Renal-cell carcinoma with intracaval neoplastic extension: stratification and surgical technique

Surgical removal continues to be the mainstay in the treatment of renal-cell carcinoma with neoplastic venous extension. The steady improvement of surgical and anesthesiological techniques and the introduction of complete circulatory arrest has dramatically improved the morbidity even of patients with extensive thrombi. If ultrasound or computerized tomography (CT) scanning suggests the presence of a venous extension in a patient with renal-cell carcinoma, cavography, magnetic resonance imaging (MRI), transesophageal color-coded ultrasound, and echocardiography may be needed to resolve the questions of cranial extension and vascular wall infiltration. Surgical stratification and, thus, classification of the venous extension depend on the potential need for complete circulatory arrest. Surgical removal is done en bloc for smaller venous extensions and in a two-step procedure (radical nephrectomy followed by thrombectomy) for more extensive thrombi. In patients with infiltration of the suprahepatic inferior vena cava, the hepatic veins or atrium, pending thrombotic embolism, or large masses of suprahepatic thrombotic material, the use of cardiopulmonary bypass and complete circulatory arrest is recommended.

alpha-thrombin bound to extracellular endothelial matrix induces pronounced fibrin deposition and platelet thrombus growth in flowing non-anticoagulated human blood

Previous studies have shown that thrombin binds to the extracellular endothelial matrix and remains biologically active. In the present study, the role of matrix-bound alpha-thrombin in thrombus formation was investigated by utilizing a model system of thrombogenesis. Plastic cover-slips coated with either matrix-bound alpha-thrombin or matrix-bound active site inactivated thrombin (DIP-alpha-thrombin) were positioned in parallel-plate perfusion chambers and subsequently exposed to non-anticoagulated human blood at a venous wall shear rate of 100/s. The blood was drawn directly from an antecubital vein by a roller pump placed distally to the perfusion chamber. The thrombotic deposits on the matrix, fibrin deposition and platelet thrombus volume, were morphologically evaluated. Matrix-bound alpha-thrombin enhanced the fibrin deposition and thrombus volume on matrices of non-stimulated endothelium with 91% (P < 0.001) and 94% (P < 0.05), respectively. In contrast, binding of DIP-alpha-thrombin to matrices of stimulated endothelium reduced the fibrin deposition by 33% (P < 0.05), but had no effect on the platelet thrombus volume. Translocation of thrombin molecules from upstream matrix areas to binding sites farther downstream on the matrix was indicated in experiments with matrices of stimulated endothelium, which showed enhanced fibrin deposition on downstream areas. Our findings are compatible with a prominent role for matrix-bound alpha-thrombin in thrombogenesis, and in particular on endothelial matrices without tissue factor. The role of matrix-bound alpha-thrombin on tissue factor containing matrices appears less prominent, although it is significant.

Modulation of procoagulant activity of extracellular endothelial matrix by anti-tissue factor antibody and the synthetic peptide Arg-Gly-Asp-Val. Experiments with flowing non-anticoagulated human blood

Fibrin forms on and binds to the extracellular matrix of endotoxin-stimulated endothelium when exposed to flowing non-anticoagulated blood. These processes have been investigated by employing a human ex vivo perfusion model, a synthetic peptide Arg-Gly-Asp-Val and a monoclonal anti-tissue factor antibody which inhibits tissue factor/FVIIa-induced coagulation. Procoagulant extracellular matrix on plastic cover-slips was prepared from cultures of endotoxin-stimulated human endothelium following brief exposure to 0.1 M NH4OH. Non-anticoagulated blood was drawn directly from an antecubital vein by a pump at venous (100/s) and arterial (650/s) wall shear rates over the matrix-coated cover-slips positioned in parallel-plate perfusion chambers. Deposition of fibrin and platelets on the matrix was quantified by morphometry. Preincubation of the matrix with Arg-Gly-Asp-Val inhibited fibrin deposition by 80-90% at both venous (P < 0.001) and arterial shear (P < 0.05). However, the peptide had no effect on the clotting time in a modified one-stage clotting assay where coagulation was initiated by lysed endotoxin-stimulated endothelial cells, indicating that the peptide interfered with the binding of fibrin to the matrix in the perfusion model. Preincubation of the matrix with the anti-tissue factor antibody, which blocked the coagulant activity ( > 95%, P < 0.01) in the modified coagulation assay, also inhibited fibrin deposition on the matrix by 90-95% (P < 0.01) at both shear rates. In the absence of either inhibitor, platelets adhered preferentially to the fibrin meshwork, and more so at arterial shear. Platelet thrombus formation on the fibrin coat was in particular pronounced at arterial shear. Thus, it appears that the extracellular matrix of endotoxin-stimulated endothelium initiates coagulation predominantly through tissue factor/FVIIa and that the resulting fibrin meshwork forming on the surface induces rapid platelet thrombus formation. The inhibitory effect of Arg-Gly-Asp-Val on the binding of fibrin to the matrix may indicate the presence of specific matrix fibrinogen/fibrin binding site(s) with a recognition sequence of Arg-Gly-Asp.

Single potential analysis of cavernous electrical activity in impotent patients: a possible diagnostic method for autonomic cavernous dysfunction and cavernous smooth muscle degeneration

Cavernous electrical activity was recorded in 214 patients with erectile dysfunction and in 39 normal patients. In 34 of the 39 normal patients potentials of a uniform shape were recorded during flaccidity. At cutoff frequencies of 0.5 to 500 Hz. the duration was 8 to 18 seconds (mean 12.8 +/- 2.8, seconds, standard deviation), the amplitude was 250 to 750 microv. (mean 444 +/- 109 microv.) and the polyphasity was 8 to 22 (mean 13.8 +/- 3.3). With increasing tumescence and rigidity during audiovisual sexual stimulation, high frequency potentials of low amplitude and short duration were found in the normal patients. In impotent patients with an upper motor neuron or peripheral lesion specific types of potentials were observed. In 11 of 14 impotent patients with insulin-dependent diabetes for more than 20 years and with clinical findings of cavernous myopathy the potentials showed low amplitude, irregular shape and slow depolarizations. Abnormal findings of cavernous electrical activity were recorded in 51.6% of the consecutive impotent patients. Our clinical study suggests that single potential analysis of cavernous electrical activity may be useful in the diagnosis of cavernous autonomic neuropathy and cavernous smooth muscle myopathy.

In vitro sensitivity testing of human renal cell carcinoma with cytostatic agents and interferon alpha-2a

Samples of 38 human renal cell carcinomas (RCC) were subjected to routine histopathological examination but also to in vitro sensitivity testing with mitomycin C, vinblastine and interferon Alpha-2a at various concentrations corresponding to serum titers recommended to be effective in vivo, employing a monolayer assay. Extending earlier in vitro studies, both tumor cell kill rates (TCKR) and proliferation rates (PR) were assessed. Following in vitro preparation the tumor cell cultures were simultaneously exposed to the anticancer drugs listed above. The proliferation rates were determined immunocytochemically using the monoclonal antibody Ki-67. Nine (23.7%) of the tumors investigated revealed temporary and limited response with respect to either TCKR or PR. Improvement of this percentage could only be obtained by increasing drug concentration to titers with toxicity intolerable for in vivo administration. The in vivo data presented correspond to clinical temporary and limited remissions in patients with metastatic RCC ranging up to 25%.

Sulfasalazine inhibits the binding of TNF alpha to its receptor

Sulfasalazine was found to exhibit a dose-dependent inhibition of human mucosal and peripheral blood cytotoxic T-cell function. The drug also inhibited the cytotoxic activity of supernatants from anti-CD3-triggered T-cells against murine L929 fibroblasts. TNF alpha has previously been shown to be primarily responsible for the lytic activity of such supernatants and this was confirmed. Sulfasalazine also inhibited the lytic activity of recombinant TNF alpha. When tested under conditions where TNF alpha was allowed to bind to but not lyse the target cells, the results suggested that the drug inhibits the action of this cytokine by inhibiting its binding to the cell membrane receptor. Additional evidence for an inhibitory effect of sulfasalazine on the membrane binding of TNF alpha was obtained by demonstrating a dose-dependent displacement of 125I-TNF alpha from HL60 cells. Although sulfasalazine is often considered to be a pro-drug for site-specific delivery of its component fragments 5-ASA and sulfapyridine, the results demonstrate an immunopharmacological property of the parent compound that is not shared with its component molecules.

Neuroendocrine modulation of the immune system. Possible implications for inflammatory bowel disease

Evidence for neuroendocrine regulation of the immune system is reviewed. This includes human clinical studies of the influence of psychological stress on immune function, direct experimentation in animals, including classical Pavlovian conditioning of the immune response, modulation of immune function in vitro by chemical messengers such as neuropeptides, the finding of receptors for neuropeptides on immunocytes, and the demonstration that lymphoid tissue is directly innervated. Secretory products of the immune system, which include interleukins and neuropeptides, may also influence the neuroendocrine system. Communication between the two systems is therefore bidirectional. The potential importance of the neuropeptide-immunocyte interaction within the intestinal mucosal immune system is emphasized, and its possible relevance in inflammatory disorders is discussed. This aspect of the "gut-brain" interaction deserves further study.

Segmental necrotising enterocolitis: pathological and clinical features of 22 cases in Bangladesh

To describe the pathology and clinical features of segmental necrotising enterocolitis (SNE) in children and adults, 22 diarrhoeal patients (median age two years, range two months to 50 years) in Bangladesh with this lesion detected at autopsy were examined and compared with two groups of diarrhoeal control patients. Gross pathology consisted of purplish or black mucosal or transmural discoloration with erosions or ulcerations in segments of the jejunum or ileum of 18 cases and of the colon alone in four cases. Two patients had intestinal perforations. Microscopically all specimens showed coagulation necrosis or haemorrhagic necrosis indicative of mucosal ischaemia. In 20 cases there was submucosal oedema and nine showed pneumatosis of the bowel. From 11, one or more of the invasive diarrhoeal pathogens Shigella, Campylobacter and Entamoeba histolytica were detected. From the comparison with controls significant associations were found for a long duration of diarrhoea, blood and mucus in stool, abdominal distension or tenderness, shock not attributable to hypovolaemia, septicaemia, and low concentration of serum protein (p less than 0.05). These findings indicated that segmental necrotising enterocolitis develops sometimes as a fatal complication of prolonged diarrhoeal illnesses associated with shock and hypoproteinaemia and is caused by ischaemic injury to the intestinal mucosa.

Neisseria gonorrhoeae strains isolated in Hong Kong: in vitro susceptibility to 13 antibiotics

Fifty-five Neisseria gonorrhoeae strains isolated in Hong Kong over a period of 6 months were tested for their in vitro susceptibility to 13 antimicrobial agents by the agar dilution method. Six strains were beta-lactamase producing. In addition, five beta-lactamase strains from Singapore were tested. Among the non-beta-lactamase-producing strains, 34 (62%) had intermediate resistance to penicillin, with minimal inhibitory concentrations (MICs) ranging from 0.125 to 0.5 microgram/ml, and 15 strains were fully susceptible to penicillin (MICs, 0.015 to 0.06 microgram/ml). The MICs of penicillin for all beta-lactamase-producing strains were 2 microgram/ml, and the strains were resistant to ampicillin. Although a direct correlation between the MICs for resistance to penicillin and the other antibiotics tested was not observed, the gonococci isolated in Hong Kong were notably more resistant to tetracycline and streptomycin than has been reported elsewhere, with 78% of strains requiring for inhibition an MIC of tetracycline of greater than 2 microgram/ml and 51% of the isolates requiring an MIC of streptomycin of greater than 128 microgram/ml. All strains were susceptible to spectinomycin and kanamycin as well as to sulfamethoxazole-trimethoprim (ratio, 19:1). Among the cephalosporins, the order of effectiveness was cefuroxime, cefamandole, and cefoxitin. The older generation of cephalosporins, cephradine and cephalexin, was the least effective: 45 and 37% of the strains, respectively, required for inhibition MICs of greater than or equal to 8 microgram/ml. Cefotaxime, a new parenteral cephalosporin, was the most active; the median MIC was at least 10-fold lower than that of cefuroxime.