Identification of extracellular vesicles and characterization of miRNA expression profiles in human blastocoel fluid.

In this study, for the first time, we demonstrated the presence of microRNAs and extracellular vesicles in human blastocoel fluid. The bioinformatic and comparative analyses identified the biological function of blastocoel fluid microRNAs and suggested a potential role inside the human blastocyst. We found 89 microRNAs, expressed at different levels, able to regulate critical signaling pathways controlling embryo development, such as pluripotency, cell reprogramming, epigenetic modifications, intercellular communication, cell adhesion and cell fate. Blastocoel fluid microRNAs reflect the miRNome of embryonic cells and their presence, associated with the discovery of extracellular vesicles, inside blastocoel fluid, strongly suggests their important role in mediating cell communication among blastocyst cells. Their characterization is important to better understand the earliest stages of embryogenesis and the complex circuits regulating pluripotency. Moreover, blastocoel fluid microRNA profiles could be influenced by blastocyst quality, therefore, microRNAs might be used to assess embryo potential in IVF cycles.

Expression analysis of TFIID in single human oocytes: new potential molecular markers of oocyte quality.

Molecular characterization of human female gametes should make it easier to understand the basis of certain infertility disorders. Biologically significant mRNAs have been analysed in single oocytes to search for molecular biomarkers of oocyte quality. Initial analysis was focused on mRNA for proteins involved in cell growth and cycle control, specifically those encoding members of the general transcription apparatus such as the subunits of the general transcription factor TFIID. This heteromultimeric protein, comprising about 15 subunits, is the most important general transcription factor of the second class. These proteins are essential for the initiation of transcription of protein-coding genes, so they must be present in mature oocytes for mRNA synthesis during the first phases of embryonic development. Semi-quantitative reverse transcriptionpolymerase chain reaction was used to identify different TFIID subunits in single oocytes and to search for differences in expression as compared with control tissues. The data show that the mRNAs for most TFIID subunits are indeed synthesized in oocytes, but their expression profiles differ markedly. TATAbox-binding protein associated factor 4B (TAF4B), TAF5 and TATAbox-binding protein-like 2 (TBPL2) are expressed at higher levels in oocytes than in control tissues. It is suggested that they could be used as biomarkers of oocyte quality.

Endoscopic cross-trigonal ureteral reimplantation under carbon dioxide bladder insufflation: a novel technique.

PURPOSE: To report on a novel technique of endoscopic intravesical ureteral mobilization and cross-trigonal ureteral reimplantation under carbon dioxide insufflation of the bladder (pneumovesicum) for correcting primary vesicoureteral reflux (VUR) in infants and children. PATIENTS AND METHODS: Ten boys and six girls with dilating primary VUR (7 bilateral; 23 refluxing ureters) associated with recurrent urinary-tract infections and multiple pyelonephritic renal scars underwent endoscopic Cohen's cross-trigonal ureteral reimplantation with CO(2) pneumovesicum. Their ages ranged from 10 months to 13 years (mean 4.1 years). The endoscopic procedure was preceded by distention of the bladder with saline and insertion of a 5-mm Step port over the bladder dome under cystoscopic guidance. The bladder was then drained and insufflated with CO(2) to 10 to 12 mm Hg pressure with a suction catheter inserted per urethra to occlude the internal urethral meatus. A 5-mm 30 degrees endoscope was used to provide intravesical vision. Two more 3- to 5-mm working ports were inserted on the lateral bladder wall on either side. Endoscopic intravesical mobilization of the ureter, dissection of a submucosal tunnel, and a Cohen's type of crosstrigonal ureteral reimplantation using interrupted 5-0 monofilament sutures was then performed under videoscopic guidance. Bladder drainage by a urethral catheter was maintained for 24 hours postoperatively. RESULTS: Endoscopic cross-trigonal ureteral reimplantation under CO(2) pneumovesicum was successfully performed in all except one patient, who had displacement of a port into the extravesical space after completion of the ureteral reimplantation necessitating a small vesicotomy for closure of the mucosal defect. The mean operating time was 136 minutes (range 80-230 minutes), being 112 minutes for unilateral cases and 178 minutes for bilateral cases. Two boys developed mild suprapubic and scrotal emphysema postoperatively that subsided spontaneously. All other patients recovered uneventfully and remained well. Follow-up cystograms showed complete resolution of VUR in all except one unit that had persistent grade I reflux, thus giving a success rate of 96%. CONCLUSIONS: This early experience illustrates that endoscopic intravesical ureteral mobilization and crosstrigonal ureteral reimplantation can be performed safely and effectively with routine laparoscopic surgical techniques and instruments under CO(2) insufflation of the bladder, achieving a high success rate in reflux resolution that is equivalent to that obtained with the open technique but with minimal invasiveness and much faster recovery. The longer-term outcome and potential physiological effects of CO(2) pneumovesicum on the bladder and upper-tract function will need to be evaluated further.

Congenital cystic adenomatoid malformation of the lung: indications and timing of surgery.

We review a single surgeon and surgical centre's experience with congenital cystic adenomatoid malformation of the lung (CCAML) in relation to clinical spectrum, operative experience, and postoperative course. A retrospective hospital record review was done on surgically treated cases of CCAML over a 10-year period, focusing on number with antenatal diagnosis, spectrum of postnatal presentation, type of surgery performed, and outcome. Forty-seven patients from birth to 14 years of age underwent surgery for CCAML. Antenatal diagnosis (ante) was made in 30 cases. Of these, 10 became symptomatic before surgery. Six of the 17 postnatally-diagnosed (pnd) cases were an asymptomatic incidental finding. Overall, 16 were symptomatic in the 1st year of life, and five were symptomatic beyond 1 year of age. Symptoms varied from respiratory distress (seven ante, six pnd) to chronic cough (three, and recurrent chest infection (three ante, two pnd). All preoperative diagnoses were confirmed with chest CT. Most patients (25) were operated on before 3 months of age. Eleven were operated on in the first 2 weeks of life as emergency surgery for respiratory distress. The most common lobe involved was the right upper lobe (16), and lobectomy was performed in 42 cases, segmentectomy in four, and pneumonectomy in one. Seventeen cases were extubated immediately postoperatively; 29 required postoperative ventilation overnight, and nine needed more prolonged ventilation. Early postoperative complications included pneumothorax (two), pleural effusion (one), and chylous effusion (one). Late complications included recurrence in three cases (all segmentectomy), who then subsequently underwent lobectomy. There was one death from respiratory failure. Because there is an increasing trend in the detection of asymptomatic antenatally-diagnosed CCAML, consideration of early surgical excision to prevent complications is suggested by our series. CT scanning is mandatory for postnatal evaluation because chest x-ray could be normal. Safe elective excision after 3 months is supported by our low morbidity and less need for postoperative ventilation. Lobectomy is the procedure of choice to prevent recurrence.

Selective approach for transperitoneal and extraperitoneal endoscopic nephrectomy in children.

PURPOSE: From the experience of a large combined series of transperitoneal (TP) and retroperitoneal (RP) endoscopic complete and partial nephroureterectomies in children, we present a logical selective endoscopic approach to benign renal pathology. MATERIALS AND METHODS: During a 5-year period 122 complete nephrectomies and nephroureterectomies (bilateral 2, invisible ectopic 8) and 63 partial nephroureterectomies for duplex (52 upper, 8 lower) or singleton polar disease (xanthogranulomatous pyelonephritis 1, cyst 2) were performed. Of the partial nephrectomies, ureterectomy, bladder repair and lower moiety reimplantation were performed in 8. Patient age ranged from 2.7 months to 14 years (mean 2.9 years). Preoperative weight ranged from 2.7 to 98 kg (mean 12.3). The position of the renal remnant, the presence or absence of a refluxing ureter and the need for ureterectomy were the major determining factors affecting choice of endoscopic approach. RESULTS: A total of 179 (96.7%) procedures were successfully completed endoscopically. The 6 open conversions (3.2%) occurred early in our experience. The operating time reflected the complexity of the excision and lower urinary reconstruction (lateral and posterior RP 25 to 145 minutes [mean 92]) TP with ureterocelectomy and bladder neck repair 105 to 355 minutes [mean 153]. Hospital stay for RP and simple TP was 1.5 days (mean 1 to 4) and for complicated TP 2 to 8 days (mean 3.5). CONCLUSIONS: We suggest a posterior retroperitoneal approach with isolated renal excision without extended ureterectomy. The lateral retroperitoneal approach allows complete ureterectomy as well as better exposure to horseshoe and pelvic kidneys and, therefore, avoids exposure to intraperitoneal structures. Finally, the transperitoneal approach is recommended when complete moiety excision with lower urinary reconstruction is anticipated.

Laparoscopic Swenson procedure--an optimal approach for both primary and secondary pull-through for Hirschsprung's disease.

BACKGROUND/PURPOSE: Several pull-through procedures are available for the surgical management of Hirschsprung's disease (HD) in children. The authors have adopted a laparoscopic approach since 1995, including laparoscopic Swenson procedure (LSw), both for one-stage primary and 2-stage secondary procedures. The aim of this study was to examine the role of LSw in children with HD in both primary and secondary procedures. METHODS: From January 1995 to December 2001, 42 children with biopsy-proven HD underwent laparoscopic pull-through procedure for HD. This group included 29 children who underwent LSw, a detailed analysis of which forms the basis of this report. RESULTS: Sixteen children underwent a single-stage neonatal LSw; the median weight of this group at the time of surgery was 3.2 kg and the median age was 5 days. Secondary LSw was performed in the remaining 13 children, which included 3 children with total colonic HD who underwent laparoscopic total colectomy and LSw. The median operating time was 105 minutes (range, 66 to 175 minutes). The median time to commence full diet was 48 hours (range, 24 to 86 hours), and median time to return to normal play and activity was 72 hours (range, 48 hours to 5 days). There was no difference in operating time between primary and secondary pull-through procedures. There were no intraoperative complications, and no patient required open conversion. Postoperative ileus was noted in 3 children and enterocolitis in 2. The median hospital stay was 4 days (range, 2 to 6 days). Follow-up was between 6 months to 7 years with a median follow-up of 2.2 years. At follow-up, 2 children required laparoscopic antegrade continence enema procedure. A satisfactory continence was noted in 15 of the 19 children who were older than 3 years at the time of last follow-up. CONCLUSIONS: LSw seems to be a suitable procedure for laparoscopic management of HD in children. LSw is safe and effective, both for primary and secondary type of pull-through procedures, with good short-term results.

Retroperitoneal paraganglioma in a child: resection and vena caval reconstruction.

Retroperitoneal paragangliomas (PG) are tumors of neuroectodermal origin rarely seen in children. A 10-year-old boy presented with back pain and a palpable mass secondary to a large right-sided retrocaval PG inferomedial to the kidney. Preoperative chemotherapy and perioperative embolisation were instigated to reduce tumor vascularity. En-bloc resection of the inferior vena cava below the left renal vein and above the caval bifurcation was achieved. Caval reconstruction was completed using a complex autograft of anterior uninvolved vena cava and right renal vein. At 4-year follow-up, the child remains tumor-free with normal caval flow and patency.

Laparoscopic management of complicated urachal disease in children.

PURPOSE: The laparoscopic approach to the complete excision of urachal abnormalities in adults has recently been advocated by some groups but little has been reported in the pediatric literature. We highlight the need for the complete removal of symptomatic urachal remnants as well as the feasibility of the laparoscopic approach in children. MATERIALS AND METHODS: Four children 5 months, 4, 8 and 10 years old, respectively, who presented with complicated urachal disease underwent laparoscopic resection of urachal remnants. We describe the manner of presentation and surgical technique in these 4 cases. RESULTS: Laparoscopic radical excision was successfully performed in all 4 cases with an uneventful convalescence. CONCLUSIONS: Our experience suggests that laparoscopic excision of urachal remnants can be safely and satisfactorily performed in children of all ages.

Allowing small businesses and the self-employed to buy health care coverage through public programs.

The large number of uninsured working Americans and the extent of public support enjoyed by employment-based health insurance argues for a coverage initiative that fosters access to affordable benefits through employment. This proposal, which reflects models in both Massachusetts and Michigan, entails the development of publicly organized and subsidized group health insurance for small firms with low-wage workers. States would provide overall administration and subsidies to both employers and employees. Employers would enroll workers, select insurers, pay premiums, and report data on employment status. The program would be a legislative extension of the State Children's Health Insurance Program (SCHIP), with federal financing to participating states at each respective SCHIP rate. Anti-crowd-out provisions would be included. This program is both administratively and politically feasible. It is also consistent with current thinking regarding public/private partnerships and the desirability of preserving a voluntary employer-sponsored health insurance system.

Neonatal intestinal obstruction from solitary intestinal fibromatosis.

Solitary intestinal fibromatosis (SIF) is a very rare condition, with only 13 cases reported. We present a new case of SIF causing neonatal intestinal obstruction and review the literature on this condition. SIF appears to be a condition of infancy and carries a very good prognosis after segmental resection.

Conservative management of mesenchymal hamartomas of the chest wall.

Mesenchymal hamartomas of the chest wall are rare benign lesions usually discovered in infancy. The authors present their experience with 3 cases. All of these cases were managed initially conservatively, although 1 child required a thoracotomy and partial tumour resection at 5 months of age because of respiratory compromise. The other 2 children have now reached 5 and 6 years of age with the tumors becoming less prominent. The authors believe many cases can be managed conservatively because malignant change has not been reported, and the lesions often become relatively smaller as the child grows.

Splenosis in a port site after laparoscopic splenectomy.

Splenosis, the autotransplantation of splenic tissue, is most commonly seen after traumatic splenic rupture and splenectomy. It also can occur during embryonic development. Intraperitoneal, intrathoracic, and retroperitoneal sites have been reported. Although the presence of the splenic tissue often is asymptomatic and an incidental finding, it may present with pain or be confused with various pathologies including neoplasia. Because most pediatric splenectomies are performed for hemolytic disorders, parenchymal disruption must be contained to avoid recurrent disease. We present a case in which the devascularized spleen was contained in a bag and fragmented in situ. Splenosis developed in the retrieval port site after laparoscopic splenectomy and cholecystectomy. Port-site splenosis needs to be considered in the differential diagnosis of port-site pain and a palpable nodule postsplenectomy.

Surgical correction of pelviureteric junction obstruction in childhood--dorsal lumbotomy approach and selective internal ureteric stenting.

Ninety-four children (average age 3.6 years) underwent surgery for pelviureteric junction (PUJ) obstruction between 1994 and 1999. There were 96 operations: 94 dismemberment pyeloplasties (2 bilateral) and 2 ureterocalycostomies. The surgical approach in all cases was by a dorsal lumbotomy incision. Internal ureteric stenting was employed selectively for solitary kidneys, inflamed renal pelves, long strictures, and ureterocalycostomies. The average operative time was 57 min and the average postoperative stay in hospital was 2.5 days. Of the 94 patients, 93 had a good outcome. Of the 78 pyeloplasties that were unstented, 7 (9%) required stenting in the early postoperative period for urinary leak or obstruction. There were no wound-related complications. PUJ surgery via a dorsal lumbotomy approach with selective internal ureteric stenting is recommended as a safe and effective approach to PUJ obstruction in childhood.

A comparison of the lateral and posterior retroperitoneoscopic approach for complete and partial nephroureterectomy in children.

OBJECTIVE: To report the comparative results of a selective posterior or lateral retroperitoneoscopic approach (RPA) for nephroureterectomy in children. PATIENTS AND METHODS: Following an established experience with RPA, 36 complete and 19 partial nephrouretectomies were prospectively randomized to a posterior and lateral retroperitoneoscopic approach The patients were aged 4 months to 14 years, with a body weight at operation of 5.7-82 kg. For posterior RPA the child is positioned prone, with three access ports. The operating space was created with balloon dissection and maintained with CO2 insufflation. The child was then rotated 30 degrees with the kidney in the dependent position, and the operator and assistant standing on the affected side. In the lateral approach the child is in the lateral decubitus position with the operator and assistant facing the dorsal aspect of the patient. RESULTS: There was no significant difference in operative duration between the lateral and posterior approaches for nephrectomy (65 and 47 min) or partial nephrectomy (85 and 75 min). Two lateral nephrectomies required open conversion (one upper pole and one lower pole). CONCLUSION: The posterior approach gives easy and quick access to the renal pedicle. It is preferable for complete nephrectomy alone and partial or polar excision. In children under 5 years old a near complete ureterectomy can be achieved. The lateral approach creates more inferomedial space, gives better access to ectopic kidneys and allows complete ureterectomy in all cases. Access to the pedicle in the normal position requires more frequent positioning of the kidney. Care must be taken as peritoneal tears are more common.

Behavioral health benefits for public employees: effect of mental health parity legislation.

With the passage of the Mental Health Parity Act of 1996 (MHPA), Congress took an important first step toward equalizing treatment under medical plans between physical and mental illnesses by requiring parity in annual and lifetime dollar limits between physical and mental illness. But the Act was limited in scope: it did not mandate mental health benefits nor prohibit other common types of differentials between physical and mental illnesses, such as higher cost-sharing or lower limits on outpatient visits or inpatient treatments. Before Congress' action in 1996, a few of the states had adopted some type of parity requirement. Since 1996, state parity activity has accelerated.Recently, the Center for Health Services Research and Policy through a grant from the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services, examined contracts providing for mental health benefits for state employees in eight states to assess whether legislative attempts to require parity between physical and mental illnesses resulted in noticeable differences in behavioral health benefits for state employees. We concluded that, except in states that have mandated full parity for some or all types of mental illnesses, behavioral health benefits for state employees have not changed significantly as a result of the state parity laws, since they still remain subject to traditional restrictions, such as higher cost-sharing and greater limitations on outpatient visits and inpatient treatment days, than those imposed on physical illnesses. Thus the considerable state activity surrounding mental health parity may have little effect on state employees' access to mental health services, since although state laws required parity in dollar limitations, they generally permitted the continuation of other plan design features that are more restrictive for mental health coverage. However, many of the contracts we examined were multi-year contract and may not have fully reflected recent state activity. Moreover, if Congress renews the Mental Health Parity Act when it expires in September, 2001, and expands the scope of the Act to cover some of these other plan design features, states with more limited parity laws are likely to follow. In that case, perhaps state employees with mental illnesses may see significant change in the future.

Laparoscopic orchidopexy for the intra-abdominal testis.

The role of laparoscopy in the management of the impalpable testis has been largely as a diagnostic tool only. Its therapeutic application as a single or two-stage Fowler-Stephens procedure for the intra-abdominal testis is assessed and a management algorithm derived. A retrospective review was performed of 26 children with 33 intra-abdominal testes (IAT) who were operated upon between 1992 and 1997; 5 had a single-stage (6 testes) and 21 had a staged approach. All children had the operated testis located in an acceptable scrotal position on review. Six operations were performed as a single-stage procedure. Four testes were palpably smaller at follow-up: 2 in the single-stage (33.3%) and 2 in the two-stage group (7%). Of the 26 children, 24 were day-case admissions. Minor self-limiting complications were observed in 5 cases. Laparoscopic localisation and Fowler-Stephens orchidopexy can be safely employed in the definitive management of the IAT.