Glenn M. Cannon

Evaluation of gel spun silk-based biomaterials in a murine model of bladder augmentation.

Currently, gastrointestinal segments are considered the gold standard for bladder reconstructive procedures. However, significant complications including chronic urinary tract infection, metabolic abnormalities, urinary stone formation, bowel dysfunction, and secondary malignancies are associated with this approach. Biomaterials derived from silk fibroin may represent a superior alternative due their robust mechanical properties, biodegradable features, and processing plasticity. In the present study, we evaluated the efficacy of a gel spun silk-based matrix for bladder augmentation in a murine model. Over the course of 70 d implantation period, H&E and Massons trichrome (MTS) analysis revealed that silk matrices were capable of supporting both urothelial and smooth muscle regeneration at the defect site. Prominent uroplakin and contractile protein expression (α-actin, calponin, and SM22α) was evident by immunohistochemical analysis demonstrating maturation of the reconstituted bladder wall compartments. Gel spun silk matrices also elicited a minimal acute inflammatory reaction following 70 d of bladder integration, in contrast to parallel assessments of small intestinal submucosa (SIS) and poly-glycolic acid (PGA) matrices which routinely promoted evidence of fibrosis and chronic inflammatory responses. Voided stain on paper analysis revealed that silk augmented animals displayed similar voiding patterns in comparison to non surgical controls by 42 d of implantation. In addition, cystometric evaluations of augmented bladders at 70 d post-op demonstrated that silk scaffolds supported significant increases in bladder capacity and voided volume while maintaining similar degrees of compliance relative to the control group. These results provide evidence for the utility of gel spun silk-based matrices for functional bladder tissue engineering applications.

Should Progressive Perineal Dilation be Considered First Line Therapy for Vaginal Agenesis

PURPOSE In women with vaginal agenesis progressive perineal dilation provides a minimally invasive method to create a functional vagina without the attendant risks or complications of traditional surgical options. We report our 12-year experience with this technique. MATERIALS AND METHODS Patients with vaginal agenesis treated at our institution were analyzed retrospectively and followed prospectively using case report forms and semistructured interviews. Patients diagnosed with vaginal agenesis were counseled on vaginal reconstruction options. Those electing progressive perineal dilation were instructed on the proper use of vaginal dilators by one of us (MRL) and advised to dilate 2 or 3 times daily for 20 minutes. All patients received physician, nursing and social work education and counseling. Parameters reviewed included primary diagnosis, start and end of vaginal dilation, dilation frequency, dilator size, sexual activity and whether the patient experienced pain or bleeding with dilation or sexual activity. Functional success was defined as the ability to achieve sexual intercourse, vaginal acceptance of the largest dilator without discomfort or a vaginal length of 7 cm. Univariate and multivariate analysis was performed to identify factors associated with successful neovaginal creation. RESULTS From 1996 to 2008 we enrolled 69 females with vaginal agenesis in a progressive perineal dilation program. The primary diagnosis was Mayer-Rokitansky-Küster-Hauser syndrome in 64 patients. Mean age at the start of vaginal dilation was 17.5 years (range 14 to 35) Mean followup was 19 months (range 0 to 100). Four patients (5.7%) were lost to followup. In 7 of the remaining 65 patients (12%) treatment failed due to noncompliance and 50 (88%) achieved functional success at a median of 18.7 months. Patients who dilated frequently (once daily or greater) achieved a functional neovagina at a mean +/- SD of 4.3 +/- 2.4 months. Functional success correlated positively with frequent (once daily or greater) dilation and the initiation of sexual activity. Complications were minor. Three patients reported infrequent pain and 2 reported a single episode of bleeding with dilation. A total of 18 sexually active patients reported satisfactory intercourse without dyspareunia. CONCLUSIONS Progressive perineal dilation for neovaginal creation is a valuable, minimally invasive therapy to create a functional vagina with a high success rate and a much lower complication rate than that in published surgical series. Given these findings, progressive perineal dilation should be offered as first line therapy in adolescents with a congenitally absent vagina.

Management Strategies for Mayer-Rokitansky-Kuster-Hauser Related Vaginal Agenesis: A Cost-Effectiveness Analysis

PURPOSE The optimal method for neovagina creation in patients with vaginal agenesis is controversial. Progressive perineal dilation is a minimally invasive method with high success rates. However, the economic merits of progressive perineal dilation compared to surgical vaginoplasty are unknown. MATERIALS AND METHODS We performed a Markov based cost-effectiveness analysis of 3 management strategies for vaginal agenesis-progressive perineal dilation with and without subsequent vaginoplasty, and up-front vaginoplasty. Cost data were drawn from the Pediatric Health Information System database (2004 to 2009) for inpatient procedures and from governmental cost data (2009) for outpatient procedures and clinical followup. Other model parameters were derived from a systematic literature review and comparison with other congenital and acquired pediatric and/or adolescent gynecologic conditions. Bounded and probabilistic sensitivity analyses were used to assess model stability. RESULTS Including all procedures, equipment and physician visits, progressive perineal dilation had a mean cost of

A computer-assisted quality assurance system for an emergency medical service

796, while vaginoplasty cost

Cost analysis of pediatric robot-assisted and laparoscopic pyeloplasty.

18,520. Up-front vaginoplasty was strongly dominated at any age, ie was more expensive but no more effective than other options. In cases of progressive perineal dilation failure the incremental cost-effectiveness ratio of progressive perineal dilation with subsequent vaginoplasty was

An Akt- and Fra-1-Dependent Pathway Mediates Platelet-Derived Growth Factor-Induced Expression of Thrombomodulin, a Novel Regulator of Smooth Muscle Cell Migration

1,564 per quality adjusted life-year. Only the utility weights of life after treatment impacted model outcomes, while frequency of followup and probability of treatment success did not. CONCLUSIONS Initial progressive perineal dilation followed by vaginoplasty in cases of dilation failure is the most cost-effective management strategy for vaginal agenesis. Initial vaginoplasty was less cost-effective than initial progressive perineal dilation in 99.99% of simulations.

Computerized tomography findings in pediatric renal trauma--indications for early intervention?

A busy urban emergency medical service answering more than 50,000 calls each year developed a plan for quality assurance using a computer-assisted model designed to employ a full-time quality assurance officer whose work was supplemented with computer evaluation of EMS field reports. The development of standardized reporting formats, protocols and computer programs enabled a significant improvement in detection of errors of documentation and patient care. Investigated cases rose dramatically in the month following implementation of the system, from five patient care errors per month to 35 (P less than .05), and from 50 documentation errors to 265 per month (P less than .05). Our experience indicates that computer-assisted evaluation of field performance, as judged by prehospital records, is a useful tool to ensure standards in patient care and EMS recordkeeping.

Timing and Predictors for Urinary Drainage in Children with Expectantly Managed Grade IV Renal Trauma

PURPOSE An increasing percentage of pediatric pyeloplasties are being performed with assistance of the da Vinci® Surgical System. A review of the recent literature shows decreased operative times and length of hospital stays when robotic procedures are performed, although there are few published data comparing the cost of pediatric robotic and pure laparoscopic pyeloplasty. We reviewed a representative sample of pyeloplasties performed at our institution and performed a cost analysis. MATERIALS AND METHODS We retrospectively identified 23 robot-assisted and 23 laparoscopic pyeloplasties performed at our institution between August 2008 and April 2012. Total cost was calculated from direct and indirect costs provided by our billing department. RESULTS Robotic procedures were shorter than pure laparoscopic procedures (200 vs 265 minutes, p <0.001) but there was no significant difference in the total cost of the 2 procedures (

Noninvasive assessment of testicular torsion in rabbits using frequency-domain near-infrared spectroscopy: prospects for pediatric urology

15,337 vs

Cystatin C as a marker of early renal insufficiency in children with congenital neuropathic bladder.

16,067, p <0.46). When compared to laparoscopic cases, subgroup analysis demonstrated decreased operative times (140 vs 265 minutes, p <0.00001) and total cost (