Neonatal urinary ascites complicated by ileal perforation in a recipient of twin-to-twin transfusion syndrome.

We present a case of iatrogenic neonatal urinary ascites following antenatal amnioreduction in one of the monochorionic diamniotic recipient twin 2 of twin-to-twin transfusion syndrome (TTTS). He had ileal perforation following postnatal abdominal paracentesis. The patient had an uneventful recovery following exploratory laparotomy, resection of perforated segment of ileum with end-to-end anastomosis and open vesicostomy with subsequent closure of the vesicostomy.

Steroid treatment for recurrent epididymitis secondary to idiopathic urethritis and urethrovasal reflux.

We describe a case of recurrent left-sided epididymitis secondary to severe idiopathic posterior urethritis extending to left seminal vesicle and vas deference with associated urethrovasal reflux (UVR). Cystourethroscopy and micturating cystourethrogram were essential for the diagnosis. Following cystourethroscopy, intravesical, and urethral instillation of topical steroid triamcinolone, patient had a full recovery. Idiopathic urethritis in association with veru montentitis, utriculitis leading to left-sided UVR, inflammation of the seminal vesicle, and vas deference causing secondary epididymitis is rare. We report the first such rare case presenting as recurrent acute scrotum and response to innovative treatment we used.

Balanitis xerotica obliterans in children and its incidence under the age of 5 years.

OBJECTIVE: To analyse the incidence of BXO among paediatric circumcisions for preputial pathology, in particular in children under the age of 5 years. METHODS: Retrospective review revealed 1769 paediatric circumcisions performed between 1997 and 2008 at our institution. Data were collected on patient's age, date when sample received by pathology department and histological findings for all the foreskin samples received and examined during the study period. Epidemiological data were obtained from the Office for National Statistics, UK. RESULTS: A total of 346 foreskin samples were received and BXO was found in 182 (52.6%). There were 31 children under the age of 5 years circumcised for preputial pathology. BXO was reported in 6 (19.3%) and chronic inflammation in 16 (51.6%) of these patients. The foreskin was reported normal in 2 (6.5%) and the remaining 7 (22.6%) patients had preputial cysts or other pathology. Epidemiological population data analysis revealed the incidence of BXO per year to be 3.01 cases/1000 boys under 15 years of age and 0.322 cases/1000 boys under 5 years. CONCLUSION: The incidence of BXO in boys noted in our study is higher than previously reported. BXO can result in significant complications and should be considered in children even under 5 years.

Acute scrotum: is scrotal exploration the best management?

AIM: Selective scrotal exploration of only those boys believed to have testicular torsion (TT), relying on history and clinical examination for diagnosis, can result in a missed or delayed diagnosis of TT. To minimise testicular loss we propose early scrotal exploration in all boys with acute scrotum (AS). To validate our approach we investigated the accuracy of clinical diagnoses of all boys with AS admitted to our unit. Clinical features and diagnoses were correlated with operative findings. METHODS: A retrospective review of the records of all boys (1-16 years of age) presenting with AS between 2003 and 2007 was done. Overall, 138 boys were seen during this period. Three boys were treated conservatively. The 135 boys who underwent scrotal exploration were divided into three groups: Group A (47 boys) with a history and clinical features considered preoperatively to be consistent with torsion of appendix of testis (TAT); Group B (46 boys) whose characteristics were thought to be more consistent with TT; and finally Group C (42 boys) in whom a preoperative definitive diagnosis could not be made. The preoperative clinical features and diagnoses of the 135 boys were correlated with the operative findings. RESULTS: In Group A, exploration confirmed TAT in 37 (78%) boys, but in 7 (15%) boys it revealed TT. In Group B, exploration confirmed torsion in 31 (68%) boys, but 13 (28%) had TAT. In Group C, exploration revealed 39 (93%) cases of TAT and 3 (7%) cases of TT. CONCLUSION: Surgical exploration in all cases of paediatric AS offers an accurate diagnosis and treatment, thus minimising the risk of testicular loss.

Intravesical steroid instillation--a novel therapeutic intervention for idiopathic urethritis of childhood.

Idiopathic urethritis is a disorder that typically occurs in male children between the ages of 5 and 15 years. The commonest symptoms are blood stained urethral discharge, urethral bleeding between episodes of micturition and dysuria. As the aetiology is poorly understood, there is no reliable means of treating this condition. In this case report we describe the use of intravesical steroid instillation in such patients to alleviate symptoms.

Effect of freezing time on the quality of Indian mackerel (Rastrelliger kanagurta) during frozen storage.

The present study aims to find the effect of freezing methods on the quality of mackerel (Rastrelliger kanagurta) in commercial plate and air blast freezers during freezing and subsequent frozen storage (-18 degrees C). Total time for freezing was significantly different (P < 0.05) between the plate and air blast freezers (90 and 220 min, respectively). This difference in the freezing time could be attributed to the varied quality of the 2 samples. Upon freezing, the moisture content decreased in air blast frozen samples compared to plate freezer where protein content decreased in both the samples. Upon freezing and during frozen storage, lipid oxidation products (peroxide value, thiobarbutiric acid value, and free fatty acid value) and volatile bases (total volatile base nitrogen and trimethyl amine nitrogen) showed an increasing trend in both the samples with values slightly higher in air blast frozen samples compared to plate frozen samples. The total plate counts showed a significantly (P < 0.05) decreasing trend in both the samples. K value did not show any significant (P < 0.05) difference between the samples where as the histamine formation was significantly (P < 0.05) increased in air blast frozen samples compared to plate frozen samples. The taste and overall acceptability was significantly different (P < 0.05) in plate frozen samples compared to air blast frozen samples on 3rd month. Both samples were in acceptable condition up to 3 mo but the plate frozen samples quality was slightly better than the air blast frozen samples.

Delayed postoperative extradural hematoma.

Postcraniotomy complications include various types of intracranial hematomas and systemic complications like cardiac and renal failure. This is a report of a patient who underwent a reexploration of a previous craniotomy and then went into status epilepticus, which was controlled, but the patient developed acute renal failure and then a delayed extradural hematoma.

Acute appendicitis: the continuing role for active observation.

We present the results of a 6-year review of appendicitis. In the event of diagnostic doubt, a policy of active observation was instituted. This review endorses the validity of such a policy, indicating that it does not expose patients to increased morbidity. Data were collected prospectively over a 6-year period on 1,479 children admitted with suspected acute appendicitis (AA); 1,028 (69.5%) were discharged with a diagnosis of non-specific abdominal pain after a mean observation period of 2.5 days, whilst in the remaining 451 a clinical diagnosis of AA was confirmed. The male-to-female ratio was equal, with no difference in the mean age of males (11 years) or females (12 years); 95% of patients were over the age of 5 years. In 324 (72%) cases surgery was performed on the day of admission, whilst in the remaining 126 (28%) it was deferred for 1 to 6 days because the clinical diagnosis of AA remained doubtful. The mean hospital stay was 4 days (range 1-32). Analysis of the histological reports of all 451 cases confirmed a positive predictive value for clinical assessment alone of 97.9% and a normal appendicectomy rate of 2.6%. No mortality was observed; surgical morbidity was recorded at 6% with no correlation between postoperative morbidity and timing of surgery evident (Spearmans correlation coefficient = -0.079, p = 0.9). Active observation for suspected AA thus remains a valid technique for achieving an accurate diagnosis and successful outcome.

Serum cytokine profile in reflux nephropathy.

Cytokines are small regulatory peptides with diverse functions. They regulate the immune system and modulate the inflammatory response, both of which are implicated in vesico-ureteric reflux (VUR) and associated reflux nephropathy (RN). The cytokine profile in VUR and RN has yet to be fully investigated. Blood was obtained from three subject groups immediately after induction of anaesthesia: group A [subjects with VUR and established RN, (N=9)]; group B [VUR alone but no associated RN, (N=6)]; and group C [age- and sex-matched controls with no history of urinary sepsis, (N=14)]. Serum cytokine levels of tumour-necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), soluble TNF receptor-1 (sTNF-R1), and interleukin-8 (IL-8) were measured using standard ELISA technique. Serum levels of IL-6 were higher in group A subjects (1.798-4.638 pg/ml, median 3.253 pg/ml) than controls (1.531-2.078 pg/ml, median 1.798 pg/ml). There was no significant difference in levels in group B subjects (1.498-3. 048 pg/ml, median 1.948 pg/ml) and controls. These same relationships were observed for levels of TNF-alpha (group A: 8. 501-14.471 pg/ml, median 13.483 pg/ml; group B: 7.088-10.650 pg/ml, median 8.886 pg/ml; group C: 6.746-13.344 pg/ml, median 7.671 pg/ml) and sTNF-R1 (group A: 690.34-5780.74 pg/ml, median 1197.38 pg/ml; group B: 366.65-1401.62 pg/ml, median 592.82 pg/ml; C: 313.49-636.33 pg/ml, median 504.17 pg/ml). IL-8 was not significantly elevated in any of the study groups (A or B) compared with control group C (group A: 27.08-56.38 pg/ml, median 31.35 pg/ml; group B: 29.90-35. 87 pg/ml, median 31.35 pg/ml; group C: 25.05-30.22 pg/ml, median 29. 90 pg/ml). These results suggest there may be an immunological basis to RN.

Urinary cytokines as markers of reflux nephropathy.

PURPOSE: We established whether the urinary cytokines interleukin-6 (IL-6), tumor necrosis factor (TNF)-alpha and soluble TNF receptor-1 have a role as noninvasive markers of renal damage in children with vesicoureteral reflux. MATERIALS AND METHODS: We performed an observational study in a surgical and urological unit at a pediatric teaching hospital. Urine cytokine levels of IL-6, TNF-alpha and soluble TNF receptor-1 were measured using a standard enzyme-linked immunosorbent assay technique in children stratified into group 1--11 with vesicoureteral reflux and reflux nephropathy, group 2--6 with vesicoureteral reflux only and no associated nephropathy, and group 3--15 age and sex matched controls. RESULTS: Urinary levels of the cytokines IL-6 and soluble TNF receptor-1 were significantly elevated in group 1 versus group 3 (0.048 to 13.25 pg./micromol. creatinine, mean 3.658 versus 0.027 to 0.677, mean 0.247 and 102.89 to 4,502.9 pg./micromol. creatinine, mean 1,395.3 versus 13.06 to 569.6, mean 145.357, respectively). Neither cytokine in group 2 (0.074 to 10.96 pg./micromol. creatinine, mean 2.94 and 51.52 to 1,115.48, mean 413.137, respectively) was elevated compared to that in group 3. TNF-alpha was not elevated in group 1 or 2 compared to that in group 3 (0.104 to 2.518 pg./micromol. creatinine, mean 0.56, 0.094 to 1.278, mean 0.334 and 0.065 to 0.694, mean 0.241, respectively). CONCLUSIONS: Measuring the urinary levels of the cytokines IL-6 and soluble TNF receptor-1 may be useful as a noninvasive marker of reflux associated renal damage. Further studies with larger patient groups are necessary to locate the source of production of the elevated urinary cytokines measured in our study.

Sequestrated tubular duplication of the ileum.

Duplication of the small bowel is uncommon, and a sequestrated tubular duplication of the ileum that is isolated from the normal bowel and mesentry has not been previously described in the literature. We report one case of such a sequestrated duplication.

Subureteric Teflon injection (STING). Results of a European survey.

Subureteric Teflon injection (STING) has been successfully used by several investigators for treating vesicoureteric reflux (VUR) in children. This multicentre European survey reviews the results of STING in 6,216 ureters. Twenty-two paediatric surgeons/urologists from 18 centres in Europe answered an enquiry regarding their experience with STING in the treatment of VUR. 6,216 refluxing ureters were injected with Polytef paste in 4,166 children during 1984-1990. There were 975 boys and 3,191 girls. Their ages ranged from 2 months to 14 years (mean 5.1 years). The reflux was grade I in 4.4% of ureters, grade II in 36.1%, grade III in 40.2%, and grades IV and V in 19.3% of ureters. All patients were followed up for periods ranging from 3 months to 81/2 years and 90% were followed up for more than 2 years. 76.3% of all ureters stopped refluxing after a single injection of Teflon paste, cure rate increased to 84.9% after a second injection. A further 10.2% of refluxing ureters showed significant improvement in the grade of reflux after a single injection and needed no further treatment. 1.3% of ureters were cured after a third or fourth injection. Failure to correct or improve VUR was seen in 224 ureters (3.6%), necessitating reimplantation. Twenty ureters (0.32%) developed vesicoureteric junction obstruction following STING and these were reimplanted without difficulty. Results of this multicentre survey confirm that STING is an effective day care procedure for treatment of all grades of VUR. 95% of all ureters were cured or showed significant improvement after two injections of Teflon paste.(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic correction of vesico-ureteric reflux in duplex systems.

Between May 1984 and April 1990, 37 children with vesico-ureteric reflux (VUR) in 43 duplex systems were treated by endoscopic subureteric Teflon injection (STING). There were 32 girls and 5 boys; the duplex systems were complete in 27 refluxing units and incomplete in 16 refluxing units. All patients had high-grade reflux. In incomplete duplicated systems, VUR was corrected in 14 (87.5%) after a single injection of polytef paste and 2 patients required 2 injections to correct VUR. Of the 27 refluxing units with complete ureteral duplication, reflux was corrected in 16 (59%) units after a single injection of polytef paste, and 3 (11%) units showed improvement of VUR to grade I or II after 1 injection; no further treatment was given. 7 units with complete ureteral duplication required 2-4 injections for correction of VUR. STING failed to correct VUR in 1 duplex system which required a re-implantation. In 93% of refluxing units where VUR was corrected by a single injection, the quantity of polytef paste used was less than 0.3 ml. 36 (97%) of patients were discharged home on the day of the procedure. All patients were followed up for 2-8 years. Of the corrected ureters, there were no recurrences in the incomplete duplicated ureters. 3 of the completely duplicated ureters showed recurrence of reflux at follow-up micturating cystography.(ABSTRACT TRUNCATED AT 250 WORDS)

Delayed primary anastomosis for esophageal atresia: 18 months' to 11 years' follow-up.

In 1977 we started treating babies with isolated esophageal atresia by delayed primary anastomosis and in 1981 reported our early experience in five cases treated between 1977 and 1979. Since 1979, 11 further consecutive cases have been managed by initial gastrostomy followed by delayed primary esophageal anastomosis. Their mean gestation was 35 weeks (range, 28 to 40 weeks) and mean birth weight was 2,040 g (range, 1,140 to 2,720 g). The esophageal gap between the two ends when assessed initially at fluoroscopy ranged from 2.2 to 4.5 cm (mean, 3.2 cm). Age at delayed primary anastomosis ranged from 6 to 20 weeks. Anastomotic leak occurred in three babies in the immediate postoperative period and all were successfully managed conservatively. Eight of the 11 patients developed anastomotic strictures; seven cases required 1 to 5 esophageal dilatations. One patient who did not respond to multiple esophageal dilatations required resection of an esophageal stricture. One patient died at 15 months of age of unrelated causes. The 10 surviving patients have been followed-up from 18 months to 11 years. At follow-up, seven patients were eating normally. Three patients had swallowing difficulties and all three were found to have esophageal strictures on barium swallow, two of them also had gross esophageal reflux and hiatus hernia. The height and weight in the 10 patients varied from 3rd centile to 75th centile. Delayed primary anastomosis is feasible in cases of isolated esophageal atresia and the patient's own esophagus is the best. A more aggressive approach should be applied to gastroesophageal reflux in these patients.

Preoperative stabilisation in congenital diaphragmatic hernia.

Between January 1983 and November 1986, 26 newborn infants with congenital diaphragmatic hernia were treated by early operation at a mean of 7 hours of age. A further 23 infants admitted between December 1986 and December 1989 were stabilised for a mean period of 40 hours before operation. There was no significant difference in survival between the two groups. Delayed operation is not detrimental to infants with congenital diaphragmatic hernia.

Epidemic hepatitis B caused by commercial human immunoglobulin.

An epidemic of acute hepatitis B followed the administration of human immunoglobulin to members of the staff of a mission hospital in India and their families. Jaundice developed in 123 (38%) of 325 persons inoculated. Hepatitis-B surface antigen was detected in three of the batches of immunoglobulin which were available for testing.