[Revascularization of the corpora cavernosa in ischemia-induced erectile dysfunction]

Revascularization of the cavernous bodies (CB) has its place in a highly selected patient population as the only causal therapy for erectile dysfunction (ED) and provides an alternative to the implantation of alloplastic erectile aids. The indication for arterialization of the CB is currently only established when conservative treatment has failed. The most important criteria for the intervention are controversial: an age of under 50, an incidence of not more than two classical risk factors for impotence and the exclusion of diabetes mellitus. The leading revascularization procedure in German-speaking countries comprises arteriovenous shunting of the inferior epigastric artery with the dorsal vein and artery of the penis. A retrospective analysis of results is problematic due to the nonuniform indicational criteria, the multiplicity of applied revascularization procedures and a nonstandardized follow-up. Subjective assessment of improved erectility is the sole target criterion in the majority of studies. Therapeutic results range from 33 to 87% with regard to subjective success rates. Attempts to objectify the treatment results were made in only few of the studies and disclosed bypass patency in 44 to 92% one year after the intervention. The conclusions drawn at the last "Consensus Development Conference on Impotence" (CDCI) of the National Institutes of Health (NIH) in Washington have not lost their topicality in view of the great number of still unanswered questions. There the recommendation was made in 1992 to perform penile arterialization only in controlled prospective clinical trials. The European Urological Association (EUA) is currently organizing a Consensus Conference that will provide the framework for prospective studies that can serve as a basis for clarifying the open questions.

Alloreactivity of umbilical cord blood mononuclear cells: specific hyporesponse to noninherited maternal antigens

Earlier studies noted that patients who underwent cord blood (CB) transplantation had a lower incidence of graft-versus-host disease (GVHD) than those who underwent bone marrow transplantation (BMT). The premise that the immune reactivity of CB mononuclear cells (CB-MNC) to HLA mismatched combinations and to noninherited maternal antigens (NIMA) may be one of the factors involved in this phenomenon is still debatable. In this study we have attempted to evaluate the alloresponse and alloreactivity induced by CB-MNC by means of the standard mixed lymphocyte reaction test (SMLR) and the more sensitive, modified mixed lymphocyte reaction test (MMLR). Both techniques were used to test CB-MNC (n = 28) against HLA class II mismatched MNC from mothers (n = 26), fathers (n = 12), and unrelated individuals (n = 60) who served as controls. Alloresponse capabilities and stimulation capacities of CB-MNC in the SMLR were similar to those of control MNC: relative response (RR) = 73 vs. 65 and 58 vs. 65, respectively. Similar results were obtained in the MMLR. CB-MNC responded weakly to the maternal MNC in comparison with control MNC (RR = 47 vs. 73 [p = 0.0099]), while a stronger response was noted to the paternal than the maternal MNC (RR = 72 vs. 47 [p = 0.045]). Our results demonstrate that CB-MNC both respond to and induce alloresponse in HLA mismatched combinations. Moreover, the hyporesponse of CB-MNC to maternal cells that we observed suggests a form of tolerance to NIMA, which is probably due to the fetus's exposure to these antigens in its intrauterine life.

Objective monitoring of physical activity using motion sensors and heart rate

Although neither motion sensors nor heart rate are perfect markers of physical activity, they certainly eliminate subjectivity of obtaining physical activity information. The objective method of choice depends on how the measurement will be used. For example, if walking behavior is the desired outcome, then a pedometer may be sufficient. If patterns and intensity of activity over longer periods of times such as a week or longer are needed, then an accelerometer with large memory capacity should be selected. In the future, efforts should be directed towards developing an objective motion sensor as inexpensive as a pedometer but with the data acquisition capabilities of the CSA or Tritrac accelerometer. Providing simultaneous heart rate with motion is also recommended to further verify that elevated heart rate does in fact represent a physical activity response. As the cost of the electronic components continues to decrease, these activity monitor configurations may become possible.

Chronic sequels after thoracoscopic procedures for benign diseases

OBJECTIVE

Chronic pains after lateral thoracotomy are present in up to 40% of cases. Chronic sequels after thoracoscopy are less common, but nevertheless, a cause for complaints by patients. Pain often reflects a recurrence of malign disease. For this reason, we only investigated patients with benign disease.

METHODS

We retrospectively investigated the incidence of chronic sequels in a consecutive series of 161 patients who underwent thoracoscopy for benign disease and were not converted to an open procedure. The data from all 144 patients, contactable at the time of investigation, who were at least 2 months postsurgery, were analyzed.

RESULTS

Chronic sequels were present in an overall of 31.4% of patients. Patients complained of chronic pain (20.1%), numbness distal to the incision sites (16.9%) and disaesthesia (8.3%). Painkillers are taken on a regular basis by 82.8% of patients with chronic pain. The use of Staplers, as well as the number of drains (1 vs. 2) used, were statistically significant (P>0.05) for chronic sequels. All other investigated factors, such as sex, age, and length of drainage, were not significantly different in the two groups.

CONCLUSION

The thoracoscopic approach is not likely to impact on the prevalence of long-term postthoracotomy sequels, and therefore, further strengths are necessary to reduce this number.

Ordinal knowledge: number names and number concepts in Chinese and English

Previous research has demonstrated cross-language variation in early counting associated with linguistic differences in number-naming systems. Ordinal number names are typically learned later than cardinal names, but languages also differ in the regularity with which they form these names. Elementary school children in China and the U.S. showed differences in the acquisition and use of ordinal numbers corresponding to linguistic differences in ordinal names in their native languages. On tasks assessing children's conceptual knowledge of ordinal relations, a more complicated picture emerged. These results suggest that (a) children induce their language's set of ordinal number names by generalization based on rules sanctioned by early examples, and (b) the relation between ordinal names and ordinal concepts is a complex one, with language only one source of difficulty in understanding ordinal relations. Implications for studies of the relation between linguistic structure and cognitive development are discussed, in particular the possibility that effects of linguistic differences may vary for different levels of development and for different aspects of cognition.

Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation

BACKGROUND

The purpose of this study was to determine the predictive value of an endotracheal tube cuff leak for the development of postextubation stridor and the need for reintubation.

STUDY DESIGN

Consecutive trauma patients who required intubation at a level I trauma center from July 1997 to July 1998 were studied prospectively. Pediatric patients and those who did not meet the standard weaning protocol criteria established by the Division of Trauma and Surgical Critical Care were excluded. Injury Severity Score, endotracheal tube size, reason for intubation, and the number of days intubated before the initial extubation attempt were recorded. At the time of extubation, the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation was calculated. This number was then divided by the exhaled tidal volume before cuff deflation and was recorded as the percent cuff leak. Patients were followed for 24 hours after extubation for the development of stridor or need for reintubation. Statistical analysis to compare subgroups of patients was performed using ANOVA with Scheffé post hoc analysis.

RESULTS

Among the 110 patients analyzed, the most common reason for intubation was closed-head injury. Seven patients (6.4%) developed stridor alone and had a mean cuff leak of 5 8 mL (8.4% of tidal volume before cuff deflation). Six patients (5.5%) experienced stridor that required reintubation and had a mean cuff leak of 68 mL (9.2% of tidal volume before cuff deflation). Patients who developed stridor or needed reintubation had been intubated for a significantly greater length of time than those not developing stridor or requiring reintubation (2.6 versus 3.0 days, p < 0.001). There were no differences in Injury Severity Score, endotracheal tube size, or reason for intubation between these groups.

CONCLUSIONS

A cuff leak of less than 10% of tidal volume before cuff deflation is useful in identifying patients at risk for stridor or reintubation (96% specificity). It appears that the amount of cuff leak decreases after intubation for more than 3 days, increasing the risk of stridor and need for reintubation. This information may be helpful in identifying those patients who need treatment for laryngotracheal edema, ie, use of steroids or anesthesia during extubation, the efficacy of which remains to be determined.

Cerebral metabolic and cognitive decline in persons at genetic risk for Alzheimer's disease

The major known genetic risk for Alzheimer's disease (AD), apolipoprotein E-4 (APOE-4), is associated with lowered parietal, temporal, and posterior cingulate cerebral glucose metabolism in patients with a clinical diagnosis of AD. To determine cognitive and metabolic decline patterns according to genetic risk, we investigated cerebral metabolic rates by using positron emission tomography in middle-aged and older nondemented persons with normal memory performance. A single copy of the APOE-4 allele was associated with lowered inferior parietal, lateral temporal, and posterior cingulate metabolism, which predicted cognitive decline after 2 years of longitudinal follow-up. For the 20 nondemented subjects followed longitudinally, memory performance scores did not decline significantly, but cortical metabolic rates did. In APOE-4 carriers, a 4% left posterior cingulate metabolic decline was observed, and inferior parietal and lateral temporal regions demonstrated the greatest magnitude (5%) of metabolic decline after 2 years. These results indicate that the combination of cerebral metabolic rates and genetic risk factors provides a means for preclinical AD detection that will assist in response monitoring during experimental treatments.

[Prophylactic treatment in children with migraine presenting changes in electrophysiological and cerebral blood flow examinations: preliminary report]

Idiopathic headache is common in children, but lack of specific tests makes diagnosis and treatment of migraine difficult. It has been proved, that in some migrainous children paroxysmal changes in eeg records can be found. The aim of the study was to examine the influence of prophylactic treatment on clinical course and bioelectric brain activity in children. The group examined consisted of 50 migrainous children (29 girls and 21 boys aged 6-18 years, mean 11.5 y.). In every patient routine eeg and ecg were recorded, and in 30 of them cerebral blood flow was examined. Some ecg abnormalities were observed in 6 children (12%) and cerebral blood flow disturbances--in 23 (77%). In 15 patients, in whom paroxysmal changes in routine eeg were found, an average 6-month prophylactic antimigrainous treatment (with Hydacorn in 14 and with Sermion in 1 patient) was performed and then control routine eeg and 24-hours eeg were recorded. In all children clinical improvement was observed after prophylactic medication. Paroxysmal changes in eeg records persisted in 6 children. The coexistence of electroencephalographic changes with disturbed cerebral blood flow migrainous children can indicate some connection between migraine and epilepsy, and/or reflect an influence of angiospasm resulting in hypoxia on the incidence of epileptiform changes in eeg records. The obtained results show clinical efficiency of combined treatment in child migraine and they reflect its good influence on bioelectrical brain activity.

A double-blind, placebo-controlled trial of pegylated recombinant human megakaryocyte growth and development factor as an adjunct to induction and consolidation therapy for patients with acute myeloid leukemia

Newly diagnosed patients with acute myeloid leukemia (AML) were randomized to receive either 2.5 or 5 microg/kg/day of pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF) or a placebo administered subcutaneously after completion of chemotherapy. The study evaluated the toxicity of PEG-rHuMGDF and any effect on the duration of thrombocytopenia. Each of 35 patients under 60 years of age received the following therapy: 45 mg/m(2) daunorubicin on days 1-3, 100 mg/m(2) cytarabine (ARA-C) for 7 days, and 2 gm/m(2) high-dose ARA-C (HIDAC) for 6 doses on days 8-10. The 22 patients 60 years or older received standard daunorubicin and ARA-C without HIDAC. PEG-rHuMGDF was well tolerated, and no specific toxicities could be attributed to its use. There was no difference in the time to achieve a platelet count of at least 20 x 10(9)/L among the 3 groups (median 28-30 days for patients less than 60 years old and 21-23 days for patients 60 years or older). Patients receiving PEG-rHuMGDF achieved higher platelet counts after remission. However there was no significant difference in the number of days on which platelet transfusions were administered among the 3 groups. The complete remission rate was 71% for patients less than 60 years and 64% for those 60 years or older, with no significant difference among the 3 groups. Postremission consolidation chemotherapy with either placebo or PEG-rHuMGDF was given to 28 patients beginning the day after completion of chemotherapy. There was no apparent difference in the time that was necessary to reach a platelet count of at least 20 or 50 x 10(9)/L or more platelets or in the number of platelet transfusions received. In summary, PEG-rHuMGDF was well tolerated by patients receiving induction and consolidation therapy for AML; however, there was no effect on the duration of severe thrombocytopenia or the platelet transfusion requirement. (Blood. 2000;95:2530-2535)

Blinded, multicenter quality control study for the quantification of human immunodeficiency virus type 1 RNA in plasma by the Belgian AIDS reference laboratories

OBJECTIVE

In order to evaluate the interlaboratory variation of HIV-1 RNA measurements in plasma, the Belgian AIDS reference laboratories organized a blinded multicenter quality control study.

METHODS

Atest panel of coded spiked HIV-1 plasma samples reflecting the dynamic range of the assay was composed and distributed. The HIV-1 RNA concentration of these samples was determined by the eight Belgian AIDS reference laboratories by means of the Amplicor HIV-1 Monitor version 1.5 assay.

RESULTS

Analysis of the results demonstrated that there was little interlaboratory variation for the high concentration range (4.0-5.7 log10 copies/mL), never exceeding 0.2 log10 copies/mL. However the standard deviation for the low concentration range (2.6-3.9 log10 copies/mL) reached up to 0.22 log10 copies/mL.

CONCLUSIONS

Since interlaboratory variability never reached 0.5 log10 copies/mL and each of the laboratories was able to detect four-fold differences in plasma HIV-1 RNA levels, the Amplicor assay can be used in multicenter studies without a centralized analysis of samples. Furthermore, this well-characterized proficiency panel of spiked plasma samples could be used as a standard in the study of interassay comparisons.

Cardiac responses to exercise in competitive child cyclists

PURPOSE

Cardiovascular responses to exercise in highly trained child endurance athletes have not been well-defined. This study compared hemodynamic responses with progressive cycle exercise in seven competitive child cyclists (mean age 11.9 yr) compared with 39 age-matched untrained boys.

METHODS

Doppler echocardiography and gas exchange variables were utilized to assess cardiovascular changes during submaximal and maximal exercise.

RESULTS

Mean VO2max was 60.0 (+/-6.0) and 47.0 (+/-5.8) mL x kg(-1) x min(-1) in the cyclists and nonathletes, respectively. At rest and maximal exercise, the cyclists demonstrated greater stroke index than the untrained subjects (resting mean 59 (+/-6) vs 44 (+/-9) mL x m(-2); maximal mean 76 (+/-6) vs 60 (+/-11) mL x m(-2)), but the ratio of maximal:rest stroke index was similar in both groups (1.31 for cyclists, 1.41 for nonathletes). Both groups showed a plateau in stroke volume beyond low-intensity work levels. No significant difference was observed in maximal arteriovenous oxygen difference.

CONCLUSIONS

These findings indicate that 1) maximal stroke volume is the critical determinant of the high VO2max in child cyclists and 2) factors that influence resting stroke volume are important in defining VO2max differences between child endurance athletes and untrained boys.

Appropriateness of intravenous cannulation by paramedics: a London study

INTRODUCTION

The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions.

OBJECTIVES

To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings.

METHODS

Skill usage data were analyzed for all LAS paramedics for 1995-96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (A&E) and prehospital specialists judged each case for appropriateness.

RESULTS

Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (kappa = 0.43, p < 0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05).

CONCLUSION

Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review.

Telomerase activity and expression of telomerase subunits in the testicular tissue of infertile patients

OBJECTIVE

Determination of telomerase activity and the expression of human telomerase RNA (hTR) and human telomerase reverse transcriptase (hTERT) in the testicular tissue of patients with infertility arising from various causes.

DESIGN

Prospective observational study.

SETTING

A university hospital.

PATIENT(S)

Thirty-three patients with azoospermia arising from various causes. There were 12 testicular biopsy specimens from patients with Sertoli cell-only syndrome, 9 from patients with maturation arrest, and 12 from patients with obstructive azoospermia and normal histologic findings.

INTERVENTION(S)

Thirty-three testicular biopsies.

MAIN OUTCOME MEASURE(S)

Correlation of histologic findings at testicular biopsy with telomerase activity, hTERT, and hTR.

RESULT(S)

All 12 biopsy specimens from patients with obstructive azoospermia were positive for telomerase activity, hTR, and hTERT. Biopsy specimens from the 9 patients with maturation arrest were positive for telomerase activity in 8 cases, hTR in 9 cases, and hTERT in 5 cases. None of the patients with Sertoli cell-only syndrome showed either telomerase activity or hTERT, but all of them showed hTR.

CONCLUSION(S)

Telomerase activity and evidence of hTERT in testicular tissue are highly sensitive and highly specific markers of gametogenesis, which could gain in importance as part of the fertility workup before microinjection procedures.

Constitutive modelling of abdominal organs

Abdominal organs are very susceptible to trauma. In order to protect them properly against car crash and other impact consequences, we need to be able to simulate the abdominal organ deformation. Such simulation should account for proper stress-strain relation as well as stress dependence on strain rate. As the step in this direction, this paper presents three-dimensional, non-linear, viscoelastic constitutive models for liver and kidney tissue. The models have been constructed basing on in vivo experiments conducted in Highway Safety Research Institute and the Medical Centre of The University of Michigan (Melvin et al., 1973). The proposed models are valid for compressive nominal strains up to 35% and fast (impact) strain rates between 0.2 and 22.5 s(-1). Similar models can find applications in computer and robot assisted surgery, e.g. the realistic simulation of surgical procedures (including virtual reality) and non-rigid registration.

Efficacy and tolerability of tolterodine in children with detrusor hyperreflexia

OBJECTIVES

To investigate the urodynamic effects and tolerability of the new antimuscarinic drug tolterodine in children with detrusor hyperreflexia.

METHODS

Twenty-two children (12 boys and 10 girls; age range 3 months to 15 years, mean age 5.7 years) with detrusor hyperreflexia resulting in maximum detrusor pressures exceeding 40 cm H(2)O during filling cystotonometry were enrolled to receive tolterodine tartrate (a total of 0.1 mg/kg orally daily, divided into two doses) either as a first-line therapy (n = 12, group 1) or replacing oxybutynin chloride therapy (n = 10, group 2). Within 3 months, all patients underwent urodynamic re-evaluation during ongoing tolterodine treatment.

RESULTS

In group 1, the mean maximum bladder capacity increased from 120.2 to 173.0 mL (+44%), the mean detrusor compliance increased from 8.7 to 13.5 mL/cm H(2)O (+55%), and the mean maximum detrusor pressures decreased from 70.1 to 37.9 cm H(2)O (-46%); the differences were significant (P < 0.001). In group 2, no differences in the urodynamic effects of oxybutynin versus tolterodine were noted. Only 1 patient experienced a transient and moderately adverse effect with tolterodine.

CONCLUSIONS

Although based on a limited number of subjects, these data indicate that in pediatric patients with detrusor hyperreflexia, tolterodine may be better tolerated than and equally effective as the standard drug oxybutynin chloride.

Flow cytometric immunophenotypic characterization of pediatric and adult minimally differentiated acute myeloid leukemia (AML-M0)

We reviewed the clinicopathologic and immunophenotypic profiles of 7 pediatric and 11 adult minimally differentiated acute myelogenous leukemias (AML-M0). We also compared and evaluated myeloperoxidase in leukemic blasts using standard cytochemical and polyclonal antibody immunohistochemical stains. No distinctive clinical findings were noted in either patient group; however, thrombocytopenia typically was more prominent in adults. Adult AML-M0 also was associated with an immature myeloid profile (CD34+, terminal deoxynucleotidyl transferase positive, CD13+, and CD33+), in contrast with pediatric AML-M0, which usually lacked terminal deoxynucleotidyl transferase or CD34 but expressed bright CD33 with weak or negative CD13. Coexpression of the T-cell-associated antigen CD7 was observed in both groups. Antibody immunohistochemical stains were more sensitive than cytochemical stains for detection of myeloperoxidase activity and a useful adjunct for establishing a diagnosis of myeloid leukemia in paraffin-embedded marrow tissues.

Out-of-hospital intravenous cannulation: the perspective of patients treated by London Ambulance Service paramedics

OBJECTIVES

Previous research has highlighted concern about infection rates in field-placed intravenous (IV) cannulae. In a study of IV placement by London Ambulance Service (LAS) paramedics, 17% of placements were judged to be inappropriate. Large variations in rates of IV placement between LAS paramedics were found. The authors' hypothesis was that placement of an IV carries disadvantages-pain, discomfort, distress, and infection-which may be unacceptable to patients.

METHODS

This was a survey of all patients having an IV placed by LAS paramedics and transported to one of three London emergency departments (EDs) over a three-week period in December 1996. Patients were excluded if they had a self-inflicted injury/illness, were less than 14 years old, had no known address, or were visitors to the UK, or if their family doctor suggested it was not appropriate to contact the patient. Pain, discomfort, and distress; infection; satisfaction; understanding of the reason for cannulation; and out-of-hospital cannula use were all ascertained and analyzed with chi-square analysis.

RESULTS

Thirty-nine percent of the respondents experienced some discomfort, 39% some pain, and 17% some distress. No patient reported an infection. Distress was more likely to be reported if there was no understanding of why the IV cannula was placed (chi2 [1] 6.1; p < 0.05). Further unstructured information revealed satisfaction with the IV cannulation and with general care.

CONCLUSIONS

Despite the disadvantages of IV placement being reported by some respondents, overall levels of satisfaction were high, suggesting that these disadvantages were not unacceptable to patients. However, in the context of the 24,000 patients cannulated each year by LAS paramedics, "costs" to the patient are considerable.

Cardiovascular fitness in premenarcheal girls and young women

Maximal oxygen uptake (VO2max) in females, expressed as ml x kg(-1) x min(-1), declines steadily during the first three decades of life. The contribution of diminished cardiovascular function to this apparent fall in aerobic fitness is unknown. Cardiac responses to maximal cycle exercise were compared in 24 premenarcheal females (mean age 11.7 years) and 17 young adult women (mean age 27.4 years) using Doppler echocardiography. Mean VO2max was 40 ml x kg(-1) x min(-1) and 34.7 ml x kg(-1) x min(-1) in the girls and women, respectively (p < 0.05). When VO2max was expressed relative to allometrically-derived mass(0.52), however, no significant difference was observed in aerobic fitness between the two groups. Similar allometric analyses revealed no significant differences in average maximal cardiac output (10.50 vs 10.07 L x min(-1) BSA(-1.11) for girls and women, respectively) nor maximal stroke volume (53 vs 56 ml BSA(-1.13) respectively). These findings suggest that 1) allometric scaling is important in eliminating the effects of body size on VO2max, 2) body dimension differences can account for variations in VO2 in young females, and 3) cardiac functional reserve is similar in premenarcheal girls and young adult women.