Laparoscopic enterolysis and placement of an intestinal sling before radiation therapy for the treatment of prostate cancer

We present an interesting application of laparoscopy in a man who was otherwise not a candidate for radiotherapy because of an adherent loop of small bowel in the proposed treatment field. Laparoscopic enterolysis was performed and the involved segment was displaced out of the pelvis; a synthetic mesh was placed to serve as a sling to prevent caudal migration back into the pelvis. The patient had a rapid recovery and subsequently completed a full course of radiotherapy. The experienced laparoscopist may find this a good alternative to open surgery in patients with a fixed loop of small bowel who require radiation therapy for pelvic malignancies.

Matrix modulates uptake of calcium oxalate crystals and cell growth of renal epithelial cells

Handling of urinary crystals by renal epithelial and medullary interstitial cells may play an important role in the pathogenesis of renal stones and associated renal scarring. We examined the effects of calcium oxalate monohydrate (CaOM) crystals on the proliferative activity of renal tubular cells (opossum kidney) and renal medullary interstitial cells in culture. We also studied the impact of altered extracellular matrix on cell proliferation as well as on uptake of crystals by epithelial cells. Epithelial cells incubated with CaOM showed greater (p < 0.05) growth when compared with untreated cells (control, 10.5 +/- 1.1 versus CaOM, 16.6 +/- 1.6 x 10(6) cells per dish). the CaOM crystal-cell interaction also enhanced proliferation of interstitial cells (at 48 hours, control, 3.3 +/- 0.2 versus CaOM, 4.2 +/- 0.1 x 10(6) cells per dish, p < 0.02; at 72 hours, control, 3.6 +/- 0.3 versus 5.5 +/- 0.4 x 10(6) cells per dish, p < 0.01). Collagen, a constituent of extracellular matrix, inhibited (p < 0.01) proliferation of epithelial cells. Semiconfluent epithelial cells grown on collagen gels showed greater (p < 0.01) uptake of 45CaOM crystals when compared with uptake by cells grown on either uncoated (control) or albumin-coated plastic dishes (control, 979.9 +/- 51.1, albumin, 876.4 +/- 28.3, collagen gel, 1502.5 +/- 103.8 cpm per well). Epithelial cells grown to confluence on collagen gels also showed enhanced (p < 0.05) uptake of 45CaOM crystals. Reflectance microscopy as well as ultrastructural studies revealed intracellular localization of CaOM crystals. These results indicate that CaOM crystals stimulate the growth of both epithelial and interstitial cells. Enhanced growth of interstitial cells may also lead to increased synthesis of extracellular matrix. The latter may further modulate crystal uptake as well as cell growth of adjacent epithelial cells. These findings may be important in the development of nephrolithiasis and associated interstitial scarring.

Relative roles of plaques and tangles in the dementia of Alzheimer's disease: correlations using three sets of neuropathological criteria

We have performed a quantitative analysis of the amyloid load (plaques), neuritic plaques and neurofibrillary tangles (NFT) in the frontal, temporal and parietal association cortices of autopsied brains from 49 prospectively evaluated patients with Alzheimer's disease (AD) diagnosed according to three sets of published pathological criteria. These patients had been assessed clinically with psychological testing of cognitive abilities within 6 months of death. Correlations were sought between severity of pathological change and cognitive status before death, duration of disease and age at death. Using Khachaturian and CERAD criteria highly positive correlations were obtained between the extent of cognitive deficit and the density of NFT in frontal and parietal lobes. The percentage area of cortex occupied by amyloid in the parietal lobe was correlated to the cognitive deficit only in the CERAD-diagnosed cases. The density of all amyloid plaques (AP) showed no correlation with the extent of cognitive deficit, but the densities of neuritic plaques did correlate with cognitive deficit. Both amyloid load and tangle densities were positively correlated with disease duration. All these correlations were reduced or absent in a subgroup of cases fulfilling the Tierney et al. A3 diagnostic criteria for AD. We found no pathological measure that correlated with the age of patients at death. Amyloid loads and NFT densities showed highly significant but selective positive correlations, the most striking being between temporal lobe NFT density and frontal and parietal lobe amyloid load and between temporal lobe NFT density and frontal and parietal lobe NFT densities. Correlations involving AP density as a measure of amyloid load were almost always less significant than those involving the percentage area of cortex occupied by amyloid, suggesting that the latter measures amyloid load more accurately. However, the highest correlations of NFT densities were with neuritic plaque densities. Overall this study highlights the relevance of neuritic changes (revealed by NFT and neuritic plaques) and the irrelevance of amyloid plaques to the dementia of AD.

The diagnosis of Alzheimer's disease: a question of image?

The most common cause of dementia in the developed world is Alzheimer's disease. Histopathology is required to confirm diagnosis, but most evaluations of the accuracy of clinical criteria and neuroimaging in the diagnosis of dementia of the Alzheimer type are without such confirmation. The average specificity of clinical criteria alone is about 75%. This paper discusses the contribution of simple structural (x-ray computed tomography [CT]) and functional (Tc-99m-HMPAO single photon emission computed tomography [SPECT]) imaging to the diagnosis of Alzheimer's disease in 71 histopathologically confirmed cases (47 with Alzheimer's disease, 16 with other dementias, 8 controls) and 84 living controls. Medial temporal lobe atrophy assessed by temporal lobe-oriented CT gave 94% sensitivity and 93% specificity, while parietotemporal hypoperfusion on SPECT revealed 96% sensitivity and 89% specificity. The combination of both changes yielded a sensitivity of 90% and a specificity of 97%. These investigations clearly enhance diagnostic accuracy, can be readily applied in the clinical situation, and could be used in epidemiologic studies of Alzheimer's disease.

Endourologic management of complications in renal allografts

Because of the altered anatomy, the presence of immunosuppression, the possibility of graft rejection, and the serious implications of a problem involving a solitary kidney, the transplanted kidney presents unique challenges in the diagnosis and treatment of urologic complications. Historically, the mortality rate in these patients has been as high as 68%, and as many as 15% of the allografts have been lost. Today, endourologic procedures are used for prompt diagnosis, temporization, and even definitive management of many urologic complications, and many patients and allografts are being saved. The authors review present techniques and suggest others that may be available in the future.

Monosynaptic innervation of facial motoneurones by neurones of the parvicellular reticular formation

In order to determine whether neurones in the parvicellular reticular formation are in direct synaptic contact with motoneurones innervating facial muscles, a combined retrograde and anterograde transport study was carried out in the rat. Animals received injections of the retrograde tracer cholera toxin B conjugated to horseradish peroxidase into facial muscles and of the anterograde tracer biocytin into the parvicellular reticular formation. The facial motor nucleus was then examined for anterograde and retrograde labelling in the light and electron microscopes. Retrogradely labelled neurones were found in the facial motor nucleus with a distribution that was dependent on the muscles injected. Terminals anterogradely labelled with biocytin from the parvicellular reticular formation was observed in the motor nucleus amongst the retrogradely labelled neurones. At the electron microscope, the retrogradely labelled cells were found to receive input from unlabelled terminals and from terminals that were anterogradely labelled from the injections of biocytin in the parvicellular reticular formation. The labelled terminals were 1-2 microns in diameter at the active zone and packed with spherical vesicles. They formed both symmetrical and asymmetrical synapses with their labelled or unlabelled targets. It is concluded that neurones in the parvicellular reticular formation form direct synaptic contact with motoneurones of facial muscles. This may represent a pathway by which the basal ganglia can directly influence orofacial movement, as the substantia nigra is known to project to that part of the reticular formation.

The effect of inhibition of synthesis, release, metabolism and uptake on the microdialysis extraction fraction of dopamine

The present study was designed to determine the effects that synthesis, release, metabolism and uptake have on the in vivo extraction fraction (relative recovery) of dopamine (DA) in the nucleus accumbens of the rat. The extraction fraction and extracellular concentration of DA were established for rats that were perfused with artificial cerebrospinal fluid (aCSF) with or without substances inhibiting synthesis (100 microM alpha-methylparatyrosine (alpha-MPT)), release (1 microM tetrodotoxin (TTX)), uptake (1 microM, 20 microM cocaine or 1 microM GBR-12909) or metabolism (100 microM tropolone or 100 microM pargyline) with DA concentrations ranging from 0 to 200 nM. Inhibiting synthesis with alpha-MPT or release with TTX had no effect on the extraction fraction of DA. Inhibiting intracellular or extracellular metabolism with pargyline or tropolone, respectively, did not cause any changes in the extraction fraction. However, inhibiting uptake with 20 microM cocaine or 1 microM GBR-12909 decreased the extraction fraction by one-third and one-half, respectively. These results provide evidence that uptake is the primary neuronal process affecting the extraction fraction of DA in the nucleus accumbens and indicate that the extraction fraction may be useful as an index of DA uptake in vivo.

Laparoscopic excision of urachal cyst

The treatment of choice for persistent urachal anomaly is radical surgical excision intended to prevent complications, notably malignancy in a retained remnant. We report a case of the radical laparoscopic excision of an infected urachal cyst. This effective alternative to an open technique has the advantages inherent in minimally invasive surgery.

Rapidly progressing atrophy of medial temporal lobe in Alzheimer's disease

The symptoms of Alzheimer's disease are associated with pathological change and loss of neurons in the medial temporal lobe. By yearly temporal-lobe-oriented computed tomograms the average rate of atrophy of the medial temporal lobe was 15.1% per year (95% CI 10.0, 20.2) in 20 patients with histopathologically, confirmed Alzheimer's disease and 1.5% (0.2, 2.8) in 47 healthy ageing controls. Such excessive atrophy presumably reflects the vulnerability of the medial temporal lobe to a catastrophic event, probably a pathological cascade process. Thus, Alzheimer's disease may not be due simply to an acceleration of normal ageing but, rather, is the consequence of a true disease process.

Endourologic management of retained surgical drains and nephrostomy tubes

A retained surgical drain or nephrostomy tube is a troublesome predicament that often has necessitated open surgical extraction. To assess the efficacy of endoscopic techniques in the management of this problem, several types of drains and tubes were placed intraperitoneally in a female pig and left for 3 weeks. Flat drains could be removed by traction. Jackson-Pratt drains could be removed by clearing the lumen of amorphous material with a guidewire and releasing the external adhesions with a 9.5Fr rigid ureteroscope passed beside the tube. The retained re-entry nephrostomy tubes could be removed under fluoroscopic control by using stone-grasping forceps and electrocautery inside the tube to incise the tissue holding the Malecot flanges. This latter method also was successful in a patient who had received intracavitary BCG after percutaneous tumor resection. Endourologic techniques can reduce the number of open operations that need to be performed to remove retained drains and tubes.

Endourologic management of obstructed hydrocalyx after blunt renal trauma

Significant renal injuries caused by blunt trauma can produce early and delayed complications. We report a case of blunt trauma that resulted in what appeared to be a persistent encapsulated hematoma, but was in reality an obstructed hydrocalyx. Communication with the collecting system was re-established percutaneously by a method similar to that used in the management of caliceal diverticula.

Design and construction of rhinovirus chimeras incorporating immunogens from polio, influenza, and human immunodeficiency viruses

This paper describes the design and construction of chimeric human rhinoviruses that contain immunogenic regions from other pathogens as part of their surface coat proteins. Segments encoding the poliovirus 3 Sabin VP1 and VP2 proteins, the influenza hemagglutinin (HA) glycoprotein, and the human immunodeficiency virus gp120 surface and gp41 transmembrane glycoproteins were inserted into a full-length clone of human rhinovirus 14 (HRV14) at regions corresponding to neutralizing immunogenic sites IA (NIm-IA) and II (NIm-II). Of 12 chimeric constructs described, 3 produced viable virus. An HRV14 chimeric virus containing five amino acids of influenza HA (corresponding to 300 A2 of solvent-accessible surface area) had wild-type HRV14 growth characteristics and was neutralized by four of four anti-influenza HA antisera with reciprocal neutralizing titers ranging from 180 to 330. However, antisera raised in two guinea pigs against the HRV14:influenza HA chimera did not show significant neutralization of relevant strains of influenza. These results are the first to demonstrate the feasibility of making viable chimeras of human rhinoviruses displaying heterologous immunogens.

Use of random systematic mutagenesis to generate viable human rhinovirus 14 chimeras displaying human immunodeficiency virus type 1 V3 loop sequences

Random systematic mutagenesis was used to generate a library of human rhinovirus 14 chimeras that each display a segment from the V3 loop of human immunodeficiency virus type 1. The sequence XXIGPGRAXX, where X could be any of the 20 amino acids, was inserted at the neutralizing immunogenic site II of human rhinovirus 14 between VP2 residues 159 and 160. Twenty-five unique chimeric viruses were isolated, and the identity of their randomized residues was determined. A nonrandom amino acid distribution that may reflect structural requirements for viability was observed at the randomized positions. Fifteen of 25 chimeras were neutralized by one or more of a panel of four anti-human immunodeficiency virus type 1 V3 loop antibody preparations, indicating that antigenicity had been successfully transplanted. Libraries of chimeric viruses produced by using the techniques described may be a source of vaccines and other immunotherapeutic reagents. The random systematic mutagenesis methodology described should be generally useful for the rapid transplantation of foreign sequences into viral coat and other proteins to produce libraries containing members with the desired properties.

Percutaneous approach to indeterminate caliceal filling defects

Although the radiologic characteristics and endoscopic appearance of aberrant renal papillae have been described, a tissue diagnosis is the only way to exclude a low-grade urothelial malignancy. We report on three caliceal filling defects managed percutaneously in which biopsy findings confirmed aberrant papillae.

Complications of intracavitary bacillus Calmette-Guerin after percutaneous resection of upper tract transitional cell carcinoma

Percutaneous resection and intracavitary instillation of bacillus Calmette-Guerin (BCG) is currently being used in treatment protocols in select patients in whom the standard nephroureterectomy for upper tract transitional cell carcinoma is undesirable. However, the complications of BCG in these patients are not well defined. Among 16 patients treated in this manner 4 (25%) had asymptomatic granulomatous involvement of the renal pelvis discovered during regular followup nephroscopy and biopsy: 2 had recurrent carcinoma at discovery, whereas the other 2 remain free of disease. The significance and therapeutic consequences of BCG granulomatosis are unknown. Continued followup is necessary to identify any complications of BCG therapy.

Special considerations in the technique of laparoscopic ureterolithotomy

Laparoscopic ureterolithotomy was performed in 2 men, accompanied in 1 by unroofing of a complex renal cyst. This new technique is indicated as an alternative to open lithotomy when more conventional minimally invasive measures have failed and in patients in whom laparoscopy is being performed for another indication. Modifications in technique are necessary depending on the location of the stone. Laparoscopic ureterolithotomy should not be performed unless a guide wire or catheter can be placed past the stone preoperatively. The technique is described in detail.

Hugh Blaschko, FRS (1900-1993)

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Monosynaptic innervation of trigeminal motor neurones involved in mastication by neurones of the parvicellular reticular formation

In order to determine whether neurones in the parvicellular reticular formation are in direct synaptic contact with motor neurones innervating masticatory muscles, a combined retrograde and anterograde transport study was carried out in the rat at both light and electron microscopic levels. The animals received injections of the retrograde tracers wheat germ agglutinin conjugated to horseradish peroxidase or cholera toxin B conjugated to horseradish peroxidase into the masticatory muscles and of the anterograde tracer biocytin into the ipsilateral parvicellular reticular formation. The trigeminal motor nucleus was then examined for both anterograde and retrograde labelling in the light and electron microscopes. Retrogradely labelled motor neurones were identified in the trigeminal motor nucleus. They were large and their locations within the nucleus depended on the muscle injected. In addition, terminals anterogradely labelled with the biocytin that was injected in the parvicellular reticular formation were identified throughout the motor nucleus. At the electron microscopic level, the retrogradely labelled cells were found to receive input both from distinct types of unlabelled terminals and from terminals that were anterogradely labelled from the parvicellular reticular formation. The labelled terminals comprised one of the four classes of afferent terminals, being 1-2 microns in diameter and densely packed with spherical vesicles. They formed mostly asymmetrical but also symmetrical synapses with the labelled perikarya and dendrites. Anterogradely labelled terminals were also observed to form both symmetrical and asymmetrical synaptic contacts with unlabelled structures in the motor nucleus. It is concluded that neurones in the parvicellular reticular formation form direct synaptic contact with motor neurones of masticatory muscles. This pathway may represent the anatomical substrate by which the reticular formation exerts at least part of its influence on mastication. Since the parvicellular reticular formation receives input from the substantia nigra pars reticulata, it is possible that this pathway represents a system whereby the basal ganglia directly influence orofacial movement.

Endopyelotomy in the elderly

Elderly patients with ureteropelvic junction obstruction present higher risks for operative repair than younger patients and may benefit from a less invasive approach. We review 18 patients older than 65 years who underwent endopyelotomy for a primary (8) or secondary (10) ureteropelvic junction obstruction. Average followup was 32 months (range 3 to 80). Average operating time, including cystoscopy and patient positioning, was 85 minutes. Average hospital stay was 6.3 days. No intraoperative complications were encountered. One failure occurred immediately postoperatively and the patient underwent corrective pyeloplasty. One patient has had intermittent pain but a negative Whitaker test with no evidence of obstruction. The success rate is 88%. Endopyelotomy can be considered a safe and satisfactory procedure for initial treatment of significant ureteropelvic junction obstruction in the elderly.

Autumn southward 'return' migration of the mosquito Culex tritaeniorhynchus in China

Direct evidence for a southward 'return' migration in autumn of the mosquito Culex tritaeniorhynchus in China was obtained by aerial sampling with a net suspended from a balloon. In a preliminary study between 2 and 20 September 1990 at Jiangpu, near Nanjing, in Jiangsu Province, 11 females and 4 males of this species were taken at heights of 150-250 m. During 17-26 October 1991 at Dongxiang in northern Jiangxi Province, 44 mosquitoes (8 males, 36 females) were caught in the aerial net at heights of 80-380 m in northeasterly winds (E-NNW). Most of the specimens were flying within the subsiding air-mass behind a cold front. Cx tritaeniorhynchus was the only species identified (31 females) among the mosquitoes from Dongxiang. Of 24 females dissected, 17 had N stage ovaries--interpreted as diapause, five had stage I ovaries, one had stage II ovaries, and one was gravid (stage V), but none was freshly blood-fed. Cx tritaeniorhynchus is the main vector of Japanese viral encephalitis in China, and it is possible that the virus is reintroduced to northern temperate areas in spring by northward migration of infected Cx tritaeniorhynchus females.

Failed endopyelotomy: implications for future surgery on the ureteropelvic junction

During the last 8 years we performed 212 endopyelotomies with an overall success rate of 86%. To determine if the failed endopyelotomies resulted in a more difficult subsequent open corrective procedure, we compared the procedures and outcomes of 15 failed endopyelotomies with 16 control patients undergoing pyeloplasty who had not undergone a previous endopyelotomy. The variables of duration of the surgical procedure, average estimated blood loss, average number of transfusions and average length of hospitalization were analyzed for both groups. No statistically significant differences were detected for any of these variables. We conclude that despite a previously failed endopyelotomy, a subsequent open operation on the ureteropelvic junction, although slightly more difficult, was not associated with an increased morbidity rate nor less successful than de novo pyeloplasty. Therefore, we continue to advocate endopyelotomy as the procedure of choice for obstruction of the ureteropelvic junction.