Anterior Urethral Advancement as a Single-Stage Technique for Repair of Anterior Hypospadias: Our Experience.

PURPOSE: Many techniques have been described to correct anterior hypospadias with variable results. Anterior urethral advancement as one stage technique was first described by Ti Chang Shing in 1984. It was also used for the repair of strictures and urethrocutaneous fistulae involving distal urethra. We report our experience of using this technique with some modification for the repair of anterior hypospadias. MATERIALS AND METHODS: In the period between 2013-2015, 20 cases with anterior hypospadias including 2 cases of glanular, 3 cases of coronal, 12 cases of subcoronal and 3 cases of distal penile hypospadias were treated with anterior urethral advancement technique. Patients' age groups ranged from 18 months to 10 years. Postoperatively, patients were passing urine from tip of neomeatus with satisfactory stream during follow up period of 6 months to 2 years. RESULTS: There were no major complications in any of our patients except in one patient who developed meatal stenosis which was treated by periodic dilatation. Three fold urethral mobilization was sufficient in all cases. CONCLUSION: Anterior urethral advancement technique is a single-stage procedure with good cosmetic results and least complications for anterior hypospadias repair in properly selected cases.

Durham Smith Vest-Over-Pant Technique: Simple Procedure for a Complex Problem (Post-Hypospadias Repair Fistula).

OBJECTIVE: Urethrocutaneous fistula, which occurs after hypospadias surgery, is often a baffling problem and its treatment is challenging. The study aimed to evaluate the results of the simple procedure (Durham Smith vest-over-pant technique) for this complex problem (post-hypospadias repair fistula). METHODS: During the period from 2011 to 2015, 20 patients with post-hypospadias repair fistulas underwent Durham Smith repair. Common age group was between 5 and 12 years. Site wise distribution of fistula was coronal 2 (10%), distal penile 7 (35%), mid-penile 7 (35%), and proximal-penile 4 (20%). Out of 20 patients, 15 had fistula of size <5 mm (75%) and 5 patients had fistula of size >5 mm (25%). All cases were repaired with Durham Smith vest-over-pant technique by a single surgeon. In case of multiple fistulas adjacent to each other, all fistulas were joined to form single fistula and repaired. RESULTS: We have successfully repaired all post-hypospadias surgery urethrocutaneous fistulas using the technique described by Durham Smith with 100% success rate. CONCLUSION: Durham Smith vest-over-pant technique is a simple solution for a complex problem (post hypospadias surgery penile fistulas) in properly selected patients.

Ureterocalycostomy - final resort in the management of secondary pelvi-ureteric junction obstruction: our experience.

Ureterocalycostomy can be performed in patients in whom desired methods of treating secondary PUJ (Pelvi-Ureteric Junction) obstructions either failed or could not be used. In our study, one child and two adults in whom one redo-ureterocalycostomy and two ureterocalycostomies were performed for severely scarred PUJ. The causes for secondary PUJ obstruction were post-pyelolithotomy in one case, post-pyeloplasty and ureterocalycostomy for PUJ obstruction in the second patient and the third patient had long upper ureteric stricture post-ureteropyeloplasty due to tuberculosis. In all these cases ureterocalycostomy proved to be salvage/final resort for preserving functional renal unit.

Ureterocalycostomy - final resort in the management of secondary pelvi-ureteric junction obstruction: our experience

ABSTRACT: Ureterocalycostomy can be performed in patients in whom desired methods of treating secondary PUJ (Pelvi-Ureteric Junction) obstructions either failed or could not be used. In our study, one child and two adults in whom one redo-ureterocalycostomy and two ureterocalycostomies were performed for severely scarred PUJ. The causes for secondary PUJ obstruction were post-pyelolithotomy in one case, post-pyeloplasty and ureterocalycostomy for PUJ obstruction in the second patient and the third patient had long upper ureteric stricture post-ureteropyeloplasty due to tuberculosis. In all these cases ureterocalycostomy proved to be salvage/final resort for preserving functional renal unit

A Scalable Cyberinfrastructure for Interactive Visualization of Terascale Microscopy Data.

The goal of the recently emerged field of connectomics is to generate a wiring diagram of the brain at different scales. To identify brain circuitry, neuroscientists use specialized microscopes to perform multichannel imaging of labeled neurons at a very high resolution. CLARITY tissue clearing allows imaging labeled circuits through entire tissue blocks, without the need for tissue sectioning and section-to-section alignment. Imaging the large and complex non-human primate brain with sufficient resolution to identify and disambiguate between axons, in particular, produces massive data, creating great computational challenges to the study of neural circuits. Researchers require novel software capabilities for compiling, stitching, and visualizing large imagery. In this work, we detail the image acquisition process and a hierarchical streaming platform, ViSUS, that enables interactive visualization of these massive multi-volume datasets using a standard desktop computer. The ViSUS visualization framework has previously been shown to be suitable for 3D combustion simulation, climate simulation and visualization of large scale panoramic images. The platform is organized around a hierarchical cache oblivious data layout, called the IDX file format, which enables interactive visualization and exploration in ViSUS, scaling to the largest 3D images. In this paper we showcase the VISUS framework used in an interactive setting with the microscopy data.

Functional convergence of oxylipin and abscisic acid pathways controls stomatal closure in response to drought.

Membranes are primary sites of perception of environmental stimuli. Polyunsaturated fatty acids are major structural constituents of membranes that also function as modulators of a multitude of signal transduction pathways evoked by environmental stimuli. Different stresses induce production of a distinct blend of oxygenated polyunsaturated fatty acids, "oxylipins." We employed three Arabidopsis (Arabidopsis thaliana) ecotypes to examine the oxylipin signature in response to specific stresses and determined that wounding and drought differentially alter oxylipin profiles, particularly the allene oxide synthase branch of the oxylipin pathway, responsible for production of jasmonic acid (JA) and its precursor 12-oxo-phytodienoic acid (12-OPDA). Specifically, wounding induced both 12-OPDA and JA levels, whereas drought induced only the precursor 12-OPDA. Levels of the classical stress phytohormone abscisic acid (ABA) were also mainly enhanced by drought and little by wounding. To explore the role of 12-OPDA in plant drought responses, we generated a range of transgenic lines and exploited the existing mutant plants that differ in their levels of stress-inducible 12-OPDA but display similar ABA levels. The plants producing higher 12-OPDA levels exhibited enhanced drought tolerance and reduced stomatal aperture. Furthermore, exogenously applied ABA and 12-OPDA, individually or combined, promote stomatal closure of ABA and allene oxide synthase biosynthetic mutants, albeit most effectively when combined. Using tomato (Solanum lycopersicum) and Brassica napus verified the potency of this combination in inducing stomatal closure in plants other than Arabidopsis. These data have identified drought as a stress signal that uncouples the conversion of 12-OPDA to JA and have revealed 12-OPDA as a drought-responsive regulator of stomatal closure functioning most effectively together with ABA.

Derivation of a risk assessment tool for emergency department patients with sickle cell disease.

INTRODUCTION: Sickle cell patients commonly present to the emergency department (ED). Identifying those requiring admission and those who can safely be discharged is difficult. It was hypothesised that ED variables predictive of 96-h adverse sickle cell patient outcomes are identifiable. METHODS: This observational cohort study included all adult sickle cell patient visits (1 June 2004-31 May 2005) to two ED. Patients were identified by ICD-9 codes of vaso-occlusive crisis and lists from treating haematologists. ED charts were abstracted for history, physical examination, laboratory/imaging data and outcomes. Outcomes were hospitalisation within 96 h of ED presentation for transfusion/antibiotic treatment, acute chest syndrome, or aplastic or sequestration crisis. Logistic regression was used to derive a risk score, which was tested in a validation cohort. The area under the receiver operating curve (AUC) was used to measure score performance. RESULTS: There were 884 ED visits by 125 patients (mean age 36 years/55% female/58% homozygous sickle cell disease). 199 ED visits had one or more outcome (197 transfusion/antibiotic treatment, 71 acute chest syndrome, and one aplastic crisis). The risk score included sickle variant, chest pain, chills, pain dissimilar to past, temperature (<36 degrees C/>38 degrees C), oxygen saturation (<95%), haemoglobin (<10 g/dl), urine nitrites and chest x ray abnormality. The score had an AUC of 0.816 (95% CI 0.778 to 0.854) in the derivation cohort, 0.824 (95% CI 0.760 to 0.889) in the validation cohort. CONCLUSION: Those ED variables predictive of 96-h adverse sickle cell patient outcomes can be identified and combined into a risk score. Prospective validation is necessary before any clinical decision-making based on this score.

In vivo model to determine fetal-cell enrichment efficiency of novel noninvasive prenatal diagnosis methods.

OBJECTIVE: To develop an in vivo model to determine fetal-cell enrichment efficiency of novel noninvasive prenatal diagnosis methods. METHODS: Efficiency of our three-step enrichment protocol was determined in vitro before fetal nucleated red blood cells (FNRBCs) were enriched from first-trimester maternal blood samples collected from the same patients pre- and postsurgical termination of pregnancy (TOP) (n = 10). FNRBCs enriched were identified using embryonic epsilon-globin immunocytochemistry and chromosomal fluorescence in situ hybridization. RESULTS: We recovered 37% of spiked FNRBCs (95% confidence interval (CI) 28.5-45.6; n = 8) in in vitro experiments. We show a consistent threefold increase in the number of epsilon + FNRBCs in maternal blood obtained immediately post-TOP (p = 0.005). A mathematical relationship was derived: observed number of pretermination primitive FNRBCs = 0.6 + 0.31 (coefficient between pretermination/post-termination primitive FNRBCs, 95% CI 0.12-0.49; p = 0.005) x observed number of post-termination primitive FNRBCs (R2 = 0.65). CONCLUSION: Our data demonstrate that maternal blood obtained immediately post-TOP would be a good in vivo model to determine the enrichment efficiency of novel protocols and methods for noninvasive prenatal diagnosis.

Comparison of characteristics of admitted emergency department patients requiring cardiopulmonary resuscitation in the ICU and non-ICU setting.

BACKGROUND: Hospitalised patients requiring cardiopulmonary resuscitation (CPR) have better outcomes in intensive care units (ICUs) than wards. Survival could potentially be improved for patients at high risk for CPR if they can be identified while in the emergency department (ED) and admitted to an ICU setting. It is currently unknown whether patients requiring CPR who are admitted to the ward show a similar pattern of physiological deterioration to those admitted to the ICU, and thus whether future research should consider these two patients groups as distinct. It is hypothesised that, since both groups of patients decompensate to the point of requiring acute resuscitation shortly after hospital admission, they should also share similar premonitory signs of deterioration in their basic physiological parameters. METHODS: A retrospective chart review was performed of adult patients at an urban ED requiring CPR within 72 h of admission from March 2002 to March 2005. Data were compared between subjects admitted to ICU and non-ICU beds. RESULTS: 45 patients (58% women) of mean age 59 years met the inclusion criteria; 40% required CPR in a non-ICU ward. There were no differences in demographic characteristics, ED chief complaint or admission diagnosis between the two groups. Blood pressure was significantly higher in the non-ICU subjects at ED arrival (129/75 vs 100/50), time of admission (122/74 vs 103/58) and before CPR (117/70 vs 92/50) (p

Induction policy and missed post-term pregnancies: a mathematical model.

The aim of this study was to compare the clinical performance of ultrasound dates and ultrasound dates combined with menstrual dates for the detection of post-maturity. A computer model was designed which uses the statistical distributions of the duration of normal pregnancy, day of ovulation in relation to the menstrual cycle and ultrasound error for estimating gestational age. The clinical performance of the different dating methods was then analysed from these variables, on simulations of 30,000 cases. The efficacy of different dating methods for detecting post-maturity was determined by generating receiver-operator characteristics (ROC) curves. The proportion of post-term pregnancies (294 days and over) predicted by the model (3.5%) agrees with published values. There is a steep rise in missed cases if induction is delayed beyond 10 days from the expected date of delivery, reaching 20% on day 294. Elective delivery on day 290 will detect 98.9% of cases destined to deliver post-term, with an induction rate of 10%; the respective figures for induction on day 294 are 79% and 3.8%. The ROC curves for the detection of post-maturity suggest that use of the mid-trimester biparietal diameter (BPD) is better than a 7-day or 10-day rule. Timing of elective delivery is the most important variable affecting the detection rate for post-maturity There is no advantage in using menstrual dates when ultrasound biometry is available.

Sonographic fetal weight estimation in a south-east Asian population.

OBJECTIVES: To determine the optimal sonographic fetal weight estimation formula for a mixed south-east Asian population near term. METHODS: Seventy-eight uncomplicated pregnancies were monitored between January 1996 and January 1997. Biparietal diameter, head circumference, abdominal circumference and femur length were measured and the following formulae were tested: Campbell, Shepherds and Hadlock. The estimated fetal weight was calculated by 12 different methods. The weight estimate was then projected forward to the time of delivery using the gestation-adjusted forward projection method. The weight estimation error was derived from the difference between the projected fetal weight and birth weight, and expressed as a percentage of birth weight. RESULTS: The mean time interval from the time of ultrasound fetal weight estimation to delivery was 4.4 days. The birth weight ranged between 2,330 to 4,215 g. The best performing formula was Hadlock's formula using the head circumference, abdominal circumference and femur, with the perimeters calculated using the ellipse function. The standard deviation of error for this formula was 8.66%. CONCLUSION: Even though the Hadlock formula was originally derived from an American population, it was equally useful in south-east Asian population.

Intrahepatic vein fetal blood sampling: current role in prenatal diagnosis.

OBJECTIVE: To identify the site of fetal blood sampling (FBS) with lesser complications; and also analyses the reasons for targetting the intrahepatic vein (IHV) for FBS. METHODS: Fetal blood sampling (FBS) performed on 382 women over a period of 7 years at the National University Hospital, Singapore was analysed. FBS was performed from 13 weeks of gestational age onwards. In 76.4% (292 of 382) the intrahepatic part of the umbilical vein (IHV) was targetted; in 18.3% (70 of 382) percutaneous umbilical cord sampling (PUBS) was performed; in 5.2% (20 of 382) cardiocentesis was performed to obtain fetal blood. RESULTS: Multivariate analysis showed an increase in odds of fetal loss for umbilical cord and cardiocentesis groups compared with the IHV FBS group. It was statistically significant (p < 0.01) only in the cardiocentesis group for fetal loss at < 2 weeks of performing the procedure.

A case report: vesico-rectal fistula with ano-urethral atresia.

Vesico-rectal fistula is a rare congenital abnormality causing severe early second trimester oligohydramnios. Prenatal diagnosis of such a case is reported here. Ultrasound diagnosis could be aided by transabdominal amnio-infusion and, if necessary, fetal intraperitoneal saline installation. In a karyotypically normal fetus with normal somatic growth, demonstration of normal fetal kidneys together with a functioning urinary bladder, in presence of severe oligohydramnios, is very suggestive of the diagnosis. Since pulmonary hypoplasia is the major cause of neonatal mortality in these cases, restoration of normal amniotic fluid volume by serial amnio-infusion was attempted. Although amnio-infusion is an important diagnostic aid in the evaluation of severe midtrimester oligohydramnios, the role of multiple therapeutic amnio-infusion in improving lung growth remains to be evaluated.