Laparoscopic pyeloplasty versus open pyeloplasty for recurrent ureteropelvic junction obstruction in children

INTRODUCTION AND OBJECTIVES

Recurrent ureteropelvic junction obstruction (UPJO) in children is an operative challenge. Minimally invasive endourological treatment options for secondary UPJO have suboptimal success rates; hence, there is a re-emergence of interest about redo pyeloplasty. The present study presented experience with laparoscopic management of previously failed pyeloplasty compared with open redo pyeloplasty in children.

STUDY DESIGN

Twenty-four children with recurrent UPJO who underwent transperitoneal dismembered laparoscopic pyeloplasty were studied. Operative, postoperative, and follow-up functional details were recorded and compared with those of open pyeloplasty (n = 15) carried out for recurrent UPJO by the same surgeon during the same study period.

RESULTS

Demographic data were comparable in the laparoscopic and open groups, except for a significantly lower GFR in the open group (24.8 vs 38.2 ml/min, P = 0.0001). Mean time to failure of the original repair was 20.2 months (23.6 months for redo laparoscopic pyeloplasty, 18.8 months for redo open). The success rate of laparoscopic redo pyeloplasty was 91.7 vs 100% in open redo pyeloplasty. Compared with redo open pyeloplasty, the mean operative time was longer (211.4 ± 32.2 vs 148.8 ± 16.6, P = 0.002), estimated blood loss was higher (102 vs 75 ml, P = 0.06), while hospital stay was shorter and pain score was lower in the laparoscopy group (P = 0.02) in the laparoscopic group. There were no intraoperative complications, while the postoperative complication rate was similar in the two groups (20.8 vs 20.0%).

DISCUSSION

Before the laparoscopic approach became a viable option, endopyelotomy was widely used for managing recurrent UPJO. However, the success rate of endopyelotomy for secondary UPJO was approximately 10-25% lower than for open pyeloplasty. Redo pyeloplasty had excellent results, with reported success rates of 77.8-100%. Laparoscopic redo pyeloplasty is becoming a viable alternative to open redo pyeloplasty in many centers with experience in minimally invasive techniques. The present study revealed that redo laparoscopic pyeloplasty appeared to have advantages over redo open surgery, in that it was associated with shorter hospital stay (4 vs 6 days, P = 0.046), reduced postoperative pain score (P = 0.02), and less need for postoperative analgesia (P = 0.001), still with comparable successful outcomes and patient safety. However, the procedure had a longer operative times and more blood loss.

CONCLUSION

Laparoscopic pyeloplasty is a viable alternative to open pyeloplasty in children with recurrent UPJO, with shorter hospital stays and less postoperative pain. However, the procedure is technically demanding and should be attempted in high-volume centers by laparoscopists with considerable experience in laparoscopic reconstructive procedures.

The embedded nipple: An optimal technique for re-implantation of primary obstructed megaureter in children

Objectives

To present a novel ureteric re-implantation technique for primary obstructed megaureter (POM) that ensures success in the short- and long-term, as conventional techniques are not ideal for megaureters especially in children, with ureteric stenosis and reflux being common complications after re-implantation.

Patients and methods

Between 2009 and 2012, 22 paediatric patients with POM were enrolled. We performed a new technique for re-implantation of these ureters to ensure minimal incidence of ureteric strictures and easy subsequent endoscopic access. We performed follow-up voiding cystourethrography (VCUG) at 6 months postoperatively.

Results

The cohort comprised 14 boys and eight girls, with a median age of 22 months. Six patients underwent bilateral re-implantation. The mean (range) duration of indwelling ureteric catheterisation was 7.8 (4–14) days. There were no complications in the perioperative and postoperative periods. There was no reflux on follow-up VCUG in any of the patients. One patient developed Grade I reflux after 1 year and presented with a urinary tract infection. Diagnostic cystoscopy was performed in 13 patients showing that the nipple was directed similarly to the native ureteric orifice.

Conclusion

The embedded-nipple technique for re-implantation of POM guarantees successful results and permits easy subsequent ureteroscopic access when needed.

Combined low-dose antimuscarinics for refractory detrusor overactivity in children

INTRODUCTION AND AIMS

Behavioral therapy and bowel management are the initial and mainstay treatments for overactive bladder (OAB). Antimuscarinic agents are initiated if these measures fail or symptoms are severe. This study reported the results of treatment with a high dosage of a single drug in children with refractory detrusor overactivity (DO). After the children maintained their previous antimuscarinic medication, a second antimuscarinic drug (trospium chloride) was added as a combination therapy.

MATERIALS AND METHOD

Seventy-two children with DO were enrolled in this prospective study (Figure). They had persistent urgency and urgency urinary incontinence (UUI), even with behavioral bowel therapy, and used an optimized dosage of oxybutynine. All patients demonstrated DO at urodynamic study and started on oxybutynin and trospium chloride at the lowest weight-adjusted dose (10-20 mg/day for trospium chloride). A bladder diary was recorded for 3 days, and urodynamic studies were repeated at 3 and 6 months.

RESULTS

Sixteen children (22.2%) became dry. Thirty-three children (45.8%) attained a significant decrease in incontinence from an average of 5 to 1.3 episodes per day. A statistically significant increase of mean cystometeric bladder capacity (P = 0.006) was also observed at the 6-month follow-up. The overall success rate was 68%, since 23 children (32%) discontinued combined treatment due to persistent symptoms and/or intolerable side effects. A total of 41 children (57%) reported no side effects, 25 (34.7%) reported mild side effects, six (8.3%) reported moderate side effects, and two withdrew from the study due to their side effects.

CONCLUSIONS

The addition of low-dose trospium chloride to oxybutynine seemed to be an effective and safe treatment approach for children with DO who were refractory to high-dosage monotherapy. Different combinations with different antimuscarinics drugs could be evaluated in the future.

Extractable fragment versus dusting during ureteroscopic laser lithotripsy in children: Prospective randomized study

INTRODUCTION AND OBJECTIVES

Complete eradication of stone fragments is an important goal during stone management in children. The mode of fragmentation employed to clear stones during ureteroscopic laser lithotripsy raises concerns related to operative time, associated morbidity, costs, and especially potential endoscope damage. The purpose of this study was to evaluate the outcomes of fragmentation into extractable pieces and stone dusting during ureteroscopic laser lithotripsy in children.

MATERIAL AND METHODS

One hundred children with ureteral stones undergoing ureteroscopic holmium laser lithotripsy were prospectively randomized into two groups: group I in which stones were fragmented to dust (n = 50), and group II in which lithotripsy resulted in extractable fragments (n = 50). Different Holmium laser settings were applied during ureteroscopic lithotripsy for each group: low power (500 mJ) and high frequency (12-15 Hz) for lithotripsy to dust. High power (1000-1500 mJ) and reduced frequency (8-10 Hz) for lithotripsy to extractable fragments. The fragmentation time, operating time, stone-free rate, and perioperative complications were compared (Figure).

RESULTS

The mean age of the patients was 6.8 (1-12) years and 8.2 (1-15) years, in groups I and II respectively. The mean fragmentation time and operating time were statistically significantly lower in group II (p = 0.008 and 0.0069 respectively). Minor complications occurred in eight cases (5 in group I and 3 in group II) in the form of hematuria and urinary tract infection. No major complications were encountered in either groups.

CONCLUSIONS

Fragmenting stones into extractable pieces has a significantly shorter fragmentation time and operative time than stone dusting, with similar stone-free and complication rates. Ureteroscopic laser lithotripsy treatment resulting in extractable fragments seems to be an effective and time-saving procedure in children.

Optimizing prophylactic antibiotic regimen in patients admitted for transrectal ultrasound-guided prostate biopsies: A prospective randomized study

Background

Transrectal ultrasound-guided prostate biopsies (TRUSBx), in spite of being one of the most frequently performed urological office procedures, are associated with a spectrum of complications, most significantly including infection. The aim of the study is to evaluate the prevalence of fluoroquinolone-resistant bacteria in rectal swabs from our local population prior to TRUSBx and to identify risk factors among a patient population harboring fluoroquinolone-resistant organisms.

Methods

We prospectively included 541 men who were submitted for TRUSBx in our center from March 2011 to June 2015. The indications for TRUSBx were an elevated prostate-specific antigen level and/or abnormal digital rectal exam. All patients were randomly divided into two groups: Group 1 (n = 279 cases) who received standard empirical prophylactic antibiotics and Group 2 who received targeted prophylaxis based on a rectal swab culture and susceptibility result. Differences in risk factors between quinolone-resistant and nonresistant patients were compared. Univariate and multivariate analyses were performed to identify independent potential risk factors associated with fluoroquinolone-resistant rectal flora.

Results

Sixteen out of 271 men developed infectious complications after TRUSBx in the group receiving standard empirical prophylaxis (5.7%). No men in the group who received targeted prophylactic antibiotic guided by rectal swab developed infectious complications. Among the 262 patients who underwent prebiopsy rectal swab cultures, 76 men (29%) displayed fluoroquinolone-resistant rectal flora (29%). In the multivariate analysis, a history of antibiotic exposure before prostate biopsy was the only independent factor associated with an increased risk of fluoroquinolone resistance.

Conclusion

Determining the prevalence of fluoroquinolone resistance in rectal flora has important implications in the selection of targeted prophylactic antibiotic regimens. Antimicrobial profiles guided by rectal swabs may prove useful to optimize prophylaxis prior to TRUSBx; this strategy is effective at reducing the rates of infectious complications, including sepsis, especially in men at higher risk of infectious complications.

Ferulic acid, a natural polyphenol, alleviates insulin resistance and hypertension in fructose fed rats: Effect on endothelial-dependent relaxation

Ferulic acid (FER) is a polyphenolic compound contained in various types of fruits. It has a substantial therapeutic effect inhibitory activity against aldose reductase (AR) inhibition. In this study, we examined the effect of FER on fructose-fed rats in comparison to a standard AR inhibitor, zopolrestat (ZOP). We determined the protective role of FER against metabolic syndrome by examining serum insulin/Glucose levels, triglycerides (TGs), cholesterol and advanced glycation end product (AGE) in rats supplied with 10% fructose drinking water. In addition, blood pressure, vascular reactivity of isolated thoracic aortas and acetylcholine-induced NO were all evaluated to estimate the cardiovascular complications of metabolic syndrome (MetS) associated with fructose feeding. Animals were randomly divided into four groups: control, (+10% fructose, Fru), zopolrestat-treated fructose fed (Fru-zop) and ferulic acid-treated fructose fed rats (Fru-Fer). After 12 weeks of FER treatment, we found significant reduction in both hyperinsulinemia and elevated diastolic blood pressure associated with fructose-fed to levels comparable to those achieved with ZOP. Both FER and ZOP significantly augmented the impaired relaxation associated with fructose-fed, whereas neither showed any significant effect on the developed vasoconstriction. Isolated aortas from fructose-fed rats incubated with either FER or ZOP, reinstated normal relaxation response to acetylcholine (ACh). Furthermore, isolated aortas showed attenuated nitric oxide (NO) production following the addition of (ACh), while both FER and ZOP restored normal induction of NO. Taken together, the current study shows that, FER alleviated insulin resistance and hypertension associated with metabolic syndrome compared to the standard AR inhibitor (ZOP). This potential protective effect is at least mediated by restoring endothelial relaxation.

Do flexible acrylic resin lingual flanges improve retention of mandibular complete dentures?

Objectives:

The aim of this study was to compare the retention of conventional mandibular complete dentures with that of mandibular complete dentures having lingual flanges constructed with flexible acrylic resin “Versacryl.”

Materials and Methods:

The study sample comprised 10 completely edentulous patients. Each patient received one maxillary complete denture and two mandibular complete dentures. One mandibular denture was made of conventional heat-cured acrylic resin and the other had its lingual flanges made of flexible acrylic resin Versacryl. Digital force-meter was used to measure retention of mandibular dentures at delivery and at 2 weeks and 45 days following denture insertion.

Results:

The statistical analysis showed that at baseline and follow-up appointments, retention of mandibular complete dentures with flexible lingual flanges was significantly greater than retention of conventional mandibular dentures (P < 0.05). In both types of mandibular dentures, retention of dentures increased significantly over the follow-up period (P < 0.05).

Conclusions:

The use of flexible acrylic resin lingual flanges in the construction of mandibular complete dentures improved denture retention.

Percutaneous Nephrolithotomy vs Retrograde Intrarenal Surgery for Large Renal Stones in Pediatric Patients: A Randomized Controlled Trial

PURPOSE

We compared outcomes of percutaneous nephrolithotomy and retrograde intrarenal surgery in the treatment of children with renal calculi larger than 2 cm.

MATERIALS AND METHODS

A total of 38 patients younger than 16 years with renal calculi larger than 2 cm were randomized to undergo percutaneous nephrolithotomy or retrograde intrarenal surgery between May 2011 and February 2014. Demographic data, stone criteria, operative technique, radiation time, complications, blood transfusion, hemoglobin decrease, stone-free rate and length of hospital stay were compared between the groups. Stone-free status was documented if there were no residual stones after 1 month.

RESULTS

The study included 43 renal units, of which 21 were subjected to retrograde intrarenal surgery and 22 to percutaneous nephrolithotomy. Operative time was comparable for both groups. Mean radiation time and hospital stay were longer after percutaneous nephrolithotomy (p<0.001). Stone-free rate was significantly lower after retrograde intrarenal surgery monotherapy vs percutaneous nephrolithotomy monotherapy (71% vs 95.5%, p=0.046). Patients in the percutaneous nephrolithotomy group had significantly more complications compared to the retrograde intrarenal surgery group (p=0.018). Three patients in the percutaneous nephrolithotomy group received blood transfusions, compared to none in the retrograde intrarenal surgery group (p=0.015).

CONCLUSIONS

For treatment of large or complex renal stones in pediatric patients percutaneous nephrolithotomy monotherapy has the advantage of better stone-free rates, while retrograde intrarenal surgery has the advantages of decreased radiation exposure, fewer complications and shorter hospital stay.

Pattern of prostate cancer presentation among the Egyptian population: A study in a single tertiary care center

INTRODUCTION

Prostate cancer is a common health problem that in the majority of cases starts to develop at the age of 50 years, reaching its peak at 60-70 years of age. A variation in its incidence and prevalence exists between western, Asian and Arabic populations. The aim of our work was to report the pattern of prostate cancer presentation in Alexandria University that as a tertiary referral center provides care for uro-oncology cases.

MATERIAL AND METHODS

Data collection for all patients diagnosed with prostate cancer at Alexandria University in Egypt through the year 2012 was done.

RESULTS

The mean age of the patients was 67. Mean serum total PSA, prostate volume and PSAd were 149 ng/ml, 63 grams and 3.1 ng/ml/gm respectively. 25% of patients were asymptomatic diagnosed accidentally during screening for prostate cancer. The remaining group was presenting with LUTS, including 23 patients who presented initially with back pain.

CONCLUSIONS

Egyptian men with prostate cancer have a markedly high PSA density and Gleason grade at diagnosis.

Baicalein protects against hypertension associated with diabetes: effect on vascular reactivity and stiffness

The present work investigated the possible protective effect of baicalein, a natural lipoxygenase enzyme inhibitor, on both insulin deficiency (ID) and insulin resistance (IR)-induced macro-vascular impairment. ID and IR were induced by STZ or fructose for 8 or 12 weeks respectively while baicalein was administered in the last six weeks. Blood pressure (BP) was recorded and isolated aorta reactivity to phenylephrine (PE) and acetylcholine (ACh) were studied. Blood levels of glucose, insulin, advanced glycation end products (AGEs) and tumour necrosis factor-α (TNF-α) were determined. Aortic nuclear transcription factor-κB (NF-κB) activation was assessed. Both models resulted in elevated BP, increased vasoconstriction and impaired relaxation KCl, elevated TNF-α and AGEs, NF-κB activation, marked infiltration of leukocytes in the adventitia, pyknosis of endothelial cells and marked collagen deposition. Baicalein ameliorated elevations in BP in models, prevented exaggerated vasoconstriction IR model and improved relaxation in ID model. Baicalein reduced AGEs and TNF-α level, decreased NF-κB activation and inhibited histopathological changes in both models. Baicalein offsets the hypertensive and the vascular impairment associated with both diabetic models via ameliorating functional and structural derangements of blood vessels.

Arginase inhibition alleviates hypertension in the metabolic syndrome

BACKGROUND AND PURPOSE

We have previously shown that arginase inhibition alleviates hypertension associated with in a diabetic animal model. Here, we investigated the protective effect of arginase inhibition on hypertension in metabolic syndrome.

EXPERIMENTAL APPROACH

Metabolic syndrome was induced in rats by administration of fructose (10% in drinking water) for 12 weeks to induce vascular dysfunction. Three arginase inhibitors (citrulline, norvaline and ornithine) were administered daily in the last 6 weeks of study before and tail BP was recorded in conscious animals. Concentration response curves for phenylephrine (PE), KCl and ACh in addition to ACh-induced NO generation were obtained in thoracic aorta rings. Serum glucose, insulin, uric acid and lipid profile were determined as well as reactive oxygen species (ROS) and arginase activity.

KEY RESULTS

Arginase activity was elevated in metabolic syndrome while significantly inhibited by citrulline, norvaline or ornithine treatment. Metabolic syndrome was associated with elevations in systolic and diastolic BP, while arginase inhibition significantly reduced elevations in diastolic and systolic BP. Metabolic syndrome increased vasoconstriction responses of aorta to PE and KCl and decreased vasorelaxation to ACh, while arginase inhibition completely prevented impaired responses to ACh. In addition, arginase inhibition prevented impaired NO generation and exaggerated ROS formation in metabolic syndrome. Furthermore, arginase inhibition significantly reduced hyperinsulinaemia and hypertriglyceridaemia without affecting hyperuricaemia or hypercholesterolaemia associated with metabolic syndrome.

CONCLUSIONS AND IMPLICATIONS

Arginase inhibition alleviates hypertension in metabolic syndrome directly through endothelial-dependent relaxation/NO signalling protection and indirectly through inhibition of insulin resistance and hypertriglyceridaemia.

Chrysin and luteolin alleviate vascular complications associated with insulin resistance mainly through PPAR-γ activation

Chrysin and luteolin are two flavonoids with Peroxisome proliferators-activated receptor γ (PPAR-γ) stimulating activity. Here, we investigated the protective effect of chrysin and luteolin from vascular complications associated with insulin resistance (IR). IR was induced in rats by drinking fructose for 12 weeks while chrysin and luteolin were given for 6 weeks with or without PPAR-γ antagonist, bisphenol A diglycidyl ether (BADGE). Then, blood pressure (BP) was recorded and serum levels of glucose, insulin, advanced glycation end products (AGEs) and lipids were measured. Concentration response curves for phenylephrine (PE), KCl, and acetylcholine (ACh) were obtained in thoracic aorta rings. Aortic reactive oxygen species (ROS) and nitric oxide (NO) generation were also studied. Chrysin and luteolin significantly alleviated systolic BP elevations caused by IR, while the co-administration of BADGE prevented chrysin alleviation. Although, neither chrysin nor luteolin affected ACh impaired vasodilatation, they both alleviated exaggerated vasoconstrictions to PE and KCl in IR animals. In addition, incubation of the aorta from IR animals with chrysin or luteolin prevented exaggerated vasoconstrictions to PE and KCl. On the other hand, co-administration of BADGE or co-incubation with GW9662, the selective PPAR-γ antagonist, prevented chrysin alleviation. Both chrysin and luteolin inhibited the developed hyperinsulinemia and increases in serum AGEs, lipids while, BADGE reduced the effect of chrysin on hyperinsulinemia and dyslipidemia. Chrysin and luteolin markedly inhibited elevated NO and ROS in IR aortae while BADGE did not change their effect on NO and ROS. In conclusion, chrysin and luteolin alleviate vascular complications associated with IR mainly through PPAR-γ dependent pathways.

Characterization of vascular complications in experimental model of fructose-induced metabolic syndrome

Vascular dysfunction is an important complication associated with metabolic syndrome (MS). Here we fully characterized vascular complications in a rat model of fructose-induced MS. MS was induced by adding fructose (10%) to drinking water to male Wistar rats of 6 weeks age. Blood pressure (BP) and isolated aorta responses phenylephrine (PE), KCl, acetylcholine (ACh), and sodium nitroprusside (SNP) were recorded after 6, 9, and 12 weeks of fructose administration. In addition, serum levels of glucose, insulin, uric acid, tumor necrosis factor α (TNFα), lipids, advanced glycation end products (AGEs), and arginase activity were determined. Furthermore, aortic reactive oxygen species (ROS) generation, hemeoxygenase-1 expression, and collagen deposition were examined. Fructose administration resulted in a significant hyperinslinemia after 6 weeks which continued for 12 weeks. It was also associated with a significant increase in BP after 6 weeks which was stable for 12 weeks. Aorta isolated from MS animals showed exaggerated contractility to PE and KCl and impaired relaxation to ACh compared with control after 6 weeks which were clearer at 12 weeks of fructose administration. In addition, MS animals showed significant increases in serum levels of lipids, uric acid, AGEs, TNFα, and arginase enzyme activity after 12 weeks of fructose administration. Furthermore, aortae isolated from MS animals were characterized by increased ROS generation and collagen deposition. In conclusion, adding fructose (10%) to drinking water produces a model of MS with vascular complications after 12 weeks that are characterized by insulin resistance, hypertension, disturbed vascular reactivity and structure, hyperuricemia, dyslipidemia, and low-grade inflammation.

Aqueous garlic extract alleviates liver fibrosis and renal dysfunction in bile-duct-ligated rats

There is accumulating evidence that the renin-angiotensin system (RAS) is involved in hepatic inflammation and fibrogenesis. Garlic was found to lower the activity of the angiotensin converting enzyme (ACE) in the serum of rats in a diabetic model. We examined the effect of an aqueous garlic extract (AGE) on the ACE activity, cholestasis-induced liver fibrosis, and associated renal dysfunction in comparison with the effect of the standard drug enalapril. Both AGE and enalapril were administered orally for six weeks starting from the third day after bile duct ligation (BDL). BDL significantly increased the serum activities of liver enzymes, serum lactate dehydrogenase (LDH) activity, an indicator of liver cell death, serum total bilirubin (TB) level, liver myeloperoxidase (MPO) activity, and liver malondialdehyde (MDA) content. BDL was associated with elevation of serum urea and creatinine levels indicating renal dysfunction. BDL also caused an increase in the transcript levels of the genes coding for tumour necrosis factor alpha (TNF-alpha), transforming growth factor beta-1 (TGF-beta1), and matrix metalloproteinase-13 (MMP-13), a collagenase, in liver tissues. A significant decrease in hepatic reduced glutathione (GSH) was observed in BDL rats, while serum ACE activity was increased. Both AGE and enalapril counteracted all these deleterious changes, with the exception that only AGE reduced the MPO activity. These findings suggest that AGE possesses hepato- and renoprotective properties, similar to enalapril, probably by modulating the levels of proteins such as TNF-alpha, TGF-beta1 and MMP-13, and involving a reduction of ACE and of oxidative stress.

BDNF signaling in the VTA links the drug-dependent state to drug withdrawal aversions

Drug administration to avoid unpleasant drug withdrawal symptoms has been hypothesized to be a crucial factor that leads to compulsive drug-taking behavior. However, the neural relationship between the aversive motivational state produced by drug withdrawal and the development of the drug-dependent state still remains elusive. It has been observed that chronic exposure to drugs of abuse increases brain-derived neurotrophic factor (BDNF) levels in ventral tegmental area (VTA) neurons. In particular, BDNF expression is dramatically increased during drug withdrawal, which would suggest a direct connection between the aversive state of withdrawal and BDNF-induced neuronal plasticity. Using lentivirus-mediated gene transfer to locally knock down the expression of the BDNF receptor tropomyosin-receptor-kinase type B in rats and mice, we observed that chronic opiate administration activates BDNF-related neuronal plasticity in the VTA that is necessary for both the establishment of an opiate-dependent state and aversive withdrawal motivation. Our findings highlight the importance of a bivalent, plastic mechanism that drives the negative reinforcement underlying addiction.

Single- vs. multi-stage repair of proximal hypospadias: The dilemma continues

INTRODUCTION

The surgical reconstruction of distal penile hypospadias in a single stage is the standard practice for managing anterior hypospadias. Unfortunately, it is not simple to extrapolate the same principle to proximal hypospadias. There is no consensus among hypospadiologists about whether a single- or multi-stage operation is the optimal treatment for proximal hypospadias. In this review, we assess the currently reported outcomes and complications of both techniques in proximal hypospadias repair.

METHODS

We searched Medline, Pubmed, Scopus and Ovid for publications in the last 10 years (2002-2012) for relevant articles, using the terms 'proximal hypospadias', 'posterior hypospadias' 'single stage', 'multiple stage', and 'complications'. Articles retrieved were analysed according to the technique of repair, follow-up, complications, success rate, number of included children, and re-operative rate.

RESULTS AND CONCLUSIONS

The reported complications in both techniques were similar, including mostly minor complications in the form of fistula, meatal stenosis, partial glans dehiscence, and urethral diverticulum, with their easy surgical repair. The outcomes of single- and multistage repairs of proximal hypospadias are comparable; no technique can be considered better than any other. Thus, it is more judicious for a hypospadiologist to master a few of these procedures to achieve the best results, regardless of the technique used.

Quercetin protects against diabetes-induced exaggerated vasoconstriction in rats: effect on low grade inflammation

Vascular complications are the leading cause of morbidity and mortality in patients with diabetes. Quercetin is an important flavonoid with antioxidant and anti-inflammatory activity. Here, the effect of quercetin on diabetes-induced exaggerated vasoconstriction in insulin deficient and insulin resistant rat models was investigated. Insulin deficiency was induced by streptozotocin while, insulin resistance by fructose. Rats were left 8 weeks or 12 weeks after STZ or fructose administration respectively. Quercetin was daily administered in the last 6 weeks. Then, tail blood pressure (BP) was recorded in conscious animals; concentration-response curves for phenylephrine (PE) and KCl were studied in thoracic aorta rings. Non-fasting blood glucose level, serum insulin level, insulin resistance index, serum tumour necrosis factor-α (TNF-α) and serum C-reactive protein (CRP) were determined. Nuclear transcription factor-κB (NF-κB) was assessed by immunofluorescence technique. Histopathological examination was also performed. The results showed that quercetin protected against diabetes-induced exaggerated vasoconstriction and reduced the elevated blood pressure. In addition, quercetin inhibited diabetes associated adventitial leukocyte infiltration, endothelial pyknosis and increased collagen deposition. These effects were accompanied with reduction in serum level of both TNF-α and CRP and inhibition of aortic NF-κB by quercetin in both models of diabetes. On the other hand, quercetin did not affect glucose level in any of the used diabetic models. This suggests that the protective effect of quercetin is mediated by its anti-inflammatory effect rather than its metabolic effects. In summary, quercetin is potential candidate to prevent diabetic vascular complications in both insulin deficiency and resistance via its inhibitory effect on inflammatory pathways especially NF-κB signaling.

Aldose reductase inhibitors zopolrestat and ferulic acid alleviate hypertension associated with diabetes: effect on vascular reactivity

This study investigated the effect of aldose reductase (AR) inhibitors on hypertension in diabetes. Diabetes was induced with streptozotocin, while AR inhibitors zopolrestat and ferulic acid were administered at 2 weeks after streptozotocin treatment and for 6 weeks afterwards. Then, blood pressure (BP) and serum level of glucose were determined. Concentration–response curves for phenylephrine (PE), KCl, and acetylcholine (ACh) were obtained in isolated aorta. In addition, ACh-induced NO and reactive oxygen species (ROS) generation in aorta and histopathology were examined. Compared with the control animals, diabetes increased diastolic and systolic BP. AR inhibitors reduced diastolic BP elevation without affecting the developed hyperglycaemia. Diabetes increased the contractile response of aorta to KCl, and decreased the relaxation response to Ach, while administering AR inhibitors prevented an impaired response to ACh. Incubation of aorta isolated from diabetic animals with AR inhibitors did not affect the impaired relaxation response to ACh. In addition, AR inhibitors negated the impaired Ach-stimulated NO generation seen in aorta isolated from diabetic animals. Furthermore, diabetes was accompanied with marked infiltration of leukocytes in aortic adventitia, endothelial cell pyknosis, and increased ROS formation. AR inhibitors reduced leukocyte infiltration and inhibited endothelial pyknosis and ROS formation. In conclusion, AR inhibitors negate diabetes-evoked hypertension via ameliorating impaired endothelial relaxation and NO production.

Factors that predict the spontaneous passage of ureteric stones in children

Objective

To study the natural history of stone passage in children with ureterolithiasis and to define factors predictive of spontaneous passage.

Patients and methods

In all, 72 children with ureteric stones were evaluated; patients with ureteric calculi of >10 mm were excluded, as were those with absolute indications for surgical stone removal. Stone size, location, side, presence of hydronephrosis, perinephric stranding and degree of the tissue-rim sign were estimated by unenhanced helical computed tomography (UHCT). All patients were sent home with no administration of an α-blocker. The stone status was evaluated by a plain abdominal film or CT at ≈6 weeks after the initial diagnostic evaluation. The time from the initial complaint to the passage of the stone was recorded for each patient.

Results

In all, 54 (75%) children with ureteric stones of ⩽6 mm eventually passed their stones spontaneously. However, stones of <4 mm and those in the distal ureter had a significantly higher spontaneous passage rate and shorter time to stone passage (P < 0.05). The UHCT findings of a higher degree of the tissue-rim sign, hydronephrosis and perinephric fat stranding were associated with a lower likelihood of stone passage.

Conclusions

The rate of spontaneous passage of ureteric stones in children varies with stone location, and perinephric stranding on UHCT seems to be useful for predicting the possibility of spontaneous passage. In cases with unfavourable signs an early intervention might have better outcomes than conservative therapy.

Ureteroscopy in infants and preschool age children: technique and preliminary results

INTRODUCTION

We present our experience with the use of semirigid ureteroscopy for the treatment of ureteric stones in children less than or equal to 6 years of age.

MATERIAL AND METHODS

The records of 21 children (12 female, 9 male) with an average age of 4.7 years (range 8 months to 6 years) treated with semirigid ureteroscopy between June 2006 and July 2010 were reviewed. In 13 ureteral units 7Fr semirigid ureteroscopy was carried out in a retrograde manner to treat stone disease, while an adult ureteroscope (9.5 fr) was used in the remaining patients. Stones were located in the upper ureter in 2 cases, middle ureter in 2 cases, and lower ureter in 17 cases. Ureteral dilation was not required in all patients.

RESULTS

Stone size varied from 4 to 13 mm (mean 6 mm). The management of stones in 18 (90.7%) children was straightforward and a single ureteroscopy was required to clear the ureters. In 2 (6.2%) children, repeat ureteroscopy was undertaken to render the ureters stone free, and in 1 child (3.1%) it was not possible to remove the stone. Stones were fragmented with pneumatic lithotripsy in 12 cases and stones were removed mechanically without fragmentation in the remaining 9 cases. Intraoperative complications occurred in 2 (9.3%) children and included extravasation (1 patient), which was managed with ureteral stenting and stone upward migration (1 patient). Early postoperative complications included pyelonephritis (1 patient). Mean follow-up was 6.4 (3-36) months. Incidence of stricture at the site of stone impaction was not detected in any patients. None of the patients managed without a post-operative stent required subsequent intervention.

CONCLUSIONS

In the hands of an experienced surgeon, ureteroscopy in young children can be a safe and efficient treatment for ureteral stones that can be performed without ureteral dilation. Routine ureteral stenting is not a requirement when the procedure is relatively atraumatic. Further studies and longer follow-up are necessary to determine the success of this technique.

Cinnamaldehyde protects from the hypertension associated with diabetes

Here we investigated cinnamaldehyde (CA) effect on diabetes-induced hypertension. Insulin deficiency was induced by streptozotocin while, insulin resistance by fructose. Rats were left 8 weeks or 12 weeks after STZ or fructose administration respectively. CA (20 mg kg(-1)day(-1)) was daily administered in the last 6 weeks. Then, blood pressure (BP) was recorded. Isolated Aorta reactivity to phenylephrine (PE), KCl, acetylcholine (ACh) was studied as well as nitric oxide (NO) generation plus Ca(2+) influx. Insulin deficiency was associated with elevated BP, increased response to PE and KCl, decreased response to ACh and impaired NO generation. CA treatment prevented hyperglycemia and its associated impaired vascular reactivity. Insulin resistance was associated with elevated BP while, CA prevented this elevation. Insulin resistance increased response to PE and KCl, decreased response to ACh, while CA treatment normalized response to KCl and PE but not to ACh. Insulin resistance was accompanied with reduced NO generation but exaggerated Ca(2+) influx while CA restored normal Ca(2+) influx but did not affect NO generation. In conclusion, CA prevents development of hypertension in insulin deficiency and insulin resistance through normalization of vascular contractility in addition to its insulinotropic effect in insulin deficiency.

Efficacy and cardiovascular tolerability of continuous veno-venous hemodiafiltration in acute decompensated heart failure: a randomized comparative study

BACKGROUND AND OBJECTIVES

Recently, continuous veno-venous hemodiafiltration (CVVHDF) has received increased attention in the treatment of congestive heart failure (CHF). The aim of this study is to assess the safety and efficacy of CVVHDF compared with intravenous furosemide in patients with CHF.

METHODS

Forty patients having CHF were included in this prospective, randomized, comparative trial. We randomized patients to treatment for 72 hours with CVVHDF or intravenous furosemide. Outcomes assessed were weight loss, total fluid output, length of stay (LOS) in the intensive care unit (ICU), 30-day mortality, and cardiovascular stability.

RESULTS

Demographic data were comparable in both groups. Weight loss (P ≤ .05) and total fluid output (P ≤ .01) were greater in the CVVHDF group. Length of stay in the ICU was significantly reduced in the CVVHDF group (P ≤ .05). The mortality rates were comparable in both groups. The cardiac output and the stroke volume significantly increased, whereas the pulmonary capillary wedge pressure significantly decreased (P ≤ .05) in both groups compared with the baseline. A transient attack of hypotension occurred in 1 patient in the CVVHDF group.

CONCLUSION

In CHF, the use of CVVHDF effectively and safely produced greater weight and fluid loss and decreased LOS in the ICU more than the intravenous furosemide with no hemodynamic instability.

Management of biochemical failure following radical prostatectomy: salvage radiotherapy - a case series

A retrospective analysis of the outcome of radical prostatectomy (RP) for prostate cancer in a single centre and assessment of the role of salvage radiotherapy (RT) for patients with biochemical relapse. Hundred and thirty-seven patients underwent RP for adenocarcinoma of the prostate in our centre between December 1994 and June 2003. Fifty-four of these patients developed a biochemical relapse prostate-specific antigen (PSA > or = 0.2 ng/ml). Thirty-two patients including five from elsewhere (one with a palpable local recurrence) received salvage RT. Twenty-five of these had positive margins at resection and four had involvement of seminal vesicles. Nine had Gleason score > or = 8. Median PSA before RT was 0.55 ng/ml (range 0.2-5.0). Median age at surgery was 63.5 years (range 52-71). Median age at RT was 65 years (range 53-73). Median time from surgery to biochemical relapse was 11 months (range 0-37) and median interval from surgery to RT was 22 months (range 3-71). Twenty-seven patients received 64 Gy in 32 fractions, three patients received 55 Gy in 20 fractions and two patients received 50 Gy in 20 fractions. Twenty-seven patients were managed by observation or hormone therapy. Twenty-seven patients (84%) achieved complete biochemical remission following RT. Eighteen (56%) remain in complete remission with a median follow-up since RT for the whole group of 30 months (range 8-85). Fourteen patients have relapsed, eight of whom had either clear margins or PSA >1.0 ng/ml at the time of RT (PSA > or = 0.2 ng/ml). Salvage RT is an effective treatment for achieving biochemical remission in selected patients who relapse following RP.

Case-control study of non-Hodgkin's lymphoma and hepatitis C virus infection in Egypt

BACKGROUND

Chronic infection with hepatitis C virus (HCV) has been associated in some studies with increased risk for B-cell non-Hodgkin's lymphoma (NHL). To assess this further, we conducted a case-control study in Egypt, where HCV prevalence is extremely high.

METHODS

Cases with B-cell NHL (N = 227) were recruited from the National Cancer Institute of Cairo University, a major referral centre. Controls (N = 227) were patients with fractures being treated at the Kasr El-Aini Orthopaedic Hospital, from the same referral base as the cases, and were frequency-matched by gender, rural versus urban birthplace, and age. Subjects were interviewed about their medical history and possible risk factors, and blood samples were collected for HCV diagnostic tests. Anti-HCV and HCV RNA were determined by enzyme-linked immunoassay and reverse transcription-polymerase chain reaction, respectively. Odds ratios (OR) and 95% CI were calculated from logistic regression models.

RESULTS

Overall, 42% of subjects were anti-HCV positive and 33% had HCV RNA. There was a statistically significant unadjusted association of HCV RNA with NHL (OR = 2.3, 95% CI: 1.5, 3.5), which differed slightly by gender (males: OR = 2.1, 95% CI: 1.2, 3.7 versus females: OR = 2.5, 95% CI: 1.3, 4.8). Anti-HCV without HCV RNA was not associated with case status (OR = 0.9, 95% CI: 0.5, 1.6). After adjustment for age, gender, rural versus urban birthplace, and rural versus urban current residence, the association of HCV RNA with the risk of NHL remained statistically significant (OR = 2.9, 95% CI: 1.9, 4.5).

CONCLUSIONS

These data support the hypothesis that NHL is a malignant outcome of chronic HCV infection.

Mucoepidermoid carcinoma: a clinicopathologic study of 80 patients with special reference to histological grading

We sought to review our experience with salivary mucoepidermoid carcinoma (MEC) over two decades to confirm the validity and reproducibility of histologic grading and to investigate MIB-1 index as a prognosticator. Diagnosis was confirmed on 80 cases, and chart review or patient contact was achieved for 48 patients, with follow-up from 5 to 240 months (median 36 months). Immunohistochemistry with citrate antigen retrieval for MIB-1 was performed on a subset of cases. Kaplan-Meier survival curves were generated for each stage, site, and grade according to our proposed grading system. To address the issue of grading reproducibility, 20 slides were circulated among five observers, without prior discussion; slides were categorized as low-, intermediate-, or high-grade according to one's "own" criteria, and then according to the AFIP criteria proposed by Goode et al.10 Weighted kappa (kappa) estimates were obtained to describe the extent of agreement between pairs of rating. The Wilcoxon signed rank test or the Friedman test as appropriate tested variation across ratings. There was no gender predominance and a wide age range (15-86 years, median 49 years). The two most common sites were parotid and palate. All grade 1 MECs presented as Stage I tumors, and no failures were seen for this category. The local disease failure rates at 75 months for grades 2 and 3 MEC were 30% and 70%, respectively. Tumor grade, stage, and negative margin status all correlated with disease-free survival (DFS) (p = 0.0091, 0.0002, and 0.048, respectively). The MIB index was not found to be predictive of grade. Regarding the reproducibility of grading, the interobserver variation for pathologists using their "own" grading, as expressed by the kappa value, ranged from good agreement (kappa = 0.79) to poor (kappa = 0.27) (average kappa = 0.49). A somewhat better interobserver reproducibility was achieved when the pathologists utilized the standardized AFIP criteria (average kappa = 0.61, range 0.38-0.77). This greater agreement was also reflected in the Friedman test (statistical testing of intraobserver equality), which indicated significant differences in using one's own grading systems (p = 0.0001) but not in applying the AFIP "standardized" grading (p = 0.33). When one's own grading was compared with the AFIP grading, there were 100 pairs of grading "events," with 46 disagreements/100 pairs. For 98% of disagreements, the AFIP grading "downgraded" tumors. This led us to reanalyze a subset of 31 patients for DFS versus grade, for our grading schema compared with the AFIP grading. Although statistical significance was not achieved for this subset, the log rank value revealed a trend for our grading (p = 0.0993) compared with the Goode schema (p = 0.2493). This clinicopathologic analysis confirms the predictive value of tumor staging and three-tiered histologic grading. Our grading exercise confirms that there is significant grading disparity for MEC, even among experienced ENT/oral pathologists. The improved reproducibility obtained when the weighted AFIP criteria were used speaks to the need for an accepted and easily reproducible system. However, these proposed criteria have a tendency to downgrade MEC. Therefore, the addition of other criteria (such as vascular invasion, pattern of tumor infiltration [i.e., small islands and individual cells vs cohesive islands]) is necessary. We propose a modified grading schema, which enhances predictability and provides much needed reproducibility.

A clinicopathological study of sinonasal neuroendocrine carcinoma and sinonasal undifferentiated carcinoma

OBJECTIVE

Sinonasal undifferentiated carcinoma (SNUC) and sinonasal neuroendocrine carcinoma (SNEC) are relatively newly recognized, rare entities requiring further clinicopathological analysis to advance our understanding and determine prognostic distinctions between them.

STUDY DESIGN

Retrospective chart review.

METHODS

Cases were retrieved from the Copath system. One patient was seen in consultation from an outside institution. Histological and immunohistochemical findings, patient demographics, treatment regimens, and outcomes were analyzed and compared.

RESULTS

Ten patients (7 men, 3 women) ranging in age from 17 to 58 years (mean age, 44.7 y) were included. Four patients were classified with SNEC, six as having SNUC. The predominant site was the superior nasal cavity or ethmoids (seven cases), followed by the maxilla (four cases). Disease in four patients was clinically staged as N1 (three with SNUC, one with SNEC), and in six patients as NO (three with SNEC, three with SNUC). Of the nine patients who were treated initially with surgical resection, seven received postoperative radiation therapy alone, one received postoperative radiation and chemotherapy, and one had only limited postoperative chemotherapy. One patient was treated with radiation therapy and chemotherapy alone, without surgical resection. Follow-up was obtained ranging from 6 to 108 months (mean period, 26.4 mo). Three patients died of disease 10, 14, and 41 months, respectively, after diagnosis. Three patients had persistent disease at 6, 9, and 21 months, respectively, two of them with distant metastases. Four patients were disease free after 6, 18, 31, and 108 months, respectively.

CONCLUSIONS

SNUC and SNEC are both aggressive tumors, usually presenting in middle age as a nasal mass. Both tumors have the capacity to metastasize locally and distantly, and both can result in poor outcomes. This small series precludes a demographic or prognostic distinction between the two groups.

A mild form of mucolipidosis type III in four Baluch siblings

Four Baluch siblings with mucolipidosis type III (pseudo-Hurler polydystrophy) are described. The patients had features commonly found in mucolipidosis III, including claw hands, joint stiffness, aortic valve involvement and radiological dysostosis multiplex. However, intelligence was normal, there were no eye abnormalities on slit-lamp examination and skin elasticity was normal. Many lysosomal enzymes were elevated in serum and diminished in cultured fibroblasts, although the findings for beta-galactosidase were atypical. Assays for the two enzymes involved in formation of the phosphomannose recognition marker revealed normal activity of the phosphotransferase with alpha-methylmannoside as an acceptor, and normal activity of the phosphodiester glycosidase. Metabolic labelling of fibroblasts with 32P followed by immunoprecipitation of cathepsin D, electrophoresis and fluorography showed that this enzyme was not labelled in the patients' cells, although some label was detected in the secreted precursor polypeptide. The data are consistent with the assumption that activity of the phosphotransferase is low towards lysosomal enzymes as substrates, and that the patients belong to complementation group C.

Unusual clinical presentations of secundum atrial septal defect

Atrial septal defect (ASD) is one of the most common congenital cardiac anomalies found in the adult population. Although usually asymptomatic in childhood, ASD will be symptomatic in approximately 75 percent of adults. The most common symptoms include fatigue, dyspnea on exertion, and palpitations. However, the presentation of ASD can be protean. We present four patients with secundum ASD with unusual clinical manifestations. Patient 1 had moderately severe mitral regurgitation. Patient 2 had pulmonary edema with generalized left ventricular impairment. Patient 3 had chest pain typical of angina pectoris. Patient 4 had right-to-left shunt following an orthopedic surgical procedure. These patients had chest radiographs and electrocardiograms typical of secundum ASD, but their presentations were uncommon. In three of four of these patients, dramatic resolution of symptoms followed surgical repair of their ASD.

The effect of glucose on insulin release and ion movements in isolated pancreatic islets of rats in old age

1. The effect of glucose on 86Rb+ efflux, 45Ca2+ net uptake and insulin secretion of pancreatic islets from 3- and 24-month-old rats was studied. 2. Raising the glucose concentration from 3 to 5.6 and 16.7 mM had no effect on 86Rb+ efflux from islets of 24-month-old male rats whereas that from 24-month-old female rats was decreased. 3. At 16.7 mM-glucose, net uptake of 45Ca2+ was significantly diminished in islets of 24-month-old rats compared to islets of 3-month-old rats. 4. In the presence of 16.7 mM-glucose, islets of 24-month-old rats exhibited only 60-70% of the insulin release obtained with islets from 3-month-old rats. 5. Neither net uptake of 45Ca2+ nor insulin secretion appear to differ between the sexes. 6. These data suggest that the decreased insulin secretory response to glucose during old age is due, at least in part, to inadequate inhibition of K+ efflux and diminished net uptake of Ca2+.

Muir-Torre syndrome. Histologic spectrum of sebaceous proliferations

The sebaceous proliferations seen in patients with Muir-Torre syndrome are unique and difficult to classify. Having reviewed over 50 skin biopsies from five patients with Muir-Torre syndrome, we conclude that the primary proliferation involves the hair follicle and most often resembles either a keratoacanthoma or a sebaceous proliferation, but may have histologic features of both lesions. Unusual patterns seen in the sebaceous components may include solid basaloid sheets, mucinous areas, and convoluted glands.

Failure of glucose to affect 86rubidium efflux and 45calcium uptake of fetal rat pancreatic islets

Ion movements and insulin secretion of pancreatic islets of adult and fetal rats have been studied at three glucose concentrations. In islets of adult rats, 86Rb efflux is maximally decreased by 5.6 mM-glucose. 16.7 mM-glucose caused a biphasic efflux pattern which may be due to glucose-stimulated Ca uptake. In islets of fetal rats elevation of the glucose concentration from 3 to 5.6 or 16.7 mM does not cause a change of 86Rb efflux, and the fractional efflux from fetal islets in the presence of 3 mM-glucose is similar to that from adult rat islets in the presence of 5.6 mM-glucose. Elevation of the glucose concentration from 3 to 16.7 mM is not associated with an increase in 45Ca uptake into fetal islets, although this change in glucose concentration doubles 45Ca uptake into adult islets. When challenged with 16.7 mM-glucose, fetal islets exhibit no insulin secretory response; however, they do respond to theophylline. It is concluded that the failure of fetal islets to exhibit an insulin-secretory response when challenged with glucose might be related to the inability of glucose to affect 86Rb efflux and Ca uptake. The present data are discussed in light of differences between pancreatic islets of fetal and adult rats with respect to the redox state of pyridine nucleotides, thiols and glucose metabolism.

Ethanol-Ascorbate Interrelationship in Acute and Chronic Alcoholism in the Guinea Pig

The effects of low (200 ppm) and of high (2000 ppm) ascorbic acid, in a nutritionally adequate diet, on blood ethanol levels have been studied in permanently carotid-cannulated, ethanol-infused, unanesthetized guinea pigs. In the acute study, the postinfusion rate of ethanol decline in the blood of animals treated with ascorbic acid was significantly higher when compared with animals treated with fructose, and the rate in the two treated groups was significantly higher than in untreated controls. In the chronic study, animals were infused with sublethal doses of ethanol (30% of the total caloric intake) for 8 weeks. Blood ethanol levels monitored throughout this period showed, at 3 hr postinfusion, a lower concentration in the group on a high ascorbic acid diet. Both experimental groups receiving ethanol lost significantly more body weight in the second week of dieting; but, while the group on high ascorbic acid regained weight steadily thereafter, the group on low ascorbic acid was still 50 g below the controls at the end of the experiment. Liver, kidney, and adrenal ascorbic acid concentrations were lower in the ethanol-treated groups compared to controls. Examination of the liver revealed more fatty metamorphosis or steatosis in the low ascorbic acid group, but there was no evidence of liver fibrosis or cirrhosis. These results demonstrate the feasibility of utilizing the guinea pig for the study of the biochemical and morphological sequelae of alcoholism. They further support the contention that a diet which is nutritionally adequate may no longer be so in the presence of high ethanol intake, and that supplemental vitamin C ingestion may afford protection against ethanol toxicity.

Histoplasmosis of the adrenal glands studied by CT

Computed tomography (CT) of the adrenal glands was performed on seven patients who had histologically proved disseminated histoplasmosis. All seven patients showed some degree of adrenal gland abnormality. The range of CT findings included minimal enlargement with faint flecks of calcium, moderate enlargement with focal low attenuation nodules, and massive enlargement with large areas of necrosis or dense calcification. The changes in each patient were bilateral and symmetrical. Adrenal gland shape was usually preserved. Findings of percutaneous adrenal biopsy, which was performed under CT guidance, made the diagnosis in one patient. Five of seven patients had adrenal insufficiency. We conclude that the diagnosis of disseminated histoplasmosis should be considered in any patient who has bilateral adrenal gland enlargement and who resides in an endemic area, especially if there is evidence of adrenal insufficiency, and that CT is superb for the assessment of adrenal gland morphology in this disease, and CT-directed biopsy is the recommended method of confirming the diagnosis in difficult cases.

Mechanisms of splenectomy protection in epinephrine-induced renal and cardiac necrosis

This study was intended to elucidate the mechanism(s) of protection afforded by splenectomy against EPI-induced ATN and myocardial necrosis. Renal function parameters, hematocrit, circulating catecholamines (EPI and NE), serum enzymes (CPK and SGOT), and urinary PGE2 were measured before and during intravenous infusion of EPI (4 micrograms/kg/min for 6 hr) in intact and chronically splenectomized animals. All but serum enzymes were measured in another group of splenectomized animals that were implanted with small fragments of the autologous spleen (autoimplanted animals) 2 weeks prior to EPI infusion. Renal function tests and urinary PGE2 levels were monitored for several hours during the recovery period. The development of ARF in intact animals was accompanied by marked increases in circulating catecholamine levels, hematocrit, and serum enzymes and by a marked decrease in urinary PGE2 levels. These animals had diffuse ATN and hemorrhagic lesions of the heart (myocardial necrosis), and none survived. Chronically splenectomized animals were protected against the adverse effects of EPI infusion. The protected animals showed minimal elevation of circulating catecholamine levels and no changes in urinary PGE2 levels or hematocrit. Serum enzymes and renal and cardiac histopathology remained essentially normal in these animals. Implantation of autologous splenic tissue in splenectomized animals caused reversal of the protective effect of splenectomy. The response of autoimplanted animals to EPI infusion was in all respects similar to that in intact animals with the exception of hematocrit, which did not rise. All autoimplanted animals survived. They showed prompt recovery of renal function associated with significant increase of urinary PGE2 levels during the recovery period. Focal ATN was observed but no hemorrhagic lesion of the heart was found. From these observations we conclude the following: (1) high circulating NE and/or low renal (urinary) PGE2 activity are important in the pathogenesis of EPI-induced ARF, (2) the spleen may release some factor(s) that modulate plasma NE level and/or renal PGE2 activity during EPI infusion, (3) EPI-induced ARF may occur independently of myocardial necrosis, and (4) hematocrit has no major role in EPI-induced ARF.

Effect of formalin on the survival of systemic fungi in tissue

Stock cultures of Blastomyces dermatitidis, Candida albicans, Cryptococcus neoformans, Histoplasma capsulatum and Sporothrix schenckii were grown in yeast phase on Sabouraud dextrose agar. Standardized suspensions (10(8) colony forming units/ml) were made and 1. the organisms treated for various times with 10% formalin/acetate buffer; 2. aliquots injected into the tail veins of Swiss-Webster mice. Minimal fungistatic and fungicidal concentrations of formalin were also determined. Five minutes or more of formalin treatment killed all organisms, in vitro, except C. albicans which withstood the 5-minute but not the 30-minute treatment. All fungi, except H. capsulatum which was not recovered, were cultured from mouse heart, kidneys, spleen, lungs and liver prior to but not after 5-minute formalin treatment. All yeasts were susceptible to concentrations of less than 1% formalin. These results emphasize the extreme fungicidal activity of 10% formalin and the uselessness of culturing even very briefly-fixed tissue.

Acute tubular necrosis in hepatorenal syndrome: an electron microscopy study

This report describes light and transmission electron microscopy (LM and EM, respectively) studies of kidneys from five cases of hepatorenal syndrome. The kidneys were removed and fixed for LM and EM between 30 and 120 min after death. All patients had progressive renal failure after admission to the hospital. All cases were jaundiced, had ascites, and exhibited features of hepatic encephalopathy. LM study revealed severe acute tubular lesions (ATL) or, more conventionally, acute tubular necrosis (ATN). EM study demonstrated necrosis of the proximal tubules characterized by swelling, disorganization of the cristae and appearance of dark bodies in the mitochondria, coalescence, fragmentation or displacement of the microvilli, loss of plasma membranes, rupture of the basement membranes, and separation of the cells from the basement membranes. Rupture of tubular basement membranes (tubulorrhexis) and mitochondrial dark bodies suggest an ATN due to ischemia or induced by vasoconstrictor substance(s). Glomerular lesions were infrequent (one in five) and therefore, do not seem to have contributed to renal failure. All cases terminally had extremely low urinary sodium (11 mEq/liter), high urinary potassium (50 mEq/liter), a remarkably low urinary sodium/potassium ratio (0.26, normal = 4.27), and a low urinary osmolality (less than 400 mOsm/kg). From this study we conclude that an ATN of variable severity may be associated with the hepatorenal syndrome. Since this ATN developed without preceding shock, sepsis, or hypotension it is possible that this ATN like that in ischemic acute renal failure may be due to reduced renal blood flow and intense cortical vasoconstriction which has been reported in hepatorenal syndrome. Finally, our data imply that low urinary sodium is consistent with this pathologic lesion in this clinical setting.

Muir-Torre syndrome: report of a case and reevaluation of the dermatopathologic features

Muir-Torre syndrome patients have multiple internal malignancies along with cutaneous sebaceous proliferations and keratoacanthomas. We describe a 62-year-old male with nine primarily internal malignancies who survived eight years after his initial tumor was identified. His sebaceous lesions ranged from innocuous adenomas to an anaplastic carcinoma of the chin which recurred and spread locally to involve the mandible and the right parotid region.