Multiple Urinary Tract Infections Research Articles

Bilateral patellar tendon rupture: a case report

<p>Bilateral patellar tendon rupture is a rare injury, usually associated with systemic disease or chronic medication side effect. Early diagnosis and prompt surgical repair are essential to achieve good functional outcomes. The authors report a case of a 44-year-old male with history of multiple urinary tract infection treated with fluoroquinolones who sustained spontaneous simultaneous bilateral patellar tendon rupture. Patient underwent bilateral transosseus tendon repair with autologous semitendinosus augmentation. Nine months after surgery, the patient was able to walk without pain and unassisted, had a normal range of motion in both knees and performed his daily activities without limitation. Surgical treatment of patellar tendon rupture is recommended to allow prevention of extensor mechanism disfunction sequelae. Transosseus tendon repair with autologous semitendinosus augment plasty is a valid surgical technique for treatment of this pathology with biomechanical and literature support.</p>

Multiple systemic cardio-embolism in native aortic valve endocarditis

We present a challenging case of native aortic valve endocarditis with Enterococcus faecalis in a patient with a history of multiple urinary tract infections and urethral strictures treated by local dilations. The case was complicated by Clostridium difficile colitis and multiple septic embolization. Despite intensive antibacterial therapy, guided by the antibiogram, the vegetations grew in size and the infection became uncontrolled causing recurrent embolism.

Calyceal diverticular stones: Does the insistence on less invasive technique keep the patient away from a major complication?

Calyceal diverticular stones are rare clinical entities without a clearly defined consensus on the treatment. Treatment indicationsinclude recurrent urinary tract infections, chronic pain and renal impairment. Treatment modality of surgical approach is usuallybased on the location of calyceal diverticulum.A 23-year-old woman was presented with a calyceal diverticular stone of 16.5 mm. Her medical history revealed multiple urinary tractinfections caused by extended spectrum beta-lactamase (ESBL)-producing Escherichia coli of which the stone was predicted to be thereason. The patient was treated ureterorenoscopically, a decision of which was taken intra-operatively.In conclusion, insisting on performing nephroscopy following an intra-operative retrograde pyelography revealed no apparentostium which could be interpreted as ureterorenoscopic retriaval would fail and development of postoperative bacteremia despite allprecautions taken pre-and intra-operatively were two lessons indicating that all efforts must be exercised to reach the most minimalinvasive method for the treatment of calyceal diverticular stones.

Ectopic intra-scrotal supernumerary kidney

Supernumerary kidney is a rare congenital urologic malformation, of which approximately a hundred cases exist to date in the literature. This anomaly is an accessory kidney that possesses its own collecting system, blood supply and encapsulated parenchyma. We report the case of an eleven-month-old male infant presenting with multiple urinary tract infections and a dilated left ectopic ureter with grade II vesicoureteral reflux. The diagnosis of ectopic intra-scrotal supernumerary kidney was evoked following MRI, scrotal ultrasound and endoscopic exploration. Surgical resection by laparoscopy was subsequently performed and the postoperative course was uneventful. Supernumerary kidney is an extremely rare urologic malformation that requires multimodal preoperative imaging and management in a specialized pediatric surgical facility.

Association between severity of prenatally diagnosed hydronephrosis and receipt of surgical intervention postnatally among patients seen at a fetal-maternal center

BackgroundHydronephrosis (HN) is the most common abnormality detected on prenatal ultrasound. This study sought to stratify outcomes of patients by severity of prenatal HN with postnatal outcomes.MethodsThis was a retrospective review of patients referred to a tertiary care fetal-maternal clinic with diagnosis of prenatal HN from 2004 to 2019. HN severity was categorized as mild, moderate, or severe. Data were analyzed to determine the association between HN severity and surgical intervention. Decision for surgery was based on factors including history of multiple urinary tract infections, evidence of renal scarring, and/or reduced renal function. Surgery-free survival time was represented by the Kaplan–Meier method, and hazard ratios were calculated using the log-rank test.Results131 kidneys among 101 infants were prenatally diagnosed with hydronephrosis; 35.9% had mild HN, 29.0% had moderate HN, and 35.1% had severe HN. 8.5% of patients with mild HN, 26.3% of patients with moderate HN, and 65.2% of patients with severe HN required surgery. Patients with severe HN were 12.2 (95% CI 6.1–24.4; p < 0.001) times more likely to undergo surgery for HN than patients with mild HN and 2.9 (95% CI 1.5–5.3; p = 0.003) times more likely to undergo surgery than patients with moderate HN. Patients with moderate HN were 4.3 times more likely to require surgery than patients with mild HN (95% CI 1.5–12.9; p = 0.01). Median age at surgery was 11.8 months among patients with mild HN (IQR 11.7–14.1 months), 6.6 months among patients with moderate HN (IQR 4.2–16.4 months), and 5.4 months among patients with severe HN (3.7–12.4 months).ConclusionAmong this cohort of referrals from a fetal-maternal clinic, severity of HN correlated with increased likelihood of surgical intervention. Continued assessment of patients with prenatal HN should be evaluated to best determine the role of the pediatric urologist in cases of prenatal HN.

A homozygous missense variant in CHRM3 associated with familial urinary bladder disease.

CHRM3 codes for the M3 muscarinic acetylcholine receptor that is located on the surface of smooth muscle cells of the detrusor, the muscle that effects urinary voiding. Previously, we reported brothers in a family affected by a congenital prune belly‐like syndrome with mydriasis due to homozygous CHRM3 frameshift variants. In this study, we describe two sisters with bladders that failed to empty completely and pupils that failed to constrict fully in response to light, who are homozygous for the missense CHRM3 variant c.352G > A; p.(Gly118Arg). Samples were not available for genotyping from their brother, who had a history of multiple urinary tract infections and underwent surgical bladder draining in the first year of life. He died at the age of 6 years. This is the first independent report of biallelic variants in CHRM3 in a family with a rare serious bladder disorder associated with mydriasis and provides important evidence of this association.

Multiple urinary tract infections are associated with genotype and phenotype in adult polycystic kidney disease.

Urinary tract infections (UTI) are one of the important clinical presentations in patients with autosomal dominant polycystic kidney disease (ADPKD). The association between UTI among genotypic and phonotypic properties of ADPKD patients is still obscure. Thus, we investigated the relationship between UTI and polycystin gene mutation with total kidney volume. Forty patients with ADPKD patients with a history of more than two UTI and age-gender-matched 40 ADPKD patients without UTI history enrolled in the study. Ambulatory blood pressure monitoring was performed in all participants. Magnetic resonance imaging (MRI) was performed with a 1.5-T system, and total kidney volumes were calculated using mid-slice technique. To determine PKD1 and PKD2 genotype, we performed molecular and genetic tests involving the following steps: DNA isolation, next-generation sequencing (NGS) and data analysis. ADPKD patients with UTI had lower eGFR values than those without UTI [64.9 (32.2-100.8) vs 89.5 (59.0-110.0) (p = 0.041)]. In addition, patients with UTI had significantly increased height-adjusted total kidney volume than patients without UTI [950 (290-1350) vs 345 (243-780.0) (p = 0.005)]. Multiple logistic regression analysis showed that the PKD1-truncating mutation and hTKV independently predicted UTI. The sensitivity and specificity of hTKV were 65% and 77% (cutoff > 727 cm3) with an area of under the ROC curve of 0.70 (95% CI 0.56-0.85, p = 005). ADPKD patients with larger kidneys and PKD1 mutation are susceptible to increased risk of multiple UTI. Additionally, renal function decreased in ADPKD patients with multiple UTI history.

Study of urinary disorders in a cohort of 137 adult patients with cerebral palsy

Adults with cerebral palsy can have lower urinary tract dysfunction with organic complications and impact on quality of life. Theses troubles are well known in pediatric population but have been less studied among adults with cerebral palsy. The aim of this study was to describe lower urinary tract dysfunction, complications, and urodynamic profiles in our population of adults with cerebral palsy. Between 2009 and 2015, 137 adults with cerebral palsy, followed in our department, were included (anyway the reason of their visit) and data were analysed retrospectively. We studied clinical parameters (gender, age, neurological clinical picture, clinical picture severity, reason for their visit, lower urinary tract dysfunction, complications) and paraclinical data (renal bladder ultrasound, renal function, urodynamic). Sixty-six men and 71 women with cerebral palsy, 36.4 years old mean, GMCSF 4 median were included. For 23 patients (16.8%), we did not have any data about their vesical status. Twenty-eight patients (20.4%) consulted for a lower urinary tract dysfunction. Eighty-eight patients (64.2%) had urinary troubles: 59 (43.1%) reported voiding symptoms, 72 (52.6%) storage symptoms and 43 (31.3%) both. Forty-nine (35.8%) had complications on bladder or kidney. Especially, renal function was altered among 24 patients (17,5%) and 26 (19%) had multiple urinary tract infections. Forty-eight patients (35%) had urodynamic explorations, sphincter hypertonia was the most frequent anomaly [ n = 31 (22.6%)], associated with dysuria in 19 patients. GMCSF in symptomatic adults was higher than no symptomatic adults ( P < 0.0001). This study shows that lower urinary tract dysfunctions are frequent in adults with cerebral palsy, with an impact on their health and quality of life. As a consequence, a minimal systematic screening may be proposed.

Acute Renal Failure Secondary to Giant Inguino-Scrotal Hernia with Bladder Herniation

1.1.Background: Inguinal hernia is one of the more frequent pathology to be treated by general surgeons. The presentation of urinary bladder herniation is less common, with a reported incidence near 0.36%-1% of cases. Most cases course asymptomatic, but urinary symptoms could be presented and in a few cases acute renal failure have been reported. 1.2.Case:We present the case of a 52-year-old man with a giant left inguino-scrotal incarcerated hernia. He has pathological background including multiple urinary tract infections and 2-years of evolution with a left inguinal hernia. He refers dysuria, urinary frequency, pushing, urgency and voiding in two times, needing partial reduction of inguinal hernia to complete (Mery sign). Previous 12 hours presented acute urine retention, with increasing left inguino-scrotal volume, in duration and severe pain, reason why he looked for hospital attention. At physical exam with analgesic position, glasgow 15, arterial tension 240/140 mmHg, 96 beats per minute, 26 breaths per minute, abdomen without compromise, left inguinal region with inguino-scrotal no-reductible hernia, painful at maneuvers and edematized, without vascular compromise signs. Both legs with edema ++/+++, tendon reflexesand distal perfusion. Acute urine retention was solved by a 18 French foley without complications. Blood chemistry evidence acute kidney injury reporting Creatinine 1.5 mg/dL, Urea 75 mg/dL, and BUN 35 mg/dL. Hematological parameters reports systemic inflammatory response with white blood cells 16200/mm3 without neutrophilia and other parameters within normal values as hemoglobine 13.8 g/dL, hematocrit 43% and platelets 448000. Urine general exam with infection data including leucocites >10μL, Nitrites+, Proteins 4g. Prostate Specific Antigen <2.5 ng/mL.Renal, bladder, inguinal and testicular ultrasounds were practiced and reported: Bleeder displacement by left inguinal canal and scrotum. Both kidneys, ureters and testis with normal characteristics. For the high suspect of urinary bladder herniation as the acute renal failure origin a retrograde cystogram was scheduled, finding in filling platecontrast material in urine bladder with 90% displacement to the scrotum by left inguinal canal. In post voiding projection residual urine is observed in left scrotum. During hospitalization the emergency hypertensive crisis was solved during first 24 hours and Lichtenstein hernioplasty was scheduled. A giant paraperitoneal scrotum cystocele was found, without ischemic signs. After three days renal function was normal with creatinine reduction to 0.8mg/dL, and antihypertensive medication were diminished progressively until day 15 when was suspended and foley removed. At six months follow up he remains asymptomatic. 1.3.Conclusion: In big inguino-scrotal hernias with urinary symptoms, bladder herniation must be suspected for the high rate of complications associated ranging from repetitive urinary tract infection to acute or chronic renal failure. Diagnosis confirmation allows surgery planning and diminishes associated morbidity.

Comparison of the microbiological milieu of patients randomized to either hydrophilic or conventional PVC catheters for clean intermittent catheterization

Control of bacteriuria is problematic in patients who perform clean intermittent catheterization for management of neurogenic bladder. This population is often burdened with multiple urinary tract infections (UTIs), placing them at increased risk of end-stage renal disease. Hydrophilic catheters are a potential way to improve smooth and clean insertion, reduce disruption of the urothelium, and reduce bacterial colonization. The goal of the study was to compare the type and virulence of microorganisms recovered from the urine of patients that use either a hydrophilic or conventional polyvinyl chloride (PVC) catheter. Fifty patients with an underlying diagnosis of myelomeningocele were recruited for a 12-month prospective, randomized, investigator-blinded study. Twenty-five patients were allocated to the hydrophilic catheter intervention, and 25 continued use of a PVC catheter. Cultures were performed on urine obtained by catheterization at enrollment, and 3, 6, and 12 months. Bacterial species were assigned a designation as either potentially pathogenic or non-pathogenic. Escherichia coli isolates were the most predominant and were serotyped to further stratify the pathogenicity of the strains. Lastly, patients were surveyed at enrollment, and at the two later time points evaluating their current catheter for satisfaction. A total of 232 different bacterial isolates were obtained from the 182 collected urine cultures. In addition, seven species were recovered from the two UTI reported during the study period. Bacterial growth was not detected in 29 of the samples (16%). Although not statistically significant, collectively there was a 40% decrease in the average number of potentially pathogenic species recovered from those patients using hydrophilic catheters (0.81 per urine sample) compared with PVC catheter use (1.24 per urine sample). Since E. coli species can be either pathogenic or non-pathogenic, we examined 14 of the most commonly implicated serotypes associated with uropathogenic E. coli (UPEC). We identified the serotype of 57% of E. coli strains recovered. There was a trend for the recovery of fewer UPEC serotypes from the hydrophilic group (54% hydrophilic verses 64% PVC), further suggesting that the catheter type may influence the microbiological milieu. Although no significant differences were reported in patient satisfaction, almost half of the patients from the hydrophilic catheter cohort continue use of this type of catheter. There was a trend for reduced recovery of potentially pathogenic bacteria with the use of hydrophilic catheters. The reduction in potentially pathogenic species will reduce antibiotic exposures and some patients may prefer the comfort hydrophilic catheters provide.

Questionnaire based assessment of risk factors for primary biliary cirrhosis

Primary biliary cirrhosis is a cholestatic liver disease characterized by immune-mediated destruction of bile ducts. Its pathogenesis is largely unknown, although complex interactions between environment and genetic predisposition are proposed. Identify disease risk factors using a detailed patient questionnaire and compare study findings to 3 published reports. Questionnaire data were prospectively collected from 522 cases and 616 controls of the Mayo Clinic Primary Biliary Cirrhosis Genetic Epidemiology Registry. Case and control responses were compared using logistic regression, adjusting for recruitment age, sex, and education level. Cases reported ever regularly smoking cigarettes more frequently than controls (P < 0.001). History of urinary tract infection was similar between groups; however, cases reported multiple urinary tract infections more commonly than controls (P < 0.001). Frequency of other autoimmune disease was higher in cases than controls (P < 0.001). As well, prevalence of primary biliary cirrhosis among first-degree relatives was higher in case families than control families (P < 0.001). Our study confirms prior reported risk factors associated with disease risk. Given the potential importance of gene and environment interactions, further examination of environmental risk factors considering genetic background may provide new insight into primary biliary cirrhosis pathogenesis.

A Pink Milk Bottle Mystery

The mother of a 5-week-old term infant brings the infant to the pediatrician’s office, along with a plastic milk bottle used to feed the baby. The bottle has splotches of red-pink material on the inside (Fig. 1). She wants to know what is happening to the milk in the bottle. The mother has been breastfeeding and has recently been transitioning to pumped breast milk in preparation for returning to work. For the past few days, she has noticed that the breast milk remaining in bottles that were left in a sink overnight after evening feedings turns bright pink by morning. The breast milk has been normal in color during pumping, in the pump tubing, and in bottles stored in the refrigerator before feedings. The mother denies taking any medications, herbal supplements, or illicit drugs while breastfeeding. The pregnancy was complicated by multiple urinary tract infections, which were treated with nitrofurantoin and trimethoprim-sulfamethoxazole. She denies any signs or symptoms of mastitis. The infant has been asymptomatic, feeding well, and is gaining weight. Birth was uncomplicated. The infant is afebrile and is well-nourished, well-hydrated, and in no distress. There are no lesions or abnormal findings on the oral mucosa. There is no lymphadenopathy. The remainder of the physical examination appears normal. The pediatrician sent samples of pink exudate in the bottle as well as stored, expressed breast milk (which had not yet been fed to the infant) for culture. Both cultures yielded the same microbe. What microbe is the most likely cause of this scenario? When the pediatrician calls to tell you this story and the culture results, what advice do you give? (See next page for discussion.) Figure 1. Infant bottle with pink material that developed after sitting at room temperature overnight after use for feeding of expressed breast milk. Pediatric ID Consultant Geoffrey Weinberg and Charles Woods, Section Editors

Hydrocolpos in cloacal malformations

Introduction Hydrocolpos is a condition rarely mentioned in the literature. The purpose of this report is to increase the index of suspicion for hydrocolpos in patients with cloaca and to describe our approach for its treatment with the hope that errors in the management of hydrocolpos can be avoided. Methods We reviewed 411 medical records of patients diagnosed with cloaca and managed at our Center during the last 26 years. Emphasis was placed on evaluating for the presence of hydrocolpos, type of drainage, and complications related to the persistence of the hydrocolpos. Results One hundred seventeen cloaca patients had an associated hydrocolpos (28.4%). Forty-two cases (36%) were initially managed at other institutions at which the hydrocolpos was not drained. Complications experienced by this group included: multiple urinary tract infections (8), hydrocolpos infection (7), sepsis (7), failure to thrive (6), ruptured hydrocolpos (4), and development of hydronephrosis in previously normal kidneys (2). Forty-one patients (35%) had other modalities of treatment, aimed to drain the hydrocolpos, including vesicostomy (26), intermittent perineal catheterization (8), single aspiration (6), or plasty of the perineal orifice (1). In all of these cases, the hydrocolpos persisted or reaccumulated. Thirty-four patients (29%) underwent an effective drainage of the hydrocolpos at birth; 29 at other institutions, 15 with a tube vaginostomy, 13 with a tubeless vaginostomy, and 1 with a catheter placed and left in the vagina through cystoscopy. Five cases had a tube vaginostomy done by us. In all these cases, the vagina remained adequately drained as demonstrated radiologically. Proper drainage of the hydrocolpos alone, with no urologic intervention, dramatically improved the hydronephrosis in 13 cases. Conclusions Hydrocolpos in patients with cloacas must be diagnosed and treated early in life. Our preferred approach is a transabdominal indwelling vaginostomy tube. The drainage of the hydrocolpos alone may dramatically improve the hydronephrosis, and therefore, we suggest that only after the hydrocolpos is drained should a urological intervention be contemplated. Failure to drain the hydrocolpos can result in serious complications.

Neurogenic Bladder

We describe the case of a 73-year-old woman with a history of chronic low back pain and 2 previous lumbar fusions who presented with complaints of worsening back and leg pain. Having previously undergone multiple interventions, physical therapy, and oral analgesics with limited pain relief, the patient opted for endoscopic lysis of adhesions for severe scarring of the epidural space. Subsequently, the patient developed a neurogenic bladder with urinary retention. Three years later, she experienced resolution of the neurogenic bladder symptoms that coincided with the use of the antibiotic nitrofurantoin. Upon discontinuation of the antibiotic, the patient noted that she was unable to void spontaneously. With reinstitution of nitrofurantoin, the patient was once again able to void effectively and has been maintained on nitrofurantoin for >3 years.

Effect of Urinary Tract Infection on Reservoir Function in Patients With Ileal Bladder Substitute

We determined the functional consequences of urinary tract infection in patients with an ileal bladder substitute in terms of urinary continence, post-void residual and urinary retention. A total of 48 patients with culture documented urinary tract infection (single organism, 10(5) or greater cfu) were retrospectively evaluated before, during and after the infection for changes in continence, post-void residual and urinary retention as well as for resolution of symptomatology after appropriate antibiotic therapy. Of the 48 patients 40 had a single infection while the remaining 8 had multiple urinary tract infection episodes. During daytime 27 of the 44 patients with previously good daytime continence experienced deterioration in their baseline voiding status while infected. Of the 40 patients who were previously continent at night 20 had incontinence while infected. There were 15 patients with documented post-void residual and urinary retention developed in 4 during the urinary tract infection. All patients returned to baseline continence status and reservoir function after appropriate antibiotic treatment based on objective and subjective assessments. Urinary tract infection may cause urinary incontinence in patients with ileal bladder substitutes. Therefore, when there are complaints of de novo urinary incontinence, a finding of post-void residual or an acute presentation of urinary retention, a urinary tract infection should be excluded. When the urinary tract infection is appropriately treated urinary continence and reservoir function return to their baseline status.

Successful closure of a rectovaginal fistula by using an endoscopically placed Resolution clip

Rectovaginal fistula (RVF) is an abnormal epithelium-lined communication between the wall of the rectum and the posterior vaginal wall. The incidence of RVFs is low and accounts for about 5% of all anorectal fistulas. Women who suffer from an RVF complain of uncontrollable passage of gas or feces from the vagina. This remains a major contributor to morbidity associated with this condition in terms of social, psychologic, and sexual dysfunction. RVFs may be managed both medically and surgically, with the latter being the preferred option. A number of different surgical techniques that pertain to fistula closure were described in various literature; however, very little has been said of much-less-invasive techniques and alternatives to surgical correction if the patient is a poor candidate or prefers not to have surgery. The purpose of our article is to show our approach in treating an RVF, given the fact that our patient was a poor surgical candidate and, moreover, refused more-invasive techniques for treatment. A case report. The patient described in this article is a 77-year-old woman with comorbidities that limited her as a candidate for less-invasive techniques rather than surgery. An inpatient at New York Hospital Queens, Flushing, New York. A 77-year-old woman, with a medical history of 2 myocardial infarctions, congestive heart failure, 2 cardiac stents, multiple urinary-tract infections, and diverticulitis, presented to the hospital with a fever of 38.3 degrees C (101 degrees F) for 2 days. On the second day of admission, the patient complained of passing stool and flatus from the vagina. A subsequent workup and sigmoidoscopy revealed an RVF. A sigmoidoscopy was performed, and fistula closure was achieved in 2 phases with the use of a Resolution clip. Complications and resolution of symptoms after the procedure were the primary end points. No complications were noted post procedure, and the patient has remained free of any complaints now for 12 months. The main limitation of the study is that this is a case report limited to a single patient, and outcomes of the procedure were concluded based on this particular patient. The endoscopic technique described here may be limited to readily visualized fistulas at endoscopy that are amenable to this treatment option. The technique described, closing an RVF with the use of an endoscopically placed Resolution clip, shows great promise and could be applied to treating uncomplicated fistulas.

Poster 165: Pregnancy Outcomes Among Women With Physical Disabilities Seen in an Integrated Care Clinic

Objectives: To determine obstetric and disability-related pregnancy complications among physically disabled women seen by an integrated-care team and to evaluate their pregnancy outcomes. Design: Retrospective chart review. Setting: Rehabilitation hospital outpatient interdisciplinary clinic. Participants: 36 physically disabled subjects were identified with pregnancies confirmed by urine and serum human chorionic gonadotropin or ultrasound from 755 charts reviewed. Clinic, therapy, and labor and delivery charts were reviewed from pregnancy diagnosis to 6-week postpartum or pregnancy termination. The interdisciplinary team included obstetrics and gynecology, physiatry, physical, occupational, and speech therapy, anesthesiology, pulmonology, and social work. Physical disability diagnoses included cervical spinal cord injury (SCI) (25%), thoracic SCI (30.6%), cerebral palsy (25%), brain injury (8.3%), and others (11%) such as spinal muscular atrophy, multiple sclerosis, Marfan’s syndrome, and transverse myelitis. Interventions: Not applicable. Main Outcome Measures: Disability Rating Scale and FIM instrument. Results: 45 pregnancies were documented in 36 subjects (mean age, 26y; range, 17−40y): 35 unplanned pregnancies with 11 elective abortions performed; 1 spontaneous abortion; 2 intrauterine fetal demise (IUFD); and 31 viable infants. 36.4% of infants were delivered by cesarean section, 12.1% required assisted delivery, and 97.8% delivered under epidural anesthesia. 21.2% of mothers attempted breastfeeding. Obstetric and disability-related complications were reported according to type and level of disability. Further obstetric complications included: urosepsis with IUFD, cocaine abuse with IUFD, uterine atony, retained placenta, chorioamnionitis, pre-eclampsia, pyelonephritis, and multiple urinary tract infections. Disability-related complications included: autonomic dysreflexia, muscle fatigue impairing swallow function, respiratory distress requiring ventilator support, increased spasticity, hospitalization for pain management, adjustments to wheelchair seating and positioning, change in bladder management, and functional status decline requiring increased physical assistance with body habitus changes. Conclusions: Disabled women can successfully experience pregnancy and childbirth with proper measures for identification, prevention, and management of obstetric and disability-related complications through comprehensive interdisciplinary care.

Lost in Transcription

Urinary urgency and fever developed in a 55-year-old, bedridden woman with multiple sclerosis, a long-term indwelling Foley catheter, and multiple prior urinary tract infections. The patient had recently been transferred from an assisted-living facility to a skilled-nursing facility because of progressive disability. The laboratory evaluation revealed pancytopenia.

Test Your Skill by Using the 2006 ICD-9-CM Codes

Test Your Skill by Using the 2006 ICD-9-CM Codes

Splenic Hamartoma: Immunohistochemical and Ultrastructural Profile of Two Cases

Splenic hamartoma (SH) is a rare, benign lesion. We present 2 cases, both in females (2 and 30 years, respectively) with multiple urinary tract infections, and left upper quadrant abdominal pain. Immunohistochemical staining with factor VIII displayed intense diffuse staining in the SH with corresponding weak staining in the adjacent spleen. CD31 showed a reverse pattern from that of factor VIII. CD34 staining pattern was identical in both the spleen and the SH. Ultrastructurally, the SH showed endothelial cells with relatively empty cytoplasm, scattered Weibel Palade bodies, and lining by basement membrane surrounded by fibrous long-spacing collagen. Our study highlights the unique immunohistochemical profile of SH. The ultrastructural features are interesting, although their diagnostic significance remains to be confirmed in future studies.