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Objective To determine the detrusor pressure rise of a normal bladder (P(cap,NL)) when filled to capacity. Patients and methods Twenty-four patients with an apparently normal bladder, i.e. with symptoms but whose cystometrogram (CMG) showed no pathology of any kind and a near-normal pressure vs volume plot, were selected from 218 clinical CMGs. A straight line was fitted to the PV plot of these CMGs and then the P(cap,NL) calculated, e.g. by a straight line extending to the point of the normal expected cystometric bladder capacity (V(cap.NL)). Published data relative to P(cap,NL) were evaluated and compared with the values obtained. Results The mean (range) P(cap,NL) was 6 (4.5-7) cmH2O for patients with apparently normal bladders infused at the maximum physiological diuresis (MPD). This value was substantiated by three other studies of published values. The P(cap,NL) was 6 cmH2O at infusion rates of 10% of glomerular filtration rate (GFR), 10 cmH2O at 20% of GFR and 7-15 cmH2O for 3-10 times the infusion rate of 10% of GFR. Conclusion P(cap,NL) is independent of age, size and sex and, at constant infusion rates of approximately MPD, will be 6. For infusion rates up to 35 mL/min, it is in the range of 6-15 cmH2O.

Intravesically applied oxybutynin has been reported to have no significant systemic anticholinergic side effects, with excellent efficacy in the treatment of neurogenic bladder dysfunction. Currently, the morphologic effects of intravesical oxybutynin on the local bladder tissue are not well established. It is the purpose of this study to address this issue in an animal model. Thirty-nine New Zealand White female rabbits were catheterized daily and intravesical solutions instilled for as long as 30 days. In part A of the study, the overall histologic effects of intravesical oxybutynin were examined by comparing oxybutynin with saline administration. Part B of this study compared the relative effects of crushed oxybutynin tablets and pure oxybutynin powder. The bladder histology and urine microbiological studies were analyzed in a blinded fashion. We found that the crushed oxybutynin tablets and saline administered intravesically produced similarly mild inflammation in the bladders (p0.05). When we compared the crushed oxybutynin tablets and pure oxybutynin powder, however, the crushed tablet group was found to have a mild eosinophilic infiltrate seen in 5 of 9 animals, which was not observed in any of the animals in the other groups (p = 0.029). Qualitative and quantitative analyses of the microbiological findings were not different among the different groups (p0.05). Our findings support the clinical use of intravesical oxybutynin as being safe for local tissue. However, consideration should be given to the use of the pure powdered form of oxybutynin, since the crushed oxybutynin tablets may lead to allergic reactions.

Hypothalamic-pituitary-adrenal (HPA) axis dysfunction is a common finding in Alzheimer's dementia. Since there is loss of hippocampal corticosteroid receptors in animal models of aging, and since hippocampal cell loss occurs in Alzheimer's disease (AD), it has been suggested that a loss of hippocampal glucocorticoid receptors (GR) may underlie some aspects of HPA axis dysfunction in patients with AD. Levels of corticosteroid receptor protein are not reliably determined in postmortem human brain due to rapid lability. In contrast, levels of mRNA coding for GR are stable in postmortem tissue. We report here initial observations from in situ hybridization experiments which indicate that regional levels of glucocorticoid receptor mRNA in hippocampus, as determined by film autoradiography, are significantly higher in AD hippocampus than in controls. While neuronal levels of GR mRNA in AD, revealed by emulsion autoradiography, were equal in control and AD tissue. Taken together these results suggest that adrenal dysfunction in AD may relate to defects in receptor function rather than corticosteroid receptor loss in the hippocampus.

Two cases of congenital midureteral adynamic segments are presented. Both children were successfully managed with excision of the lesions and primary reanastomosis. Pathologic examination revealed probe-patent ureters with muscular disarray, suggesting functional obstruction. Appropriate management of the anomaly was dependent on precise radiographic localization of the area of narrowing, and for this retrograde urography was essential. Primary ureteroureterostomy was successful in both cases. In this report we discuss the diagnosis, embryology, radiographic evaluation, and management of this rare situation.

Assessment of bladder storage function requires an accurate measure of bladder capacity and pressure. Pressure specific bladder volume is the volume that a bladder can accommodate at a specific pressure. A total of 21 consecutive children with neurogenic bladders who were candidates for bladder augmentation based on standard clinical criteria (upper urinary tract deterioration, incontinence and infection) was studied to determine the efficacy of pressure specific bladder volume as a measure of bladder dysfunction. Urodynamic indexes were compared to previously established nomograms. All 21 patients had bladder volumes at pressures of 30 cm. water or less, which decreased below the 5th percentile as determined by the nomogram. In 7 patients (33%) normal total bladder capacity was achieved at the expense of elevated storage pressures. Pressure specific bladder volume provides a better measure of bladder storage function than total bladder capacity because it relates volume to intravesical pressure, does not rely on a subjective end point to bladder filling, and is objective and reproducible.

Tumour necrosis factor-alpha (TNF-alpha) is a potent pro-inflammatory and immunomodulatory cytokine implicated in inflammatory conditions such as rheumatoid arthritis, Crohn's disease, multiple sclerosis and the cachexia associated with cancer or human immunodeficiency virus infection. TNF-alpha is initially expressed as a 233-amino-acid membrane-anchored precursor which is proteolytically processed to yield the mature, 157-amino-acid cytokine. The processing enzyme(s) which cleave TNF-alpha are unknown. Here we show that the release of mature TNF-alpha from leukocytes cultured in vitro is specifically prevented by synthetic hydroxamic acid-based metalloproteinase inhibitors, which also prevent the release of TNF-alpha into the circulation of endotoxin challenged rats. A recombinant, truncated TNF-alpha precursor is cleaved to biologically active, mature TNF-alpha by several matrix metalloproteinase enzymes. These results indicate that processing of the TNF-alpha precursor is dependent on at least one matrix metalloproteinase-like enzyme, inhibition of which represents a novel therapeutic mechanism for interfering with TNF-alpha production.

To store adequate volumes of urine at low safe pressures an elastic bladder wall is required. We developed 2 new techniques to measure this ability in our urodynamic laboratory: pressure specific bladder volume, which measures the bladder capacity at a given pressure, and dynamic analysis of bladder compliance. Recently, morphometric and histochemical techniques have been used to determine the relative volume of connective tissue in the bladder wall and to measure the 2 major types (I and III) of collagen within the bladder wall. These methods quantitate 3 parameters of bladder ultrastructure: 1) relative volume of per cent connective tissue, 2) ratio of connective tissue to smooth muscle and 3) ratio of type III to type I collagen. These parameters have been shown to be abnormally elevated in patients with dysfunctional bladders compared to normals. The purpose of the study was to describe the ultrastructural changes that occur in the wall of dysfunctional bladders and to determine the ability of these new urodynamic techniques to detect reliably the clinical effect of these histological changes. The study included 29 consecutive patients with dysfunctional bladders necessitating bladder augmentation. All patients had upper tract changes and/or were incontinent despite treatment with clean intermittent catheterization and pharmacotherapy. Preoperative urodynamic evaluation included measurement of the total bladder capacity, pressure specific bladder volume and dynamic analysis of bladder compliance. Full thickness bladder biopsies were obtained from the dome of the bladders during augmentation. The per cent connective tissue and the ratio of connective tissue to smooth muscle were determined for all patients, and 4 unselected patients from this group had the ratio of type III to type I collagen determined. These histological results were compared to previously established normal values. All 29 patients had a decreased pressure specific bladder volume and dynamic analysis of bladder compliance, whereas 9 had a normal total bladder capacity. The per cent connective tissue was 35.19 +/- 2.84 and ratio of connective tissue to smooth muscle was 0.60 +/- 0.08 compared to normal values of 10.6 +/- 0.020 and 0.131 +/- 0.021, respectively (p < 0.05). Ratio of type III to type I collagen was also significantly elevated in the 4 samples analyzed (30.53 +/- 1.37 versus 24.00 +/- 2.50, p < 0.05). We conclude that poor storage function of poorly compliant bladders is secondary to an alteration in the connective tissue content of the bladder wall. Furthermore, these pathological ultrastructural changes are universally reflected by an abnormally low pressure specific bladder volume and dynamic analysis of bladder compliance. This strong association validates the use of these parameters and suggests that they are urodynamic indicators of a loss of elasticity in bladder wall.

Elevation in the intrarenal resistive index has been suggested by many to be a physiological parameter useful for detecting functionally significant hydronephrosis. It is currently unknown whether the intrarenal resistive index changes truly reflect the changes in collecting system pressure or whether they are simply a coincidental epiphenomenon. The purpose of this study is to establish the relationship between intrarenal resistive index and collecting system pressure. Between August 1992 and October 1993, 9 patients younger than 1 year underwent a percutaneous pressure-flow study as part of hydronephrosis evaluation. During the pressure-flow study intrarenal resistive index was measured serially with simultaneous renal pelvis pressure readings. In all patients the index increased as the renal pelvis pressure increased. Furthermore, using the experimentally derived proximal tubular pressure of 14 cm. water as the probable threshold for functionally normal collecting system pressure, it was found that all intrarenal indexes of 82% or less corresponded to renal pelvis pressures of less than 14 cm. water, while all of those greater than 82% corresponded to renal pelvis pressures greater than 14 cm. water. By combining several lines of evidence, it appears probable that as maximal diuresis induced by physiological and pharmacological means leads to acute transient elevation in renal pelvis pressure in a functionally obstructed collecting system, the intrarenal resistive index is capable of reflecting this dynamic elevation in renal pelvis pressure and potentially able to distinguish physiologically significant upper urinary tract obstruction from nonobstructive dilatation.

We selected a group of children with unilateral hydroureteronephrosis to assess the significance of the differential renal function as determined by nuclear renography as a factor in defining obstructive dilatation. All children who presented to our institution during a 21-month period with unilateral hydroureteronephrosis and a normal contralateral kidney were reviewed. Patients with reflux or bladder pathology were excluded, resulting in 13 evaluable patients younger than age 2 years. Diuretic renography was performed using 99mtechnetium-diethylenetriaminepentaacetic acid in accordance with the well tempered renogram. Ancillary studies included voiding cystourethrography, ultrasonography and/or excretory urography. Of the 13 patients 5 had a differential function greater than 55% in the hydronephrotic kidney. Ten of the 13 patients, including the 5 with supranormal function, underwent surgical correction in the form of ureteral reimplantation for recurrent infections, increasing hydronephrosis, decreasing or decreased function and loss of parenchyma. Stenotic distal adynamic ureteral segments with proximal dilatation were confirmed in all cases. The implication by nuclear renography that a dilated kidney has better function than its morphologically normal counterpart is at variance with any available clinical or experimental data. The etiology of this apparently elevated function is unclear and its presence on a renographic study should not be interpreted as suggestive that the kidney is free of risk of nephron loss. Management decisions should not be based solely on the differential function as determined by nuclear renography.

Bladder exstrophy and cloacal exstrophy present challenging reconstructive problems. Traditionally, bilateral posterior iliac osteotomy has been performed in the majority of patients undergoing primary closure for these abnormalities. Recently, 2 anterior osteotomy approaches have been proposed: 1) incision of the ilium transversely above the acetabulum (transverse osteotomy) and 2) incision of the superior ramus of the pubis (superior ramus osteotomy). We devised a new anterior mid-iliac diagonal osteotomy that provides a more functional pelvic closure. To provide a fair comparison of the procedures we developed a pelvic exstrophy model based on data from a 3-dimensional computerized tomogram of a 3-year-old patient with classical bladder exstrophy. The different osteotomies were then performed on the model and the results were compared. Our new anterior mid-iliac diagonal osteotomy correction allowed the best surgical approach, provided the best correction of the flattened ilia bony deformities, was performed in the thinnest area of marrow bone and resulted in the best pelvic symmetry.

The ability of a dinucleoside monophosphate to mimic the conformation of B-DNA was tested using a combination of different phosphate models (anionic, neutral, counterion), environments (gas, water), and density functionals (B3LYP, MPWB1K, M06-2X) with the 6-31G(d,p) basis set. Three sequences (5'-GX(Py)-3', where X(Py) = T, U or (Br)U) were considered, which vary in the (natural or modified) 3' pyrimidine nucleobase (X(Py)). These bases were selected due to their presence in natural DNA, structural similarity to T and/or applications in radical-initiated anti-tumour therapies. The accuracy of each of the 54 model, method and sequence combinations was judged based on the ability to reproduce key structural features of natural B-DNA, including the stacked base-base orientation and important backbone torsion angles. B3LYP yields distorted or tilted relative base-base orientations, while many computational challenges were encountered for MPWB1K. Despite wide use in computational studies of DNA, the neutral (protonated) phosphate model could not consistently predict a stacked arrangement for all sequences. In contrast, stacked base-base arrangements were obtained for all sequences with M06-2X in conjunction with both the anionic and (sodium) counterion phosphate models. However, comparison of calculated and experimental backbone conformations reveals the charge-neutralized counterion phosphate model best mimics B-DNA. Structures optimized with implicit solvent (water) are comparable to gas-phase structures, which suggests similar results should be obtained in an environment of intermediate polarity. We recommend the use of either gas-phase or water M06-2X optimizations with the counterion phosphate model to study the structure and/or reactivity of natural or modified DNA with a dinucleoside monophosphate.

We propose an alternative method of measuring compliance that takes into account the multiple phases of bladder filling. We describe our new technique, dynamic compliance analysis, and evaluate its clinical applicability. To perform the analysis we digitized a cystometrogram curve at a sampling rate of 2 samples per second using an MS-DOS computer system. A program designed to retrieve the stored data was used to analyze the subtracted bladder pressure. The result yielded a value of compliance every half second that was then plotted on an x-y graph, with instantaneous compliance as the dependent variable and per cent of total volume infused as the independent variable. To determine the clinical applicability of this technique we chose 63 curves from clinically normal patients. The results of the dynamic compliance analyses were predictable. The dynamic compliance values for the normal group had a minimum that was always greater than 10 ml./cm. water throughout the tonus limb (phase 2) of the cystometrogram. We conclude that dynamic compliance analysis yields more information about bladder response during filling, similar to the stress-strain curve used in the study of solid mechanics.

Virtually all segments of the gastrointestinal tract have been used successfully in augmentation cystoplasty. The complications inherent in enterocystoplasty are well described. Megaureters subtending effete kidneys (poorly or nonfunctioning) provide a novel and excellent source of augmentation material with urothelium and muscular backing, free of the electrolyte and acid base disturbances, and mucus production that plague enterocystoplasty. Augmentation cystoplasty using detubularized, reconfigured, otherwise disposable megaureter, with or without ipsilateral total or partial nephrectomy, was performed in 16 patients (mean age 8.8 years, range 1 to 25) with inadequate and dysfunctional bladders. Postoperative followup varied between 8 and 38 months (mean 22). The overall renal function and radiographic appearance of the remaining upper tracts have remained stable or improved in all patients. Of the 16 patients 15 require intermittent catheterization and 1 voids spontaneously. Ten patients are continent day and night, 5 have improved continence (4 damp at night and 1 stress incontinence) and 1 has failed to gain continence despite good capacity and compliance. Complete postoperative urodynamic evaluations in 12 of 13 patients show good capacity, low pressure bladders with no instability. Complications occurred in 5 patients, including transient urine extravasation in 2, contralateral ureterovesical obstruction in 2 and Mitrofanoff stomal stenosis in 1. Augmentation ureterocystoplasty combines the benefits common to all enterocystoplasties without adding any of the untoward complications or risks associated with nonurothelial augmentations.

To determine what volume a child can normally store in the bladder at a safe pressure 923 pediatric urodynamic studies were reviewed, and 69 examinations done on 17 boys and 52 girls were considered normal. Patient ages were recorded and body surface areas were calculated. A continuous intermediate flow water cystometrogram had been performed. Total bladder capacity in milliliters, full resting pressures (cm. water), and the volumes (milliliters) and percentages of the total bladder capacity stored at detrusor pressures of less than 10, 20, 30 and 35 cm. water were measured. We found that 98.1% of the total bladder capacity could be stored at a detrusor pressure of less than 20 cm. water in more than 95% of the children independently of age or body surface area and 99.9% could be stored at a detrusor pressure of less than 30 cm. water. An approximation of the minimal acceptable total bladder capacity for age can be calculated by 16(age) + 70 in ml. According to our results, we proposed criteria for good storage characteristics of the bladder in children.

The growth of Green Employment in many countries is very significant with interests having infectious optimism regarding the potential of Green Employment and the Biofuel Technologies are rapidly improving. The Biofuel Green jobs are the wave of the future, and every municipality, village, town, city, state, and governments are looking at ways to create Biofuel Green jobs - jobs that will help the Global Environment and Global Energy. The Biofuel Green Jobs Initiative is launched to assess, analyze and promote the creation of decent jobs as a consequence of the needed environmental policies. It supports an intensive effort by Governments, Employers and Trade Unions to promote environmentally sustainable jobs and development in a climate challenged world. The paper discusses the Laws relating to Biofuel Green Jobs to develop energy and to sustain environment. The paper begins with the discussion of influence of the International Labor Organization (ILO) and the role of regulatory mitigation to develop Global Energy. The paper proceeds with Legal research on the effects of Climate Change and Opportunities available through Biofuels. The renewable Biofuels can create Green Jobs and contribute to a new Energy Economy. The new research and development programs initiatives and extension of Tax Credits for clean energy production could contribute to the completion of renewable energy projects that create Green Jobs and generate economic activity through the Biofuel Industry. This paper also discusses various issues in related to Quality Norms, Risk Management and Modern Corporate Governance pertaining to Biofuels. Collectively, this paper will address a long-term enhanced action on mitigation in Biofuel for Global Environmental Stability and Global Energy Management.

A retrospective statistical analysis with a minimum followup of 10 years was done on 102 patients who presented in early childhood with posterior urethral valves. All patients were treated with initial bladder drainage. Factors correlating with the development of renal failure were evaluated. No patient with a normal kidney on 1 side had renal failure. Calculated glomerular filtration rate was significantly higher in patients who retained adequate renal function (80.7 +/- 17.8 ml. per minute per 1.73 m.2), as compared with those who had renal failure (18.6 +/- 9.6 ml. per minute per 1.73 m.2). Patients with renal failure also had a significantly higher serum creatinine level at stabilization (2.0 +/- 0.8 mg./dl.) than those who had adequate renal function (0.5 +/- 0.2 mg./dl.). The presence of bilateral high grade vesicoureteral reflux, hydronephrosis and nonfunction was significantly higher in patients with renal failure. Patient age at presentation was not a significant factor. These data represent a guideline for the prognosis and management protocols of infants with dilated upper urinary tracts and posterior urethral valves.

The use of segments of stomach for bladder augmentation is gaining popularity in pediatric urology due to favorable muscular and secretory properties. However, in a renal failure patient who underwent gastrocystoplasty a high level of acid production within the bladder associated with persistent hypergastrinemia was noted leading to severe systemic metabolic alkalosis. This condition was unresponsive to standard acid-inhibiting or neutralizing therapies but it was treated successfully with omeprazole, a proton-pump inhibitor recently introduced for treatment of peptic ulcer disease.

The pi-pi stacking (face-to-face) interactions between the five natural DNA or RNA nucleobases and the four aromatic amino acids were compared using three different types of dimers: (1) a truncated nucleoside (nucleobase) stacked with a truncated amino acid; (2) a truncated nucleoside (nucleobase) stacked with an extended amino acid; and (3) a nucleoside (extended nucleobase) stacked with a truncated amino acid. Systematic (MP2/6-31G*(0.25)) potential energy surface scans reveal important information about the effects of the deoxyribose sugar and protein backbone on the structure and binding energy between truncated nucleobase and amino acid models that are typically implemented in the literature. Most notably, electrostatic and steric interactions arising from the bulkiness of the biological backbones can change the preferred relative orientations of DNA and protein pi-systems. More importantly, the protein backbone can strengthen the stacking energy (by up to 10 kJ mol(-1)), while the deoxyribose moiety can strengthen or weaken the stacking interaction depending on the positioning of the amino acid relative to the sugar residue. These effects are likely due to additional interactions between the amino acid or nucleobase ring and the backbone in the extended monomer rather than significant changes in the properties of the biological pi-systems upon model extension. Since the present work reveals that all calculated DNA-protein stacking interactions are significant and approach the strength of other noncovalent interactions between biomolecules, both pi-pi and backbone-pi interactions must be considered when attempting to gain a complete picture of DNA-protein binding.

During the last 6 years a treatment protocol of radiographic staging along with percutaneous biopsy to establish a histological diagnosis has been used in 37 patients with Wilms tumor. Combination chemotherapy was given for 4 to 6 weeks before definitive surgical resection. In 9 patients tumor shrinkage was sufficient to permit preservation of a portion of the affected kidney(s). In stage V disease partial nephrectomy was accomplished in 5 patients. In 4 additional patients with unilateral disease downstaging also allowed partial nephrectomy. The radiological and histological changes that allowed this limited surgery are analyzed and compared.

Popliteal cysts occur commonly in both normal and arthritic knees. Most cysts are formed by distension of the medially situated semimembranosus bursa. Popliteus bursa distension occurs uncommonly as a lateral popliteal cyst. Two cases of rupture of lateral cysts which produced symptoms related to the anterolateral lower leg are reported. The difficulty of diagnosing the condition because of this unusual site of inflammation and subsequent management problems are discussed.

Twenty-eight hernias occurred in eighteen of seventy-nine pediatric patients on peritoneal dialysis (PD). There was 18 inguinal hernias (6 bilateral) in 12 patients (11 boys and 1 girl) the average age of the male patients with inguinal hernias was 5.2 years vs 9.3 years for the remaining 32 males. Four of the 11 patients were under 2 years old, where as only 3 of the remaining 32 patients were less than 2 (p less than 0.05), and 3 of the 6 patients with bilateral hernias were under 2. A high incidence of recurrent hernias was noted when only high ligation of the hernia sac was performed. We conclude that all candidates for PD should be carefully evaluated for the presence of occult hernias, hernias should be repaired promptly and electively on an inpatient basis, surgical correction of hernias should include a formal Cooper ligament repair and males under 2 should have bilateral repairs done even if they present with a single hernia.

The Siemens Lithostar lithotriptor was used to treat 20 children (4 to 17 years old) with renal or ureteral calculi. Two patients had bilateral renal and 2 had ureteral calculi. Of 34 calculi treated 47% were in the renal pelvis, 29% in the lower calix, 12% in the upper calix, 3% in the middle calix and 9% in the upper ureter. Stone size ranged from 2 × 2 to 40 × 20mm. and averaged 10 × 7mm. Of the children 60% were treated while they were under neuroleptic anesthesia. No major complications were encountered. The 3-month rate free of stones after 1 treatment was 60% and increased to 80% with multiple treatments. The success rate, defined as being either free of stones or with residual fragments equal to or less than 4mm. in diameter, was 95%. We conclude that lithotripsy with the Lithostar device in children, at least for the short term, is safe and effective.

Between 1981 and 1987, 300 patients with high grade (III, IV and V international classification) vesicoureteral reflux were treated at a single pediatric hospital. Only patients with primary vesicoureteral reflux were included in the study. The guiding principle during this period was that all patients with high grade vesicoureteral reflux would be observed on prophylactic antibiotics (observational therapy) and surgical correction would be reserved for specific indications. Of the 300 patients 132 received observational therapy alone and 168 required surgical correction for specific indications after varying periods of observation. In both groups the duration of persistent reflux was analyzed using a life-table method. In patients with grade V reflux we observed resolution in 3 patients whereas 23 required surgical correction. Of those patients in the observation group with grade IV reflux 83% had persistent reflux at 2 years and 70% still had reflux at 5 years. For those with grade III reflux the persistence rate was 83% and 50%, respectively. Neither age, sex nor side of reflux had a correlation with the rate of resolution. When tested grade of reflux correlated loosely (p = 0.07). During the period of observational therapy new renal scars developed in 23 patients (8%). We conclude that high grade vesicoureteral reflux can resolve in a minority of patients over a protracted interval. On the basis of this analysis, we advocate consideration of surgical correction in these patients after a 4-year period of observational therapy and for specific indications.

Posterior urethral valves have a broad spectrum of clinical severity determined by the degree and reversibility of the long stepwise sequence of secondary pathology. Neonatal azotemia and severe bilateral reflux are particularly important negative prognostic factors. In the mild cases, valve ablation with or without delayed reconstruction is good therapy. In the very severe cases, our interpretation of all the clinical and experimental information now available suggests that the time interval and the level of decompression are extremely important. Achievement of consistent low caliceal pressure without stasis and infections should be achieved as soon as possible. We do not agree with the philosophy of "valve ablation and wait and see" for secondary reconstruction as applied to the severe cases. An analogous philosophy would be treating all respiratory infections as upper respiratory infections and applying aggressive appropriate therapy for pneumonia only if the patient does not respond clinically. However, all controversy aside, the management of neonatal infants with posterior urethral valves remains a difficult and challenging problem for us all. The real challenge will be to improve published management results to the point that the family faced with decisions regarding an in utero diagnosis of posterior urethral valves will have enough hope to continue the pregnancy.

The course of a patient with the phenomenon of 48-h mood cycles, including her response to medication and to systematic partial sleep deprivation, is described. She had only a partial response to tranylcypromine alone. Partial sleep deprivation during the second half of alternate nights successfully prevented depressive mood cycles. Three to four weeks after discontinuing tranylcypromine she lost her ability to sustain this regimen. This case demonstrates an interaction between antidepressant medication and partial sleep deprivation in the prevention of depressive mood cycles.

A rodent model of Parkinson's disease, the 1-methyl-4-(2'-methylphenyl)-1,2,3,6-tetrahydropyridine treated mouse, was used to determine whether striatal dopamine levels recover following grafting adrenal medulla into the striatum. Four types of grafts were performed: 1) adult mouse adrenal medulla, 2) adult adrenal medulla that had been freeze-thawed to kill viable cells, 3) postnatal day 7 adrenal medulla, and 4) sham grafts lacking tissue. At 1 month after grafting, only postnatal day 7 grafts contained surviving cells. However, all three types of tissue grafts promoted a unilateral recovery of host dopaminergic fibers on the side of the graft. In striking contrast to the unilateral recovery of the dopaminergic fibers, striatal dopamine levels were increased bilaterally in all tissue grafted mice. These observations suggest that adrenal tissue grafted into the striatum, whether it remains viable or not, has more widespread biochemical effects on the host dopaminergic system than previously recognized. Moreover, these observations bear on mechanisms that may underlie the general recovery of motor disturbances reported in human Parkinson's disease patients who have received a striatal graft of adrenal tissue.

Primary renal allograft nonfunction may be caused by acute tubular necrosis, immunological rejection or vascular thrombosis. Renal autotransplantation engenders no risk of immunological rejection. We report a case of graR nonfunction following renal transplantation in conjoined twins, which reversed rapidly after separation. A mechanism is proposed to explain our observation. CASE REPORT Two-year-old female craniopagus conjoined twins were referred for separation of shared scalp, cranium, cerebral tissue and vessels (see figure). Cerebral venous and arterial angiography of 1 twin revealed a dominant, superior sagittal sinus and partial overlap of the middle cerebral artery distribution. Significant arteriovenous shunting was also present through scalp vessels. Preoperatively, the twins were neurologically intact. Spine and bladder function were normal. Sonography revealed bilateral renal atrophy in 1 twin. Renal scintigraphy demonstrated that 99% of renal function was localized to the twin with 2 normal kidneys. After considerable discus

Purpose: We describe creation of a modified umbilical stoma as part of continent urinary diversion using appendicovesicostomy.Materials and Methods: Umbilical stomas were created using the eversion-inversion principle in 25 patients undergoing appendicovesicostomy.Results: Mean followup was 3 years. Cosmesis of the umbilical stoma was good in all cases. Stomal stenosis required surgical revision in 8 percent of cases.Conclusions: We recommend our modified umbilical stomal technique for appendicovesicostomy because it allows good cosmesis without compromising stomal function.