium citrate on urinary metabolic profiles and its impact on stoneburden among Filipino stone formers.@*PATIENTS AND METHODS@#This is a prospective, cohort study in patients seen at the UST Hospital between2016 and 2018. Twenty-four hour urine citrate levels, stone sizes and urine pH pre-therapy and post-therapy were analyzed.@*RESULTS@#Significant changes in urinary citrate, pH and stone sizes were noted as soon as 3 months afterthe onset of therapy. These changes included increase in urinary pH (6.1 to 6.7; p=0.001), increase inurinary citrate (109.1 to 253.4mg/day; p<0.001) and decrease in stone size (0.56 to 0.37cm; p=0.037).The changes in the urine citrate and the changes in the stone size were not correlated using the Pearsoncorrelation scatter plot.@*CONCLUSION@#Potassium citrate therapy provides a significant alkali and citraturic treatment among Filipino stone formers. However, there is no significant correlation between changes in stone size and changes in urine citrate level.

Comparison of the voiding pattern in toilet-trained Filipino children with urinary tract infection with and without vesicoureteral reflux: A prospective study

OBJECTIVES@#Vesicoureteral reflux (VUR) is a common abnormality of the urinary tract in children andremains a dilemma that is commonly seen by physicians. Unrecognized VUR associated with UTImay lead to long term effects on renal function and overall patient health. To date, there is no currentstudy on voiding patterns of children presenting as recurrent UTI with and without VUR. In thisstudy, the authors aim to determine if there is a difference in the voiding pattern of toilet trainedFilipino children with UTI between those with and without VUR and to see if there is associationbetween these parameters with the degree of VUR.@*MATERIALS AND METHODS@#The study employed a prospective research design. Population consisted ofpediatric patients seen in the clinic diagnosed as a case of UTI documented with positive urineculture. Voiding cystourethrogram was done to determine presence or absence of VUR. The procedurewas done by a single Urologist at a single institution. The patients were then subdivided into 2 groups,the first group consisted of patients with UTI with VUR and another group had those with UTI butwithout VUR. A subanalysis was done to determine association depending on the degree of reflux.Logistic regression analysis, chi-square test and ANOVA were used to determine if there was anystatistically significant difference between the two groups.@*RESULTS@#A total of 223 pediatric patients with ages ranging from 2 years to 17 years with mean age of9.5 years with documented urinary tract infection were noted. Among these, only 140 patientsunderwent VCUG hence included in the study. It consists of 57 male patients (40%) and 83 femalepatients (59%). Among these patients, 65 patients (46%) had vesicoureteral reflux and 75 patients(53%) had no vesicoureteral reflux. Each patient's voiding parameters such as bladder wall thickness,bladder capacity, postvoid residual, Qmax and voiding pattern were noted and compared betweengroups. A subanalysis was also done to determine any association of these parameters to the degree ofreflux.@*CONCLUSION@#In the present series, bladder capacity was the only parameter found to be statisticallydifferent between those with and those without VUR. Furthermore, this difference was only seenamong those with grades 3, 4 and 5 refluxes. Future study must be carried out to determine its clinicalsignificance. Physicians must be vigilant and must have a high index of suspicion in dealing withpatients with episodes of febrile UTI. To date, voiding cystourethrogram is still the gold standard todiagnose this disease entity.

Postoperative breakthrough infection and re-operation in patients with duplicated collecting systems: A comparative analysis of surgical outcomes

OBJECTIVE@#The purpose of surgical intervention for ureteral duplication is to decrease the risk ofinfections, preserve renal function and avoid bladder dysfunction. The objective of this study was todetermine if there is a difference in outcome between total reconstruction of the urinary tract, anupper tract approach, or a lower tract approach.@*MATERIALS AND METHODS@#The outcomes of partial nephrectomy, common sheath re- implantation, totalreconstruction and transurethral incision of ureterocele were pooled and compared against eachother. Primary outcome criteria included breakthrough infection, voiding dysfunction and need for asecond surgery. Procedural dependence of the primary outcomes for each surgery was analyzed usingChi square test. Odds ratio was then computed for each procedure with total reconstruction as thestandard. Logistic regression analysis of the odds ratio was done to determine statistical significance.@*RESULTS@#A total of 128 patients were included in the study. Breakthrough infection was seen in 18.8%of those who underwent partial nephrectomy, 23.8% of those who underwent re- implantation, 19.4%of those who underwent total reconstruction, and 46.4% of those patients who underwent TUI-U.Only 1 patient from the partial nephrectomy group and 1 patient from the total reconstruction groupexperienced voiding dysfunction. Of the 23 patients who underwent TUI-U, 5 (17.9%) needed asecondary procedure, while 3 from the partial nephrectomy, and none from the re-implantation andtotal reconstruction groups required re-operations. Analysis showed that breakthrough urinary tractinfection is dependent on the type of procedure. Using total reconstruction as the standard, the oddsratio for partial nephrectomy is 0.962, 1.302 for common sheath re-implantation and 3.611 for TUI-U. Logistic regression analysis showed statistical difference in the odds ratio of TUI-U and totalreconstruction.@*CONCLUSION@#Breakthrough infection is shown to be dependent on the procedure. TUI-U has a 3.6-foldhigher chance of breakthrough infection compared to total reconstruction, hence up to 18% of patientswho opt for TUI-U should be counseled regarding the need for a secondary operation. The odds ofbreakthrough infection in common sheath re-implantation and partial nephrectomy is not significantlydifferent from total reconstruction. No evidence was established regarding the dependence of re-operations and voiding dysfunction to the primary procedure.

Outcomes of duplex system ureteroceles in pediatric patients managed primarily with transurethral incision

@#Transurethral incision of ureterocele (TUI-U) is a simple, quick, less invasive, and less expensive,and an effective procedure for the management of ureteroceles. Several studies have already shownits utility for primary management of ureteroceles but it has also been associated with the need foradditional surgery. The authors reviewed charts of patients from their database to describe the outcomesof TUI-U done in ureteroceles associated with the upper pole moiety of a duplex system. They alsolooked into preoperative patient characteristics and post TUI-U outcomes that could influence theneed for subsequent surgeries.@*MATERIALS AND METHODS@#The authors identified patients from their duplex system database who presentedwith a ureterocele and underwent TUI-U. They reviewed the patient records of 25 patients who wereincluded in the study to determine the outcomes of TUI-U in duplex system ureteroceles. Chi squareand Mann Whitney U tests were used to determine whether preoperative patient features and postTUI-U outcomes were associated with secondary surgery.@*RESULTS@#Out of 65 patients who had duplex system ureteroceles, 25 patients (38.4%) underwent TUI-U at a mean age of 1.51 years old. TUI-U alone was successful in improving the prevalent signs andsymptoms of 15 patients (60%) in this group, while 10 patients (40%) had to undergo subsequentsurgical procedures. Breakthrough urinary tract infection (UTI) post TUI-U was the only patientfactor noted to be significantly associated with a secondary surgery for duplex system ureterocele(p=0.027).@*CONCLUSION@#TUI-U as primary treatment for duplex system ureteroceles is not yet widely accepteddue to reported rates of morbidities and need for secondary surgery. Present data however show thatTUI-U can be used as a primary procedure and even as a definitive procedure for this subset ofpatients with remarkable results in terms of symptoms resolution and improvement of upper tract profiles.

Voiding pattern of toilet-trained Filipino children with recurrent urinary tract infection and without urinary tract infection

OBJECTIVES@#The objectives of this study were to compare the voiding pattern of toilet-trained patientswith and without recurrent UTI, to describe the voiding pattern of toilet-trained patients withoutUTI aged 2 to 15 years old and to describe the voiding pattern of toilet trained patients with recurrentUTI aged 2 to 15 years old.@*MATERIALS AND METHODS@#A total of 80 toilet-trained Filipino children divided into two groups with 40each were included. R-UTI group consisted of patients aged 2 to 15 years old who presented withrecurrent UTI. The control (No-UTI) group consisted of children aged 2 to 15 years old without anyurinary symptoms and without history of urinary tract infection. Parents completed a 72-hour bladderchart at home. All participants answered Farhat's DVSS. Patients underwent uroflowmetry,uroflowmetry with EMG and post void residual assessment (PVR). Qmax, uroflowmetry pattern,bladder wall thickness and PVR were recorded and analyzed using independent t-test.@*RESULTS@#The mean age of subjects with UTI was 6.32 ± 2.77 years and those in the control group havea mean age 6.67 ± 2.77 years old. Of patients of R-UTI group the following were statisticallysignificant compared to No-UTI : Constipation (48% vs 15%), mean frequency of voiding volumesgreater than 125% of the estimated bladder capacity (EBC) at daytime (0.8 ± 0.22 vs 0.05 ± 1.20p=0.0002), frequency (45% vs 5%), mean average voided volume (126.54 ± 56.05 mL vs 84.34 ±34.26 mL p=0.0001), mean daytime average voided volume (121.33 ± 59.59 mL vs 87.90 ± 36.41mL p =0.0033), mean maximum voided volume (232.25 ± 113.99 mL vs 130.85 ± 49.99 mLp<0.0001), mean bladder thickness (3.83 ± 0.68 mm vs 3.38 ± 0.62 mm p = 0.0030), mean PVR(12.96 ± 10.54 mL vs 5.21 ± 5.68 mL p=0.0001). PVR was significant in 45% of cases compared to3% significant PVR (when 4-6 years old defined as >10ml or >10%of EBC, and if >7 years old >20mlor >15% of EBC). When mean PVR was computed as percentage of EBC, R-UTI group had astatistically higher percentage compared to the no-UTI group (6.27 ± 2.52 % vs 2.52 ± 2.75 %p=0.0001). Mean observed bladder capacity (OBC) was found to be more than the EBC in 35% ofcases in the R-UTI group compared to 12% of No-UTI group (p=0.018). Uroflow-EMG in the R-UTI group were, 85% synergic, 12% dyssynergic and 3% interrupted pattern. EMG in the No-UTIgroup were, 38% synergic, 55% dyssynergic, 2% delayed relaxation, 5% interrupted. The EMGpatterns were statistically significant between the groups (p<0.0001). Uroflow patterns werecomparable between the two groups (p=1.000).@*CONCLUSION@#Constipation was more frequent in the R-UTI group. R-UTI group had a higher meanfrequency of EBC > 125% during daytime, frequency, mean average voided volume, mean averagevoided volume during daytime, mean maximum voided volume, mean bladder thickness, mean PVRcompared to the without UTI group. Mean observed bladder capacity was observed to be greater thanthe EBC in the R-UTI group compared to the No-UTI group. R-UTI group was synergic compared toNo-UTI group which were dyssynergic.

Enteric infections complicating ulcerative colitis

Enteric infections have previously been postulated to play a role in the pathogenesis of inflammatory bowel disease (IBD), however, little evidence exists in the etiologic role of specific enteric infections in the development of IBD. When encountered in the setting of IBD, enteric infections pose a clinical challenge in management given the competing treatment strategies for infectious conditions and autoimmune disorders. Here we present the case of a young male with enteric infections complicating a new diagnosis of IBD. Our patient's initial clinical presentation included diagnoses of Klebsiella oxytoca isolation and Clostridium difficile infection. Directed therapies to include withdrawal of antibiotics and fecal microbiota transplantation were performed without resolution of clinical symptoms. Given persistence of symptoms and active colitis, the patient was diagnosed with ulcerative colitis (UC), requiring treatments directed at severe UC to include cyclosporine therapy. The finding of multiple enteric infections in a newly presenting patient with IBD is an unexpected finding that has treatment implications.

Outcome predictive values of the Society of Fetal Urology (SFU) Grading System and Urinary Tract Dilation (UTD) Classification in patients with high-grade ureteropelvic junction obstruction-like prenatal hydronephrosis

Objectives@#This study aimed to determine the surgical predictive value of both SFU and UTD classifications in a specific subset of patients presenting with high-grade (SFU 3 and 4; UTD P2 and P3) UPJO-like hydronephrosis on prenatal ultrasound. Furthermore, this study also aimed to determine the likelihood of spontaneous resolution of high grade UPJO-like hydronphrosis based on both grading systems. @*Methods@#Patients who presented with high-grade hydronephrosis on prenatal ultrasound based on the SFU grading system (Grades 3 and 4) were included in this study. The prenatal renal ultrasounds of these patients were reclassified by a single interpreter according to the UTD classification. Logistic regression was used to test the predictive value of SFU and UTD; ROC curves were plotted accordingly. Kaplan-Meier curves were used to model time to operation and mean time to operation was computed with a 95% confidence interval. Breslow Test was used to determine significant differences in survival curves across the different SFU grades and UTD classifications.@*Results@#Of the 163 patients in the database who presented with prenatal hydronephrosis, 25 patients presented with high-grade UPJO-like hydronephrosis (50 renal units). Logistic regression revealed that the SFU grading system was able to explain only 18.7% of the variance of the occurrence of pyeloplasty, thus, was a poor predictor of the occurrence of surgery. In contrast, logistic regression of the UTD classification was able to explain 47.3% of the occurrence of pyeloplasy with an accuracy of 86% making it a good predictor of surgical intervention. Both SFU and UTD classifications were poor predictors of spontaneous resolution. Mean time to pyeloplasty from the time of diagnosis was 2.98 years (95% CI: 2.45-3.53) Kaplan-Meier curve analysis for the time of pyeloplasty for the SFU grading system revealed no significant difference in the time to operation among the different SFU grades (p=0.110) while for the UTD classification, there was a significant difference in time to pyeloplasty across the different UTD classes with the higher classes correlating to a shorter time to pyeloplasty. (p<0.05) @*Conclusion@#The UTD classification system is a good predictor of surgery in patients presenting with high-grade UPJO-like hydronephrosis on prenatal ultrasound with a predictive accuracy of 86%. High-grade hydronephrosis based on the UTD classification equates to a shorter time to surgical intervention from the time of diagnosis necessitating closer follow-up of these patients.

The utility of ureteral jet angle sonography as initial screening tool for assessing vesico-ureteral reflux in the Philippines: A prospective, cross-sectional trial

@#<p style="text-align: justify;"><strong>INTRODUCTION:</strong> One of the common risk factors in urinary tract infection is vesico-ureteral reflux. According to some studies, it is seen in 30%-50% of children and 40%-50% present with febrile urinary tract infection. The presence of moderate to severe reflux is an important risk factor in terms of acute pyelonephritis and reflux nepropathy. Investigation of children with urinary tract infection has undergone change so as to detect those who will benefit from diagnosis and treatment at the same time avoid over investigation.<br /><strong>OBJECTIVE:</strong> The present study aimed to determine the role of ureteral jet angle (UJA) in detecting vesicoureteral reflux (VUR) as compared to the gold standard of voiding cystourethrography (VCUG).<br /><strong>METHODS:</strong> A total number of 152 kidneys from 76 patients (37 female and 39 males) ages from 2 months up to 11 years old were included in this study. These patients presented with recurrent urinary tract infection as confirmed via routine urinalysis and/or urine culture and sensitivity and assessed to have vesico-ureteral reflux disease as confirmed by voiding cystourethrogram (VCUG). They were included regardless of the grade of reflux (grade I-V). Patients with urinary tract infection but negative VCUG were also included. Excluded from the study were parents with no consent, patients with neurogenic bladder disorder as cause of recurrent urinary tract infection, patients who had postoperative correction of vesico-ureteral reflux prior to ureteral jet angle sonography, patients currently taking medication for urinary tract infection and patients currently symptomatic for recurrent urinary tract infection i.e. fever,chills,dysuria. All of the participants underwent kidney, urinary bladder ultrasound with ureteral jet angle sonography and all data were collected.<br /><strong>RESULTS:</strong> Out of 152 kidneys, vesicoureteral reflux was seen in 91 of them (60%). Low grade reflux defined as grade I or grade II reflux was present in 32 kidneys (21%) and high grade reflux defined as grade III-V reflux was seen in 59 kidneys (39%). In both right and left kidneys, no significant difference was observed in bladder volume and expected bladder capacity (EBC) by VUR status. On the other hand, there was a significant difference observed in volume to reach reflux by VUR status of both right and left kidneys. No significant difference was observed in UJA volume, EBC, EBC% and UJA degrees by VUR status in the right kidneys. On the other hand, UJA volume, EBC and EBC% was significantly different by VUR status in the left kidneys. All AUCs were less than 0.7 even if EBC was considered. Therefore, UJA may have poor ability to classify patients correctly according to their VUR status.<br /><strong>CONCLUSION:</strong> Doppler flow ultrasound measurement of ureteral jet angle may be a simple and real non invasive test in children of any age but it only showed poor correlation compared to voiding cystourethrography in detecting vesicoureteral reflux. The ureteral jet angle sonography may not be a good initial diagnostic test in assessing vesicoureteral reflux due to its low sensitivity and specificity in detecting the said disease.</p>

Regulation of proprietary traditional Chinese medicines in Australia / 中国天然药物

This review article describes the regulation of proprietary Chinese medicines for the Australian market, which may permit many medicines used in Traditional Chinese Medicine to have a simplified process of market access provided that certain criteria for acceptable public safety are met.

The utility of ureteral jet angle sonography as initial screening tool for assessing vesico-ureteral reflux in the Philippines: A prospective, cross-sectional trial

INTRODUCTION: One of the common risk factors in urinary tract infection is vesico-ureteral reflux. According to some studies, it is seen in 30%-50% of children and 40%-50% present with febrile urinary tract infection. The presence of moderate to severe reflux is an important risk factor in terms of acute pyelonephritis and reflux nepropathy. Investigation of children with urinary tract infection has undergone change so as to detect those who will benefit from diagnosis and treatment at the same time avoid over investigation.OBJECTIVE: The present study aimed to determine the role of ureteral jet angle (UJA) in detecting vesicoureteral reflux (VUR) as compared to the gold standard of voiding cystourethrography (VCUG).METHODS: A total number of 152 kidneys from 76 patients (37 female and 39 males) ages from 2 months up to 11 years old were included in this study. These patients presented with recurrent urinary tract infection as confirmed via routine urinalysis and/or urine culture and sensitivity and assessed to have vesico-ureteral reflux disease as confirmed by voiding cystourethrogram (VCUG). They were included regardless of the grade of reflux (grade I-V). Patients with urinary tract infection but negative VCUG were also included. Excluded from the study were parents with no consent, patients with neurogenic bladder disorder as cause of recurrent urinary tract infection, patients who had postoperative correction of vesico-ureteral reflux prior to ureteral jet angle sonography, patients currently taking medication for urinary tract infection and patients currently symptomatic for recurrent urinary tract infection i.e. fever,chills,dysuria. All of the participants underwent kidney, urinary bladder ultrasound with ureteral jet angle sonography and all data were collected.RESULTS: Out of 152 kidneys, vesicoureteral reflux was seen in 91 of them (60%). Low grade reflux defined as grade I or grade II reflux was present in 32 kidneys (21%) and high grade reflux defined as grade III-V reflux was seen in 59 kidneys (39%). In both right and left kidneys, no significant difference was observed in bladder volume and expected bladder capacity (EBC) by VUR status. On the other hand, there was a significant difference observed in volume to reach reflux by VUR status of both right and left kidneys. No significant difference was observed in UJA volume, EBC, EBC% and UJA degrees by VUR status in the right kidneys. On the other hand, UJA volume, EBC and EBC% was significantly different by VUR status in the left kidneys. All AUCs were less than 0.7 even if EBC was considered. Therefore, UJA may have poor ability to classify patients correctly according to their VUR status.CONCLUSION: Doppler flow ultrasound measurement of ureteral jet angle may be a simple and real non invasive test in children of any age but it only showed poor correlation compared to voiding cystourethrography in detecting vesicoureteral reflux. The ureteral jet angle sonography may not be a good initial diagnostic test in assessing vesicoureteral reflux due to its low sensitivity and specificity in detecting the said disease.