Laparoscopic ureteral reconstruction with small intestinal submucosa

PURPOSE

To evaluate the feasibility of laparoscopic ureteral reconstruction with small intestinal submucosa (SIS) in the pig ureter.

MATERIALS AND METHODS

Eight female pigs weighing between 25 and 30 kg were enrolled. After anesthesia was administered, a double-pigtail stent was inserted, the animals were moved to a lateral decubitus position, pneumoperitoneum was established, and three 10-mm ports were positioned. The ureter was opened longitudinally for 7 cm, and two thirds of the periphery of the upper third of the left ureter was excised. The SIS was anastomosed to the upper and distal ureteral segments with chromic 4-0 sutures. The double-pigtail stent was removed 6 weeks after the initial procedure, and retrograde pyelography was performed a week later to confirm the viability of the pelvicaliceal system.

RESULTS

The average duration of the procedures was 210 minutes (range 125-250 minutes). All animals survived the entire follow-up period of 7 weeks. Retrograde pyelography revealed a patent ureteral lumen, and no obstructive phenomena were observed. Histologically, the SIS-regenerated ureteral segments were remarkably similar to normal porcine ureters and were indistinguishable from neighboring tissue.

CONCLUSION

Laparoscopic ureteral reconstruction with SIS proved to be effective and technically feasible. The SIS seems to be an effective biodegradable scaffold, facilitating regeneration of host tissue.

Control of electrochemical reactions at the capillary electrophoresis outlet/electrospray emitter electrode under CE/ESI-MS through the application of redox buffers

It was found that combining capillary electrophoresis (CE) and electrospray ionization mass spectrometry (ESI-MS) overlays two controlled current techniques to form a three-electrode system (CE inlet, CE outlet/ES emitter, and MS inlet electrodes) in which the CE outlet electrode and the ES emitter electrode were shared between the CE and the ESI-MS circuits. Depending on the polarities and magnitudes of the voltages at the CE inlet, CE outlet/ES emitter, and MS inlet electrodes, the nature of the two redox reactions at the shared electrode was the same or different (both reduction, both oxidation, or one oxidation and the other reduction). Several redox buffers were introduced for controlling electrochemical reactions at the shared electrode. By reacting at this electrode, redox buffers were able to maintain electrode potentials below the onset of water electrolysis, thereby eliminating gas bubble formation and/or pH drift. The volume of the gas generated due to water electrolysis was used to quantitate water oxidation or reduction at this electrode. Two types of redox buffers were used. A reactive electrode with an oxidation potential below that of water was used as the electrode under anodic conditions. Also, a reactive compound with a redox potential below that of water was added to the CE and/or ESI running buffer. When the shared electrode was the anode of both CE and ESI-MS circuits, the use of iron or etched and sanded stainless steel (ss) wire, instead of platinum wire, suppressed bubble formation at the shared electrode. Under these conditions, corrosion of the Fe wire and formation of Fe2+ replaced oxidation of water, eliminating O2 gas bubble and H+ formation. When mixtures of peptides were analyzed, iron adducts of peptides were observed. For a fresh wire, however, the intensities of adduct ions were less than 3% of the protonated molecules. After a few days of operation, the intensities of the adduct ions increased to approximately 50%, due to rust formation on the Fe wire. On-column rinsing with a 40% solution of citric acid rejuvenated the Fe wire and reduced the adduct peak intensities to less than 3%. Unmodified ss wire did not quench bubble formation, which was attributed to its passivated surface. When Fe, ss, and Pt wires were used as the shared electrode under forward polarity CE and positive ESI mode, where the shared electrode acted as a cathode with respect to CE inlet and as an anode with respect to MS inlet, reduction of water at the cathodic end of the electrode and, in the case of ss and Pt wires, oxidation of water at the anodic end of the shared electrode produced a significant amount of bubbles. Under these conditions, however, a buffer containing 50 mM p-benzoquinone completely suppressed both cathodic reduction and anodic oxidation of water for CE currents up to 4 microA. Reduction of p-benzoquinone at the cathodic end of the shared electrode to hydroquinone, and oxidation of this hydroquinone at the anodic end of the electrode, replaced reduction and oxidation of water, eliminating bubble formation. A 0.1% acetic acid solution saturated with I2 was also found to suppress bubble formation at the cathode for CE currents up to 3 microA; however, strong iodine adduct ions were observed under CE/ESI-MS when a mixture of peptides was analyzed. The application of iron as an in-capillary electrode for the analysis of a peptide mixture and a protein digest demonstrated a high separation efficiency similar to when hydroquinone was used as a redox buffer.

Rapid determination of glutathione peroxidase and thioredoxin reductase activities using a 96-well microplate format: comparison to standard cuvette-based assays

Gluthatione peroxidase and thioredoxin reductase are selenocysteine-containing enzymes that are constituents of the cellular antioxidant defense system. Conventional cuvette-based assays for glutathione peroxidase and thioredoxin reductase enzymes are laborious and time consuming. The ability to assay their activities rapidly in multiple samples would aid efforts focused on understanding the impact of these enzymes on the cellular antioxidant defense system. High throughput can be achieved with assays adapted to work in a clinical analyzer but require expensive equipment. Assays designed to work in a 96-well microplate reader provide an alternative methodology for high throughput with reduced instrumentation cost. However, due to differences in the light pathlength when using a 96-well format, the values obtained cannot be compared directly with those obtained using a 1-cm cuvette. Described here are assays for glutathione peroxidase and thioredoxin reductase modified to work in a 96-well format that incorporates light pathlength determinations into the assays. The values obtained using a high throughput 96-well format in conjunction with pathlength determinations are in agreement with those obtained using a standard 1-cm cuvette. While spectrophotometrically derived pathlengths are the most accurate, calculated pathlengths based on assay volume and well size can be used with only a small amount of error introduced. This method can also be applied to many other enzyme assays, thus allowing the rapid analysis of large numbers of samples without the need for expensive equipment.

Effect of gold(I) compounds on the virulence of an amyocarditic strain of coxsackievirus B3

Coxsackieviruses, especially B strains (CVB), are known etiological agents of myocarditis. Both amyocardititc and myocarditic strains exist and at least one amyocarditic strain, CVB3/0, can convert to virulence when passaged through selenium or vitamin E-deficient mice. Gold(I)-containing compounds, such as aurothiomalate (ATM) and aurothioglucose (ATG), can act as selenium antagonists. In this study, we examined the effect of intraperitoneal administration of equal doses of ATM or ATG on the virulence of CVB3/0. ATM but not ATG increased mortality in CVB3/0-infected mice. CVB3/0-infected mice treated with ATM had total necrosis of the pancreatic exocrine tissue. Heart damage also occurred in ATM-treated mice but did not correlate with mortality. Increased viral titers and persistence were observed in ATM-treated mice and, to a lesser extent, in ATG-treated mice. Thus, under our conditions, only ATM increased the virulence of CVB3/0, whereas ATG did not. On the other hand, both ATG and ATM inhibited thioredoxin reductase activity in heart and pancreas, but neither affected glutathione peroxidase activity. In contrast, dietary selenium deficiency reduces both enzyme activities. Thus, it is unlikely that these compounds affect virulence by acting as selenium antagonists.

HLA class I, II & III genes in confirmed late-onset Alzheimer's disease

We first examined all the then known alleles (1997) at the HLA-A, B, Bw, C, DRB1, 3, 4 and 5, and DQB1 loci in 55 late-onset (>65y) AD cases and 73 elderly controls from Oxford. We found an association of HLA-B7 with late-onset AD (odds ratio = 3.1, corrected P = 0.04) that was limited to apolipoprotein E epsilon4-negative subjects (odds ratio = 5.1, corrected P = 0.005). We then studied linkages with Class III genes and, finally, we sought to replicate our HLA-B7 result in cohorts from Montreal and Nottingham. Altogether, we used 299 histopathologically confirmed cases of late-onset AD and 175 controls. Our initial, clear finding was not replicated in Montreal and Nottingham, however. We also failed to support any other previously reported association of AD with an HLA gene. Though we cannot exclude distinct linkages in different cohorts as an explanation of the conflicting results of HLA/AD studies, we conclude that there is no compelling evidence of a strong, direct association between late-onset AD and any HLA Class I or II allele.

Glutamate carboxypeptidase II: a polymorphism associated with lower levels of serum folate and hyperhomocysteinemia

Low blood folate levels result in hyperhomocysteinemia, which has been associated with increased risk for cardiovascular disease, neural tube defects and cognitive deficits. Intake of dietary folates is the chief determinant of blood folate levels. Molecular defects in the intestinal absorption of dietary folates that precipitate low blood folate levels and hyperhomocysteinemia have not been investigated previously. Dietary folates are a mixture of polyglutamylated folates which are digested to monoglutamyl folates by the action of folylpoly-gamma-glutamate carboxypeptidase (FGCP), an enzyme that is anchored to the intestinal brush border membrane and is expressed by the glutamate carboxypepidase II (GCPII) gene. We cloned GCPII cDNA from human intestine and identified both a full-length transcript and a 93 bp shorter transcript lacking exon 18, consistent with the presence of a splice variant. In addition, we identified an H475Y polymorphism in GCPII in DNA samples from a healthy Caucasian population (n = 75). We found that membranes of transfected COS-7 cells expressing the H475Y variant GCPII cDNA had 53% less FGCP activity than did cells expressing wild-type GCPII. The presence of the H475Y GCPII allele was significantly associated with lower folate and higher homocysteine levels in this population. These data suggest that the presence of the H475Y GCPII allele impairs the intestinal absorption of dietary folates, resulting in relatively low blood folate levels and consequent hyperhomocysteinemia.

Primary percutaneous approach to upper urinary tract transitional cell carcinoma

The optimal approach to upper tract TCC remains to be redefined. A routine nephroureterectomy for every filling defect in the upper urinary system, even in the case of a normal contralateral kidney, constitutes an unnecessary mutilation in more than two thirds of the cases. Nephroureterectomy does not reduce the need for a long-term cystoscopic follow-up because of the high rate of bladder tumor recurrence that may happen years later after nephroureterectomy. Relying solely on radiography and cytology, lacking sensitivity and specificity, to recommend a nephroureterectomy is against the principles of oncologic surgery, especially now that preoperative histologic proof is easy to obtain endoscopically without compromising cancer control. Ureteroscopy, rigid and flexible, provides a complete assessment of the upper urinary system. Biopsy specimens taken with ureteroscopy may be sufficient for grading but less adequate for staging of the tumor. The authors reserve ureteroscopy for ureteral tumors and small (< 1.5 cm) single tumors of the renal pelvis. They approach large or multiple tumors of the renal pelvis percutaneously, in which a full histologic assessment is possible along with a complete resection of the tumor. The decision on the therapeutic approach is made only after the final pathologic report is reviewed. Grade I and grade II superficial disease (Ta, T1) can be treated endoscopically with minimal morbidity and with an efficiency comparable with the standard more invasive nephroureterectomy (Table 5). The indications for endourologic treatment in these cases can be extended safely beyond a solitary kidney or a high surgical risk to include any healthy individual with a normal contralateral kidney who is willing to commit to a rigorous lifelong follow-up. Patients with grade II T1 lesions require a more vigilant follow-up. For grade III Ta disease, more caution should be exercised in selecting these patients for elective endourologic management. When criteria of good prognosis are found, such as absence of carcinoma in situ, presence of diploidy, low p53 expression and a single-tumor, endoscopic management can be offered [table: see text] with a closer follow-up and resorting always to immediate nephroureterectomy at the first evidence of upstaging. Because of the high incidence of recurrence and progression, elective endourologic management for grade III T1 tumors is not recommended. Endoscopic conservative surgery still can be offered in the cases of a solitary kidney or chronic renal insufficiency or for poor surgical candidates. Patients with localized stages (T2, T3) TCC should be offered immediate nephroureterectomy. The authors do not expect adequate endoscopic extirpation with muscle invasive tumors. Although the tissue removed may include deep layers, deep resection is precluded by the thin renal pelvic wall and the associated risk for perforation. Patients with more extensive disease (T3, T4) have a bad prognosis regardless of the form of therapy. Achieving local control percutaneously while preserving as many nephrons as possible for the future chemotherapy can be a reasonable option.

Chronic expansion of the renal pelvis: a new method for reconstruction of upper ureteral defects

OBJECTIVES

To evaluate whether the dilated renal pelvis can be used as an autologous source for the surgical reconstruction of upper ureteral defects or strictures.

METHODS

In 7 female pigs, the renal pelvis was expanded by a percutaneously placed Council balloon catheter. Every other day for 4 weeks, the renal pelvis was progressively dilated with a bolus injection of saline and contrast medium, which allowed expansion of the renal pelvis to 70 to 75 mL. Four to six weeks after the initial intervention, 5 to 7 cm of the proximal ureter was resected in an open operation and replaced with a tubularized spiral flap made from the expanded renal pelvis. Three weeks later, the animals were killed, and the area of manipulation was resected for pathologic evaluation.

RESULTS

All animals reached the desired expansion of the renal pelvis, and in all cases, the spiral flap was fashioned and anastomosed to the distal ureteral segment, bridging the initial defect (mean length 7 cm). Two animals died from sepsis, 4 and 6 days after the spiral flap reconstruction. A viable ureteral lumen with a patent anastomosis and a functioning pelvocaliceal unit was observed on intravenous urography in all animals. The main histologic findings were a chronic inflammatory process with concomitant mucinous metaplasia and reactive atypia of the tubules.

CONCLUSIONS

The use of a balloon expander in the renal pelvis is a safe and effective technique for producing native tissue for the reconstruction of defects or strictures of the upper ureteral segment.

Luminometric quantitation of photinus pyralis firefly luciferase and Escherichia coli beta-galactosidase in blood-contaminated organ lysates

Firefly luciferase and Escherichia coli beta-galactosidase chemiluminescent reporter gene assays are rapid and sensitive means of detecting reporter enzyme activities in cell lysates of both eukaryotic and prokaryotic systems. In these assays, expression vectors containing the luciferase or beta-galactosidase genes are transferred to cells in culture or animal tissues in vivo. Crude cell or organ lysates are then prepared and submitted to enzyme assays. The level of enzyme activity is proportional to the efficiency of gene delivery and expression. When used with modified substrates that emit light when cleaved by the appropriate enzyme, luciferase and beta-galactosidase activity can be detected luminometrically. Attempts to apply these assays to cell lysates contaminated with blood, as from any whole organ lysate, have had questionable results thus far because of light absorption by hemoglobin in the ranges of light emission by both of these assays. We have made several adjustments to standard chemiluminescent reporter gene assay protocols to minimize errors in quantitation contributed by hemoglobin. To this end, we have developed a method for quantitating the protein due to blood and due to the organ itself in a blood-contaminated organ lysate. We have also found that the use of a colorimetric protein assay that is unaffected by hemoglobin absorbance is preferred for protein quantitation. In conclusion, luciferase and beta-galactosidase assays can be applied to blood-contaminated organ lysates; however, the luciferase assay proved to be superior due to minimal endogenous activity and lower absorption by hemoglobin of light emitted by the enzyme product.

Increased production of IL-4 by gut T-cell lines from patients with dermatitis herpetiformis compared to patients with isolated gluten-sensitive enteropathy

Dermatitis herpetiformis (DH) and isolated gluten-sensitive enteropathy (GSE) are gluten-sensitive diseases in which ingestion of dietary gluten results in the development of clinical disease. Patients with DH develop cutaneous IgA deposits and a severe skin disease, but rarely develop gastrointestinal symptoms. Patients with isolated GSE develop clinically significant gastrointestinal symptoms, but not skin disease or cutaneous IgA deposits. The aim of this study was to investigate the mechanism by which a mucosal immune response to the same dietary antigen can result in two distinct clinical phenotypes. T-cell lines were derived from activated T-cells in the small bowel mucosa of five patients with DH and 14 patients with isolated GSE and analyzed for T-cell markers and cytokine production in vitro. T-cell lines from DH and isolated GSE patients produced IFN-gamma after stimulation (mean: DH = 2,619 pg/ml; isolated GSE = 1,993 pg/ml; NS). T-cell lines from patients with DH, however, produced significantly more IL-4 than the T-cell lines from patients with isolated GSE (IL-4: DH = 2,010 pg/ml; isolated GSE = 235 pg/ml; P < 0.05). Analysis of intracytoplasmic cytokine production by the T-cell lines showed that T-cell lines from patients with DH were CD4+ predominant, with a greater proportion of CD4+/IL4+ cells than CD4+/IFN-gamma+ cells. In contrast, isolated GSE T-cell lines were predominantly CD8+, with an equal proportion of IL-4- and IFN-gamma-positive cells. These studies demonstrate that T cell lines from patients with DH produce significantly more IL-4 than T-cell lines from patients with isolated GSE, while producing similar amounts of IFN-gamma. This difference in cytokine pattern may play an important role in the different clinical manifestations of these two forms of gluten sensitivity.

Transurethral microwave thermotherapy for the treatment of prostatitis

The lethal action of microwaves on various microorganisms is well established and has been exploited in various clinical settings. Transurethral microwave thermotherapy (TUMT) has become a recognized modality for the treatment of prostatic diseases. Recently, it has been applied for the treatment of patients with nonbacterial prostatitis unresponsive to traditional therapeutic schemes. We review the current literature and present our recent encouraging experience with the in vitro bactericidal effect of microwaves on bacteria considered possible etiologic agents of prostatitis. Thus, we may consider the application of TUMT in patients with chronic bacterial prostatitis.

The young skater

Figure skating is one of the best lifetime sports. Participants may skate alone or with a group, recreationally or competitively, at all ages and at all skill levels. As a sport that improves physical fitness, skating builds strength, flexibility, and cardiopulmonary endurance. As a weight-bearing or high-impact activity, it is one of the best sports for increasing bone mineral density and perhaps for preventing osteoporosis. At least half of all competitive figure skating injuries appear preventable. Boots should be as flexible as the skater can control and should be carefully fitted. Normal flexibility of lower extremity muscles, especially in the growing athlete, markedly decreases the incidence of overuse symptoms of the knee. Core body strength is critical for controlling high-impact jump landings and decreasing injuries to the spine, pelvis, and hip girdle. Adequate shoulder strength is required for pair skaters and ice dancers. A well-designed off-ice training program decreases injury incidence and enhances performance. Assisting these dedicated athletes is truly rewarding as they train and compete at their highest potential, with passion for their sport.

Stone recurrence after endopyelotomy

OBJECTIVES

The purpose of this study was to evaluate whether repair of the ureteropelvic junction (UPJ) obstruction reduces the incidence of stones in stone-forming patients with concurrent UPJ obstruction.

METHODS

We performed a retrospective study evaluating 90 patients with UPJ obstruction who underwent endopyelotomy and simultaneous stone extraction (group A) and 80 patients without UPJ obstruction who underwent only stone extraction (group B). Group A consisted of 52 men and 38 women with an average age of 54.4 years (range 15 to 82), and group B of 46 men and 34 women with an average age of 53.5 years (range 8 to 94). Metabolic evaluation was available in 47 patients of group A and 42 patients of group B.

RESULTS

We achieved a stone-free state in all patients of both groups. Stone recurrence was observed in 7 patients (8%) in group A and in 32 patients (40%) in group B. Nine of 47 patients (19%) in group A showed metabolic abnormalities. In group B we found 30 of 42 patients (71.4%) with metabolic abnormalities.

CONCLUSIONS

Our results suggest that correction of the anatomic obstruction facilitates the drainage of the previously entrapped urine, and thus decreases the incidence of recurrent urinary stone formation.

Sources of error in comparing functional magnetic resonance imaging and invasive electrophysiological recordings

OBJECT

Several authors have recently reported studies in which they aim to validate functional magnetic resonance (fMR) imaging against the accepted gold standard of invasive electrophysiological monitoring. The authors have conducted a similar study, and in this paper they identify and quantify two characteristics of these data that can make such a comparison problematic.

METHODS

Eight patients in whom surgery for epilepsy was performed and five healthy volunteers underwent fMR imaging to localize the part of the sensorimotor cortex responsible for hand movement. In the patient group subdural electrode mats were subsequently implanted to identify eloquent regions of the brain and the epileptogenic zone. The fMR imaging data were processed to correct for motion during the study and then registered with a postimplantation computerized tomography (CT) scan on which the electrodes were visible. The motion during imaging in the two groups studied, and the deformation of the brain between the preoperative images and postoperative scans were measured. The patients who underwent epilepsy surgery moved significantly more during fMR imaging experiments than healthy volunteers performing the same motor task. This motion had a particularly increased out-of-plane component and was significantly more correlated with the stimulus than in the volunteers. This motion was especially increased when the patients were performing a task on the side affected by the lesion. The additional motion is hard to correct and substantially degrades the quality of the resulting fMR images, making it a much less reliable technique for use in these patients than in others. Also, the authors found that after electrode implantation, the brain surface can shift more than 10 mm relative to the skull compared with its preoperative location, substantially degrading the accuracy of the comparison of electrophysiological measurements made in the deformed brain and fMR studies obtained preoperatively.

CONCLUSIONS

These two findings indicate that studies of this sort are currently of limited use for validating fMR imaging and should be interpreted with care. Additional image analysis research is necessary to solve the problems caused by patients' motion and brain deformation.

Percutaneous endopyelotomy

OBJECTIVES

During the past 10 years, numerous reports around the world have documented the safety and success rate of antegrade endopyelotomy. We describe the classic endopyelotomy in conjunction with some new alternatives for making the incision.

TECHNICAL CONSIDERATIONS

Antegrade endopyelotomy is performed through the 0.5-in. incision of the percutaneous nephrostomy created by way of an upper or middle calix. Using the hook-shaped cold knife, an endopyelotome is positioned, and the entire procedure can be performed under direct vision, which determines the exact position, depth, and extent of the incision. The ureteropelvic junction (UPJ) obstruction is incised in a posterolateral position, and the hook is withdrawn from the proximal ureter. Using nephroscopic scissors, a small full-thickness puncture is made into the renal pelvis and then the scissors is opened, under constant visual control, until it reaches the peripelvic space. The section of the pelvic wall is completed with the scissors running through the UPJ, without any interchange of the nephroscope. A holmium laser has been also used, with the 365-microm fiber introduced through a stent-pusher. Under direct vision, the UPJ is incised with fiber, permitting observation and coagulation of bleeding from small vessels. After the procedure, either a 14-8.2F endopyelotomy stent or a 14-7F tapered endoureterotomy stent is placed over the guidewire.

CONCLUSIONS

Percutaneous antegrade endopyelotomy is a safe and effective treatment of UPJ obstruction for most patients, regardless of the method used to perform the incision.

Offence characteristics of psychotic men who sexually assault women

Very little is known about the nature of serious sex offences against women by psychotic men. This study aimed to examine such offences by carrying out a search of Home Office records for all 80 male restricted hospital order in-patients with schizophrenia, resident in any hospital in England and Wales during May 1997, with an index conviction for a contact sex offence against a woman, committed whilst psychotic. Offences peaked in the afternoon, but were proportionally distributed according to day and month. Most (47/59%) offences occurred indoors, with over half of these in the victim's home. Assailants were strangers in 49 (61%) offences. Offences involving strangers were more likely to occur outdoors and without any preceding social interaction compared to those involving assailants known to their victims. Offenders' speech tended to be impersonal, with little attempt at intimacy. Offence sexual behaviours were: breast/genital fondling 63 (79%), vaginal intercourse 42 (52%), fellatio eight (10%), anal intercourse seven (9%), and cunnilingus six (8%). Excessive violence or bizarre behaviour occurred in a minority of offences. The findings are discussed with reference to the literature on sex offences by men without mental illness. The data do not support anecdotal or popular images that most psychotic sex attackers behave in an exceptionally violent or bizarre manner.

Caliceal diverticular calculi: is there a role for metabolic evaluation?

PURPOSE

We report our experience with the treatment and incidence of metabolic abnormalities in patients presenting with caliceal diverticular stones.

MATERIALS AND METHODS

We retrospectively evaluated 49 patients with caliceal diverticular stones (group 1) and 44 with simple renal stones (group 2). Each group successfully underwent percutaneous treatment. Mean stone size was 1.7 and 2.5 cm. in groups 1 and 2, respectively. Metabolic evaluation was available in 25 group 1 and 22 group 2 patients. Mean followup was 73.2 and 70. 8 months, respectively.

RESULTS

We achieved a stone-free rate of 95. 9% in group 1 and 100% in group 2. There was no metabolic abnormality in 75% of the group 1 patients, while 12% had type II absorptive hypercalciuria, 8% hyperuricosuric hypercalciuria and 4% hyperoxaluria. There were no metabolic abnormalities in 22.7% of the group 2 patients, while 9%, 18% and 9% had types I to III absorptive hypercalciuria, respectively, 13.6% hyperuricosuric hypercalciuria, 13.6% hyperoxaluria, 4.5% hypocitruria and 9% type II absorptive hypercalciuria associated with hypocitruria.

CONCLUSIONS

Our results reveal a low incidence of associated metabolic abnormalities in patients with caliceal diverticular stones. Thus, we believe that metabolic abnormalities do not promote caliceal diverticular calculous formation.

Hypermnesia: age-related differences between young and older adults

Hypermnesia is a net improvement in memory performance that occurs across tests in a multitest paradigm with only one study session. Our goal was to identify possible age-related differences in hypermnesic recall. We observed hypermnesia for young adults using verbal (Experiment 1) as well as pictorial (Experiment 2) material, but no hypermnesia for older adults in either experiment. We found no age-related difference in reminiscence (Experiments 1 and 2), though there was a substantial difference in intertest forgetting (Experiments 1 and 2). Older, relative to young, adults produced more forgetting, most of which occurred between Tests 1 and 2 (Experiments 1 and 2). Furthermore, older, relative to young, adults produced more intrusions. We failed to identify a relationship between intrusions and intertest forgetting. We suggest that the age-related difference in intertest forgetting may be due to less efficient reinstatement of cues at test by older adults. The present findings reveal that intertest forgetting plays a critical role in hypermnesic recall, particularly for older adults.

[Percutaneous treatment of calculosis in caliceal diverticulosis: 13-year experience]

We report our experience with the composition and management of caliceal diverticular stones for the past 13 years at our institution. Fourty patients with caliceal diverticular stones were treated percutaneously at Long Island Jewish Medical Center. The size of the diverticula ranged from 1 to 4.8 cm, with a mean size of 2.27 cm. The stone size ranged from 0.2 to 4.5 cm in diameter with an average of 1.7 cm. Twenty patients underwent a metabolic evaluation. Follow-up ranged from 8 months to 140 months with a mean of 72.5 months. We achieved a stone free rate of 95%. All 40 patients were free of pain and infection. The chemical composition of stones was identified in 38 patients. Twelve patients were found to have mainly calcium phosphate stones, 16 mainly calcium oxalate stones, 7 mainly uric acid stones and 3 were found with milk of calcium in their diverticulum. Thirty-five patients had complete resolution of their diverticula with normal urograms. The remaining 5 patients had at least 50% diminution of the diverticulum size. No one of the latter patients was found to have stone recurrence. Metabolic evaluation of the 40 patients showed in the 75% of the cases any metabolic abnormality, an absorptive hypercalciuria type II in two patients (10%), hyperuricosuric hypercalciuria in two cases (10%) and hyperoxaluria in one (5%). Percutaneous management of caliceal diverticular stones is a safe and effective modality compared to the existing alternative procedures reported in the literature.

The use of vertical-looking radar to continuously monitor the insect fauna flying at altitude over southern England

The continuous automatic monitoring of the aerial density, biomass and relative diversity of high-flying insect faunas has been made practicable by a new, vertical-looking radar. This inexpensive radar system, with its novel signal analysis capability, represents a major advance over earlier vertical-beam radars because it provides estimates of the body mass of individual overflying insects, as well as measurements of their direction and speed of movement. This paper summarizes data collected over a three-month period by the new radar in the height range from 150 m to c.1 km, over agricultural land in Worcestershire, England. The day-to-day variation in the numbers of insects and their altitudinal and diurnal patterns of flight activity are presented. Examples are also given of distributions of mass, displacement speed and direction, and orientation direction. The potential of the new radar for various research and operational monitoring tasks is briefly discussed.

Excision of the submandibular gland by an intraoral approach

To improve the outcome in patients with benign diseases of the submandibular gland, we have developed an entirely intraoral technique for excision of the submandibular gland. This procedure is anatomically safe and can be performed with minimal morbidity. We believe the essential surgical steps are as follows: (1) infiltration with Xylocaine plus epinephrine with an adequate waiting period for hemostasis; (2) careful identification of the submandibular duct/lingual nerve relationship; (3) anterior retraction of the mylohyoid muscle to expose the superficial lobe; (4) superiorly directed, extraoral, manipulation of the submandibular gland; and (5) close and blunt dissection to the gland laterally to avoid injury to the facial artery and vein.

Chemolysis of urinary calculi

Irrigant chemolysis was developed to collaborate with open surgery, removing the residual fragments. With the worldwide diffusion of the procedures performed by the endourologist in the early 1980s and the present availability of ESWL, however, direct irrigation of stones has a reduced field of influence even as an adjunctive measure. Urologists have applied economic analysis to their clinical practices, and the findings related to irrigant chemolysis made this technique an unusual procedure. The cost to the providers of medical care, the burden on the patient in terms of suffering and loss of productivity, and the amount of time required to liberate the patient even partially from the stones make irrigant chemolysis an inauspicious scenario. In this era of cost containment and decreasing length of stay, it is increasingly difficult to justify hospital admissions for this form of therapy. Being simultaneously more expensive and less effective than the existing alternatives, local chemolysis should be discarded, except for special situations, such as patients at high risk for any surgical procedure. Oral chemolysis preserves reduced indications, for example as an adjuvant to an endourologic operation or ESWL in special situations. As long as urinary stones continue to afflict humans, chemolysis is likely to retain a limited but important role in their management.

Hydrophobic protein that copurifies with human brain acetylcholinesterase: amino acid sequence, genomic organization, and chromosomal localization

The mechanism of attachment of acetylcholinesterase (AChE) to neuronal membranes in interneuronal synapses is poorly understood. We have isolated, sequenced, and cloned a hydrophobic protein that copurifies with AChE from human caudate nucleus and that we propose forms a part of a complex of membrane proteins attached to this enzyme. It is a short protein of 136 amino acids and has a molecular mass of 18 kDa. The sequence contains stretches of both hydrophobic and hydrophilic amino acids and two cysteine residues. Analysis of the genomic sequence reveals that the coding region is divided among five short exons. Fluorescence in situ hybridization localizes the gene to chromosome 6p21.32-p21.2. Northern blot analysis shows that this gene is widely expressed in the brain with an expression pattern that parallels that of AChE.

Percutaneous management of grade II upper urinary tract transitional cell carcinoma: the long-term outcome

PURPOSE

We report the long-term outcome of our experience with percutaneous treatment of grade II upper urinary tract transitional cell carcinoma.

MATERIALS AND METHODS

A total of 61 patients with transitional cell carcinoma of the upper urinary tract were treated percutaneously between 1984 and 1998. Of the patients 24 (39%) had grade II disease. Immediate nephroureterectomy was performed due to muscle invasive disease in 2 patients, bleeding in 1 and inability to resect the whole tumor in 1. Percutaneous resection was the actual treatment in 15 patients with stage Ta and 5 with stage T1 disease.

RESULTS

Recurrence was noted in 5 patients (25%), including 3 (20%) with stage Ta tumors and 2 (40%) with stage T1 disease after a median followup of 48 months (range 9 months to 12 years). All stage Ta disease recurrences were superficial. In 1 patient with a stage T1 tumor invasive and metastatic disease developed. Disease specific survival was 95% overall, and 100% for stage Ta and 80% for stage T1 disease. No tumor seeding was detected along the percutaneous tract.

CONCLUSIONS

Percutaneous surgery has proved safe and effective in treating superficial grade II upper tract transitional cell carcinoma. Offering an endoscopic approach electively to healthy individuals with a normal contralateral kidney seems viable.

Association of butyrylcholinesterase K variant with cholinesterase-positive neuritic plaques in the temporal cortex in late-onset Alzheimer's disease

In confirmed late-onset (>65 years) Alzheimer's disease, we found a greater load, both of overall neuritic plaques and of cholinesterase-positive neuritic plaques, in the temporal cortex of carriers of the butyrylcholinesterase K variant (BCHE-K) aged <80 years than of all other patients. The differences were most striking in the case of cholinesterase-positive neuritic plaques. Among BCHE-K carriers, densities of such plaques were over six times higher in patients <80 years at death than in those >80 years (P=0.01). Furthermore, in subjects <80 years, BCHE-K carriers had nearly six-fold greater densities of these plaques than non-carriers (P=0.009). We consider three potential explanations for these findings: that the K variant binds more readily to plaque constituents, that it promotes fibril formation or that it induces aberrant neurite growth.

Modular organization and identification of a mononuclear iron-binding site within the NifU protein

The NifS and NifU nitrogen fixation-specific gene products are required for the full activation of both the Fe-protein and MoFe-protein of nitrogenase from Azotobacter vinelandii. Because the two nitrogenase component proteins both require the assembly of [Fe-S]-containing clusters for their activation, it has been suggested that NifS and NifU could have complementary functions in the mobilization of sulfur and iron necessary for nitrogenase-specific [Fe-S] cluster assembly. The NifS protein has been shown to have cysteine desulfurase activity and can be used to supply sulfide for the in vitro catalytic formation of [Fe-S] clusters. The NifU protein was previously purified and shown to be a homodimer with a [2Fe-2S] cluster in each subunit. In the present work, primary sequence comparisons, amino acid substitution experiments, and optical and resonance Raman spectroscopic characterization of recombinantly produced NifU and NifU fragments are used to show that NifU has a modular structure. One module is contained in approximately the N-terminal third of NifU and is shown to provide a labile rubredoxin-like ferric-binding site. Cysteine residues Cys35, Cys62, and Cys106 are necessary for binding iron in the rubredoxin-like mode and visible extinction coefficients indicate that up to one ferric ion can be bound per NifU monomer. The second module is contained in approximately the C-terminal half of NifU and provides the [2Fe-2S] cluster-binding site. Cysteine residues Cys137, Cys139, Cys172, and Cys175 provide ligands to the [2Fe-2S] cluster. The cysteines involved in ligating the mononuclear Fe in the rubredoxin-like site and those that provide the [2Fe-2S] cluster ligands are all required for the full physiological function of NifU. The only two other cysteines contained within NifU, Cys272 and Cys275, are not necessary for iron binding at either site, nor are they required for the full physiological function of NifU. The results provide the basis for a model where iron bound in labile rubredoxin-like sites within NifU is used for [Fe-S] cluster formation. The [2Fe-2S] clusters contained within NifU are proposed to have a redox function involving the release of Fe from bacterioferritin and/or the release of Fe or an [Fe-S] cluster precursor from the rubredoxin-like binding site.

[Endourologic treatment of transitional cell carcinoma of the upper urinary tract]

Nephrourete-rectomy with excision of a bladder cuff has been the standard treatment of the upper urinary tract transitional cell carcinoma. The very indolent behavior (GI, II, Ta, T1) of more than 50% and up to 82% of the upper urinary tract tumors treated with nephroureterectomy in different series in conjunction with the advent of sophisticated endourological techniques have permitted in certain cases alternative treatments using a conservative approach with either ureteropyeloscopy or percutaneous access. Ureteroscopy is reserved for ureteral tumors and small, simple tumors of the renal pelvis (< 1.5 cm) while large or multiple tumors of the renal pelvis are approached in a percutaneous way. During 14 years 64 patients with transitional cell carcinoma of the upper urinary tract were treated percutaneously at our department at Long Island Jewish Medical Center, 15 (23.5%) with grade I, 26 (40.6%) with grade II and 23 (35.9%) with grade III and IV. After a mean follow-up of 51 months, percutaneously treated patients had a tumor specific survival of 85.6%, being 100% for GI tumors, 96.1% for GII and 60.8% for GIII. Recurrence of grade I tumors were observed in 20%, 26.9% for grade II and 56.5% for Grade III. In conclusion, with a rigorous follow-up transitional cell carcinoma of the upper tract with low and moderate grades (GI, GII, Ta, T1) can be treated endorologically even in the presence of a normal contralateral kidney with low morbility and a long term efficiency comparable to a nephroureterectomy. An elective endorologic management for GIII tumors is not recommended. Endoscopic conservative surgery can be offered when the criteria of good prognosis are found for Ta (such as absence of carcinoma in situ, presence of diploidy, low p53 expression and a single tumor) and in the cases of a solitary kidney or chronic renal insufficiency or for poor surgical candidates for T1. Patients with stage T2-T3 should be offered a nephroureterectomy.

Differential effects of dopamine receptor subtype blockade on performance of rats in a reaction-time paradigm

RATIONALE

Pharmacological manipulation of the dopaminergic system with antipsychotic agents disrupts motor behavior. Although most antipsychotic drugs have high affinity for D2 receptors, they also interact with other dopamine receptor subtypes. Therefore, the role of each of these receptor subtypes on motor performance is unclear.

OBJECTIVE

The present study sought to investigate the relative importance of D1, D2, and D3 receptors on performance in a conditioned reaction-time task known to be extremely sensitive to dysfunction of the dopaminergic nigrostriatal pathway.

METHODS

Rats were trained to release a lever in response to a visual cue within a reaction-time limit to receive a reinforcer (45mg food pellet). After the behavior of the rats had stabilized, the effects of a D1 (A69024), D2 (eticlopride), and D3 (nafadotride) receptor antagonists were assessed.

RESULTS

A-69024 had no effect on performance at any dose tested (0.3, 0.6, and 1.3 mg/kg s.c.). Nafadotride (0.1, 0.3, and 1 mg/kg s.c.) produced only a mild deficit in performance at the highest dose. This deficit was characterized by an increase in the number of delayed responses with a non-significant decrease in the number of premature responses indicative of non-specific sedative effects. In contrast, the D2 receptor antagonist eticlopride (0.005, 0.01, and 0.02 mg/kg s.c.) produced profound deficits in performance as evidenced by a dose-dependent decrease in the number of correct responses. This decrease was accompanied by an increase in the number of delayed responses and a lengthening of the reaction time at the highest doses.

CONCLUSIONS

These results provide further evidence that the execution of the reaction-time task is dependent preferentially upon the activation of D2 receptors, but not D1 or D3 receptors.

Diagnosing dementia: interrater reliability assessment and accuracy of the NINCDS/ADRDA criteria versus CERAD histopathological criteria for Alzheimer's disease

We investigated the interrater reliability and accuracy of two independent medical doctors in using NINCDS/ADRDA criteria to classify 82 elderly subjects enrolled in OPTIMA, a longitudinal study investigating dementia. Kappa statistics revealed moderate agreement (0.5) in overall classification of dementia type, and almost perfect agreement (0.9) on the absence or presence of dementia. Combining NINCDS/ADRDA 'possible' and 'probable' Alzheimer's disease (AD) categories produced substantial agreement (0.7). Comparison with CERAD histopathological criteria for AD showed that combining 'possible' and 'probable' AD resulted in a high sensitivity and accuracy, but a low specificity. To increase specificity, the NINCDS/ADRDA 'probable AD' category should be used alone. An important finding was that the accuracy of diagnoses of AD made from the case notes alone was not different from the diagnoses obtained following active involvement with participants.

Ontogeny of orientation flight in the honeybee revealed by harmonic radar

Cognitive ethology focuses on the study of animals under natural conditions to reveal ecologically adapted modes of learning. But biologists can more easily study what an animal learns than how it learns. For example, honeybees take repeated 'orientation' flights before becoming foragers at about three weeks of age. These flights are a prerequisite for successful homing. Little is known about these flights because orienting bees rapidly fly out of the range of human observation. Using harmonic radar, we show for the first time a striking ontogeny to honeybee orientation flights. With increased experience, bees hold trip duration constant but fly faster, so later trips cover a larger area than earlier trips. In addition, each flight is typically restricted to a narrow sector around the hive. Orientation flights provide honeybees with repeated opportunities to view the hive and landscape features from different viewpoints, suggesting that bees learn the local landscape in a progressive fashion. We also show that these changes in orientation flight are related to the number of previous flights taken instead of chronological age, suggesting a learning process adapted to changes in weather conditions, flower availability and the needs of bee colonies.

Tissue expansion: a promising trend for reconstruction in urology

To evaluate the role of the tissue expansion concept in reconstructive urology, the contemporary literature was reviewed, together with our own results with tissue expansion. The principle of tissue expansion has been applied in cases of bladder augmentation, ureteral dilation for the generation of indigenous tissue and subsequent ureterocystoplasties, ureteral elongation, and dilation of the renal pelvis, producing native tissue for the reconstruction of defects or strictures of the upper ureter. Even though the exact mechanism of action of mechanical strain in different tissues is not known, tissue expansion is a well-accepted technique that can amplify the armamentarium of reconstructive urologists for the management of defects along the urinary tract.

Secret patterns: validation of a screening tool to detect bulimia

We prospectively validated a two-item screening tool for bulimia. Subjects recruited from a women's health practice completed the previously developed two-item screening tool ("Do you ever eat in secret?" and "Are you satisfied with your eating patterns?") at their initial office visit. This was validated against a telephone interview with a licensed psychologist. The prevalence of current bulimia was 16% in 75 subjects, determined by psychologists' assessment (sensitivity 75%, specificity 49%) and 4% by DSM-III-R criteria. The positive and negative predictive values of one screening question positive were 22% and 91%, respectively, when compared with the psychologists' assessments as the gold standard. This screening tool allows physicians to identify patients who warrant further valuation for bulimia.

An unusual Ca(2+) entry pathway activated by protein kinase C in dog splenic artery

The characteristics of the Ca(2+) entry pathways that are activated by protein kinase C (PKC) in canine splenic artery were investigated. Phorbol 12, 13-dibutyrate (PDB) contracted tissues and increased Ca(2+) influx. PDB-induced contraction was reduced by preincubation of tissues in Ca(2+)-free Krebs' solution (1 mM EGTA) but was unaffected when Ca(2+)-free solution was applied after contraction was initiated with PDB. In contrast, (45)Ca influx and contraction induced by PDB were resistant to nifedipine, Cd(2+), Gd(3+), La(3+), or Ni(2+) whether added before or during exposure to PDB. Indeed, Cd(2+) reduced (45)Ca(2+) efflux and potentiated Ca(2+) influx, but not PDB-induced contraction. Norepinephrine (NE)-induced contractions were inhibited by preincubation in Ca(2+)-free Krebs' solution (1 mM EGTA). Nifedipine (10 microM) led to a small reduction in the NE-induced contraction but was without effect on (45)Ca(2+) influx. Pretreatment for 16 min with Cd(2+), Gd(3+), or La(3+) (each 1 mM) reduced or abolished NE-induced contraction and Ca(2+) influx. Application of these cations after exposure to NE did not affect (45)Ca(2+) influx but reduced tension. The Q(10) for the increase in (45)Ca(2+) influx was approximately 2 for high K(+) and NE, but 4 for PDB. The results suggest that stimulation of PKC in dog splenic artery activates a Ca(2+) entry pathway that is resistant to di- and trivalent cations. The inhibition of Ca(2+) influx by preincubating with cations during short-term exposure to NE may represent an action on Ca(2+) turnover that precedes activation of PKC.

Expression of interleukin-4 and interferon-gamma in the small bowel of patients with dermatitis herpetiformis and isolated gluten-sensitive enteropathy

Although possessing a morphologically similar small bowel abnormality to patients with isolated gluten-sensitive enteropathy (GSE), patients with dermatitis herpetiformis (DH) have few gastrointestinal symptoms and exhibit blistering skin lesions and cutaneous IgA deposits. To determine whether clinical discrepancies between these gluten-sensitive conditions might be the result of different patterns of small bowel cytokine expression, duodenal biopsies were obtained from eight DH patients and nine isolated GSE patients. Biopsies were evaluated for interleukin-4 (IL-4) and interferon-gamma (IFN-gamma) expression by reverse-transcriptase polymerase chain reaction (message) and immunohistochemistry (protein). In DH patients, most of whom had no gut symptoms, IFN-gamma mRNA expression was significantly less than in isolated GSE patients with symptomatic gut disease. Conversely, IL-4 mRNA expression in DH patients was greater than that found among isolated GSE patients. These findings suggest that the different clinical phenotypes of gluten sensitivity may be caused by variation in cytokine expression in the small bowel response to gluten.

Cerebrovascular disease and threshold for dementia in the early stages of Alzheimer's disease

Cerebrovascular disease and Alzheimer's disease commonly occur together in the elderly and each may contribute to dementia. Here we present evidence that cerebrovascular disease significantly worsens cognitive performance in the earliest stages of Alzheimer's disease.

Species-dependent effects of adenosine receptor agonists on contractile responses of vas deferens to ATP

1. Experiments were carried out to examine the postjunctional actions of adenosine receptor agonists on the smooth muscle of the vas deferens of the guinea-pig and rabbit. 2. Although they produced neither contraction nor relaxation by themselves, adenosine analogues enhanced contractions of the guinea-pig vas deferens induced by 10 microm ATP. The rank order of potency was N6-cyclopentyladenosine (CPA) > 5'-N-ethylcarboxamidoadenosine (NECA) > adenosine > CGS 21680. Dose-response curves for NECA were shifted to the right by the nonselective adenosine receptor antagonist 8(p-sulphophenyl)theophylline (8-SPT; 100 microM) and by the selective A1-receptor antagonist 1,3-dipropyl-8-cyclopentylxanthine (DPCPX; 1 mM). 3. In the rabbit vas deferens, contractions induced by ATP (1 mM) were inhibited rather than facilitated by NECA. Neither CPA, R(-)-N6-(2-phenyl isopropyl)-adenosine (R-PIA) nor CGS 21680 had any effect. 4. The results indicate that the smooth muscle of the guinea-pig vas deferens expresses facilitatory adenosine A1 receptors but not adenosine A2 receptors. In contrast, in rabbit there are postjunctional inhibitory adenosine A2A receptors but not adenosine A1 receptors.

Endopyelotomy review

Open pyeloplasty remained the standard treatment until the mid-1980s. The advantages of the open pyeloplasty include mucosa-to-mucosa anastomosis and excision of redundant renal pelvis and diseased ureter. Over the past decade, antegrade endopyelotomy has evolved as the treatment of choice for obstructions of the UPJ. Further experience has shown that primary UPJ obstruction responded equally well, with long-term success rates for both groups of patients approaching 85%. Endopyelotomy results in significantly less morbidity, and should this technique fail, subsequent open pyeloplasty is no more difficult than had it been performed initially. A 20% incidence of stones associated with UPJ obstruction has been reported. Antegrade endopyelotomy can treat these patients simultaneously. Our series of more than 400 endopyelotomies showed that success was based on the degree of preoperative hydronephrosis and renal function. The presence of massive hydronephrosis had a pejorative influence on endopyelotomy, lowering the success rate from 96% to 50%. Similarly poor renal function (less than 25% of total function) reduced the success rate from 92% to 54%. Although not as extensively reported in the urologic literature, indeed fewer patients with fewer follow-ups have undergone a ureteroscopic endopyelotomy compared with an antegrade endopyelotomy, success rates have ranged between 79% and 94%. Nephrectomy was required in 2.5% for bleeding and 5% for poor renal function. In patients with primary UPJ obstruction, Acucise has a success rate that is 15% lower than antegrade endopyelotomy. Acucise endopyelotomy is a blind procedure, with 1.5% of bleeding reported requiring transfusion and 3% has undergone postoperative embolization. Laparoscopic pyeloplasty is also a relatively new technique which has only been reported with some extensive experience in two institutions, although the success rate has been extremely high, despite a short follow-up. Overall, the incidence of crossing vessels at the UPJ is approximately 50%. The greatest problem lies in determining whether a crossing vessel is etiologically or clinically significant. Thus, the presence of a crossing vessel was potentially causally related to endopyelotomy failure in 4% of the patients. Our overall success rate of 78% for endopyelotomy is comparable and sometimes higher than the reported success rate for open pyeloplasty for horseshoe kidneys, which ranged from 55 to 80%. However, endopyelotomy has become an established treatment modality in the adult, with a decreased morbidity in comparison with open pyeloplasty. The benefits of endourologic management of pediatric UPJ obstruction are less well established.

CONCLUSIONS

Endopyelotomy is a safe and effective treatment for primary and secondary UPJ obstruction for most patients. The biggest experience with better results has been reported with antegrade endopyelotomy, which permits the treatment of associated stones. Laparoscopic pyeloplasty, which is technically demanding, may be considered the best treatment in patients with severe hydronephrosis and poor renal function, which resulted in a success rate of only 38% and 57%, respectively, with endopyelotomy. If we are going to minimize morbidity for our patients, open pyeloplasty is only the first choice for neonates and younger children, and should be considered in patients after failed endopyelotomy.

Acute ureteral elongation in two animal models using a balloon expander

BACKGROUND AND OBJECTIVE

Repair of ureteral injuries and strictures often necessitates a major reconstructive procedure such as a psoas hitch, Boari flap, renal mobilization, ileal interposition, or autotransplantation. Tissue expanders have been used to elongate nerves and arteries. We examined the effects of acute ureteral elongation in two animal models.

MATERIALS AND METHODS

In eight female rabbits, we exposed the left ureter through a midline incision and placed a Ruiz-Cohen balloon beneath the undermined portion. The expander was then inflated until the ureter was tightly stretched across it. After deflation, the expanded segment was measured in situ and compared with its original length. Follow-up urography was performed, and the tissue was harvested and examined by a pathologist. The same procedure was performed in five pigs; however, in these animals, a segment of ureter was excised, and a ureteroureterostomy was performed, after the acute expansion.

RESULTS

We were able to achieve acute elongation of the expanded ureteral segment. The mean elongation was 31.3% in the rabbits and 32.0% in the pigs. An intravenous urogram (IVU) 6 weeks after the elongation showed a functioning kidney and a patent ureter. Histologic examination of the ureter within 24 hours after the expansion revealed that all segments were viable, the luminal epithelium was intact, and the muscular layers appeared normal. At 6 weeks, the expanded segment showed mild inflammatory changes, but the overall morphology, size, and cytology findings were similar to those of a normal control.

CONCLUSIONS

Acute ureteral elongation using a tissue expander is a new method of increasing ureteral length. It may be useful to cover defects that would need major operations with greater morbidity.

Dyspepsia on withdrawal of ranitidine in previously asymptomatic volunteers

OBJECTIVE

H2 receptor antagonist therapy has been shown to produce rebound acid hypersecretion. The clinical significance of this phenomenon is not known. We performed this study to determine whether withdrawal of H2 receptor antagonist therapy results in dyspepsia in previously asymptomatic volunteers.

METHODS

Thirty-five Helicobacter pylori-positive asymptomatic volunteers were randomized in double-blind fashion to receive 2 months' treatment with either ranitidine 300 mg nocte or placebo. Dyspeptic symptoms were measured before starting treatment and over the course of 10 days after stopping treatment by means of a validated questionnaire.

RESULTS

Thirty-one subjects completed the study; 17 were randomized to ranitidine. The pretreatment median aggregate dyspepsia score of the placebo group was 0 (0-4), as was that of the ranitidine group (0-8) (N.S.). During the 10 days after completion of ranitidine, the median aggregate dyspepsia score was 1.4 (0-30), compared with 0 (0-6.3) after placebo (p < 0.01). Of those given ranitidine, 59% experienced dyspepsia after treatment, compared with only 14% who took placebo. In the subgroup that developed dyspepsia after active therapy, the median duration of symptoms was 2 days, symptom severity being maximal on the second day after completion of the tablets. On the days when dyspepsia was experienced, the median daily dyspepsia score was 5 (range, 2-10), which was similar to that of a control group with active duodenal ulcer disease (5; range, 0-11).

CONCLUSIONS

Withdrawal of a 2-month course of ranitidine 300 mg nocte results in the development of dyspeptic symptoms in a proportion of previously asymptomatic subjects. Patients receiving ranitidine should be warned about this rebound dyspepsia and advised not to immediately resume treatment, as rebound symptoms are likely to improve within a few days.

Escherichia coli promotes macrophage apoptosis

BACKGROUND

Escherichia coli is the bacterium most commonly isolated from the urine of patients with urinary tract infection (UTI). Recurrent episodes of UTI lead to renal interstitial scarring. In interstitial fibrosis and scarring, infiltration of mononuclear cells has been reported to play a key role.

MATERIALS AND METHODS

We evaluated the effect of two strains of E. coli--the pathogenic BH-5 and the plasmidless, nonfimbriated HB-101-on human monocyte and murine macrophage apoptosis.

RESULTS

E. coli BH-5 enhanced apoptosis in a time- and dose-dependent manner. It also promoted necrosis in a time- and dose-dependent manner. Strain HB-101 promoted monocyte apoptosis in a dose-dependent manner. However, the magnitude of HB-101-induced monocyte apoptosis was lower than BH-5-induced macrophage apoptosis.

CONCLUSION

The ability of E. coli to induce apoptosis may contribute to its virulence and play a role in renal interstitial scarring.

Failed endopyelotomy: low expression of TGF beta regardless of the presence or absence of crossing vessels

BACKGROUND AND OBJECTIVE

Endopyelotomy relies on Davis' intubated ureterotomy principle of healing by secondary intention and smooth-muscle regeneration. Approximately 15% of endopyelotomies fail, and the restrictured segment almost always shows evidence of reactive fibrosis with little smooth-muscle regeneration. Previous data suggests that an elevation of TGF beta in obstructed ureteropelvic junctures may be necessary for successful tissue repair following endopyelotomy. The role of crossing vessels in endopyelotomy failure is very controversial. To better understand the pathophysiology of endopyelotomy failure, the expression of transforming growth factor-beta (TBG beta) in patients with a failed endopyelotomy and crossing vessels was compared with that in patients without crossing vessels, as well as those having primary pyeloplasty or a normal ureteropelvic junction (UPJ).

MATERIALS AND METHODS

The expression of TGF beta was detected immunohistochemically in slide-mounted thin sections (4 microns) cut from paraffin-blocked adult UPJ segments obtained during primary pyeloplasty (N = 11), secondary pyeloplasty after failed endopyelotomy with documented crossing vessels (N = 10), secondary pyeloplasty after failed endopyelotomy without crossing vessels (N = 11), and normal UPJs removed during nephrectomy for purposes unrelated to obstruction (N = 11). Expression was graded on a scale of 0 to 4.

RESULTS

The combined failed endopyelotomy group had a significantly (P < 0.05) lower level of TGF beta (1.9 +/- 0.7) than did primary obstructed UPJs (2.6 +/- 0.7). The TGF beta level in the crossing vessels group (1.9 +/- 0.7) did not differ from that in the group without crossing vessels (1.8 +/- 0.7), nor did it differ from that in the group with normal UPJs (1.6 +/- 0.7). As expected, primary obstructed UPJs had a significantly higher level of TGF beta than normal ones (P < 0.02).

CONCLUSIONS

Obstructed UPJs that had failed endopyelotomy had a similarly reduced level of TGF beta whether or not crossing vessels were present. These data suggest that an elevation of TGF beta in obstructed UPJs may be necessary for successful tissue repair after endopyelotomy and that the presence of crossing vessels is probably not relevant.

13-year survival comparison of percutaneous and open nephroureterectomy approaches for management of transitional cell carcinoma of renal collecting system: equivalent outcomes

BACKGROUND AND OBJECTIVE

Transitional cell carcinoma (TCC) of the renal collecting system traditionally has been managed by open nephroureterectomy with en bloc resection of a bladder cuff. However, for a select patient population with a solitary kidney or bilateral disease, the morbidity and mortality associated with chronic renal insufficiency and dialysis is deterring. In these situations, a more conservative approach such as antegrade percutaneous resection should be considered. The long-term disease-free outcome of percutaneous management in comparison with open nephroureterectomy has not been previously reported. We evaluated our experience with two surgical approaches to treat upper tract TCC: percutaneous resection and nephroureterectomy/nephrectomy to assess the clinical efficacy of these surgical modalities.

PATIENTS AND METHODS

We retrospectively identified 162 patients who had clinically localized TCC of the upper urinary tract. Records were reviewed to identify those with 13-year follow-up (N = 110) in respect to tumor grade, stage, disease-free status, length of cancer-specific survival, and overall survival. Statistical analysis of the results of open nephroureterectomy/nephrectomy (N = 60) and percutaneous resection (N = 50) was performed using Kaplan-Meier survival curves and Student's t-test.

RESULTS

All patients had disease in clinical stage Ta through T3. During a mean follow-up of 46.6 (range 6-150) months, grade 1 disease demonstrated little invasive potential. Of the disease-specific deaths, 60% (17/26) were of patients with grade 3 lesions, with a mean cancer survival period of 15.2 months after the initial procedure. Disease-specific survival rates after open and percutaneous approaches for grade 2 disease were 53.8 and 53.3 months, respectively (P > 0.05).

CONCLUSIONS

Tumor grade appeared to be the most important prognostic indicator in patients with renal TCC regardless of the surgical approach. Grade 3 tumors were more aggressive, presenting in an advanced stage with invasion, and recurrences were usually associated with metastasis. In this population, nephroureterectomy is warranted if the patient is a surgical candidate. The percutaneous option for grade 1 or 2 disease may be extended beyond the population with solitary kidneys and a risk of chronic renal failure to be offered to healthy individuals with normal contralateral kidneys who are willing to abide by a strict and lengthy follow-up.

Heightened suspicion and rapid evaluation with CT for early diagnosis of partial renal infarction

BACKGROUND AND OBJECTIVE

Although renal infarction has been well studied and clearly defined, it remains greatly underdiagnosed, resulting in significant morbidity. Acute segmental renal infarction is a diagnosis even more problematic, as the problem can appear insidiously and masquerade as other entities including stone, infection, and even tumor. The clinical manifestations and evaluation of partial renal infarction in our patients were reviewed.

PATIENTS AND METHODS

Seven patients presenting to the emergency department who were subsequently found to have partial renal infarction were identified from the 5-year records of a single institution. Patients were evaluated for presenting complaints, physical findings, temperature, and blood pressure. Laboratory analysis consisted of a complete blood count (CBC); measurements of creatinine, lactate dehydrogenase (LDH), aspartate transaminase/alanine transaminase (AST/ALT), and alkaline phosphatase; and urinalysis. The sequence of the work-up was recorded, as well as time to diagnosis. The etiology of infarction was identified for all patients.

RESULTS

All seven patients were eventually discovered to have partial renal infarction as a result of dysrhythmia (N = 4), mural thrombus (N = 2), or septic emboli (N = 1). The average time to diagnosis was 65.2 hours with a range of 9.5 to 168 hours. The chief complaint was flank pain (N = 3), nonspecific abdominal pain (N = 2), left lower-quadrant pain (N = 1), and mental status change (N = 1). The presenting signs and symptoms included abdominal tenderness (N = 4), nausea and vomiting (N = 4), temperature >100.5 degrees F (N = 3), and hypertension (N = 3). Laboratory studies revealed a white cell count >11,000/microL in six, microhematuria in four, proteinuria in four, elevated LDH in all patients, elevated AST/ALT in two, and elevated alkaline phosphatase in one. The work-up varied by presentation, but definitive diagnosis was made by CT in all five patients scanned and by angiography in two. Angiography confirmed the CT findings in four of the five patients.

CONCLUSION

In evaluating partial renal infarction, a strong clinical suspicion is necessary. We found a history of dysrhythmia or other cardiac disease, the presence of abdominal or flank pain, fever with an elevated white cell count, and an elevated LDH to be clinically significant, and their presence should alert the clinician to the possibility of renal infarction. Once a degree of suspicion exists, early evaluation with CT should speed the diagnosis and effect decreased morbidity.

Serious sex offending against women by men with schizophrenia. Relationship of illness and psychotic symptoms to offending

BACKGROUND

Little is known about men who commit sex offences in the context of psychosis.

AIMS

To examine the relationship of illness and psychotic symptoms to sex offending in men with schizophrenia.

METHOD

A search of Home Office records was completed for all 84 male restricted hospital order in-patients with schizophrenia, resident in any hospital in England and Wales during May 1997, with an index conviction for a contact sex offence against a woman.

RESULTS

At the time of their index offences 80 men were psychotic and half of them had delusions or hallucinations related to the offences. Specific delusional or hallucinatory drive was pertinent in only 18 men but the majority of men committed their first sex offence after onset of schizophrenia. Exclusive sex offending was uncommon.

CONCLUSIONS

When a man with schizophrenia commits a serious sex offence the illness is, more commonly than not, relevant to that offence even though a direct symptom relationship may be relatively unusual.