Neurofibromatosis involving the urinary bladder

We present two interesting cases of a 24-year-old man and a 14-year-old boy, uncle and nephew, with lower urinary tract symptoms, café au lait patches and subcutaneous nodules. Ultrasonography and computed tomography scans showed a large, irregular lobulated soft tissue mass between the bladder and sacrum. Cystoscopy, laparotomy and biopsies revealed neurofibromatosis involving the urinary bladder. No enlargement of the tumor or upper urinary tract obstruction has occurred during the long-term follow up. We recommend meticulous follow up of patients with giant intrapelvic neurofibromatosis.

Indicators nurses employ in deciding to test for hyperbilirubinemia

OBJECTIVE

To identify the indicators nurses employ in deciding to test healthy full-term newborns for total serum bilirubin in the absence of a written protocol.

DESIGN

Secondary analysis of data available on 130 mother-newborn pairs and informal interviews of 30 postpartum unit nurses.

SETTING

Two university teaching hospitals.

PARTICIPANTS

All tested newborns and a 33% random sample of remaining newborns from a control group data set created during a previous study and a convenience sample of postpartum nurses from all shifts.

MEASUREMENT

Outcome data were obtained from a review of records. Background data were obtained from a review of records and questionnaires. Nurse data were obtained through a modified form of participant observation.

RESULTS

Ninety-one percent of newborns tested for bilirubin were tested unnecessarily. In logistic regression analyses, variables predictive of nurse-driven total serum bilirubin testing were presence of jaundice, odds ratio (OR) = 31.95 (95% confidence interval, 6.71, 152.03), and feeding frequency, OR = 0.28 (0.11, 0.72). Identifying both presence and location of jaundice simultaneously did not significantly predict testing, OR = 1.82 (0.66, 5.04). Fifty-three percent of nurses who were interviewed identified both the presence of jaundice and feeding as indicators to consider for testing.

CONCLUSION

Newborns are overtested for bilirubin. Indicators used by nurses in deciding to test a healthy newborn for total serum bilirubin are the presence of jaundice and feeding frequency. Nurses who assess feeding frequency are less likely to order bilirubin testing.

Quality of life assessment in patients undergoing endovascular or conventional AAA repair

PURPOSE

To compare health-related quality of life outcomes in a cohort of abdominal aortic aneurysm (AAA) patients treated concurrently with either a conventional or endoluminal intervention.

METHODS

Between December 1997 and April 1999, 51 AAA patients treated by either open or endovascular techniques were enrolled in this prospective study. Conventional therapy was performed in 26 patients (19 men; mean age 70.4 +/- 6.0 years) with anatomical features unsuitable for the endovascular approach. Twenty-five patients (23 men; mean age 70.7 +/- 7.2 years) underwent endoluminal AAA exclusion using either the Ancure or bifurcated Enduring stent-grafts. The Medical Outcomes Study Short-Form 36-item health survey was administered preoperatively and at 1, 4, 8, and > or = 52 weeks after discharge.

RESULTS

At 1 week, both groups showed significant reductions (p < 0.001) in mean scores compared to baseline in 4 dimensions (physical function, social function, role-physical, and vitality), but the decline was more pronounced in patients having open repair. Endoluminal patients returned to their baseline scores by the 4th postoperative week, whereas complete recovery to baseline in the conventional patients was delayed to the 8th week.

CONCLUSIONS

Patients treated endoluminally exhibit better physical and functional scores as early as 1 week after discharge; they also return to baseline status significantly earlier than the conventional group. These findings document the perceived advantage of endovascular therapy over conventional AAA treatment.

Salmonella enterica serovar Gallinarum requires the Salmonella pathogenicity island 2 type III secretion system but not the Salmonella pathogenicity island 1 type III secretion system for virulence in chickens

Salmonella enterica serovar Gallinarum is a host-specific serotype that causes the severe systemic disease fowl typhoid in domestic poultry and a narrow range of other avian species but rarely causes disease in mammalian hosts. Specificity of the disease is primarily at the level of the reticuloendothelial system, but few virulence factors have been described other than the requirement for an 85-kb virulence plasmid. In this work, by making functional mutations in the type III secretion systems (TTSS) encoded by Salmonella pathogenicity island 1 (SPI-1) and SPI-2, we investigated the role of these pathogenicity islands in interactions between Salmonella serovar Gallinarum and avian cells in vitro and the role of these pathogenicity islands in virulence in chickens. The SPI-1 mutant showed decreased invasiveness into avian cells in vitro but was unaffected in its ability to persist within chicken macrophages. In contrast the SPI-2 mutant was fully invasive in nonphagocytic cells but failed to persist in macrophages. In chicken infections the SPI-2 mutant was attenuated while the SPI-1 mutant showed full virulence. In oral infections the SPI-2 mutant was not observed in the spleen or liver, and following intravenous inoculation it was cleared rapidly from these sites. SPI-2 function is required by Salmonella serovar Gallinarum for virulence, primarily through promoting survival within macrophages allowing multiplication within the reticuloendothelial system, but this does not preclude the involvement of SPI-2 in uptake from the gut to the spleen and liver. SPI-1 appears to have little effect on virulence and survival of Salmonella serovar Gallinarum in the host.

Normal and Abnormal Heme Biosynthesis. 3.1Synthesis and Metabolism of Tripropionate Analogues of Coproporphyrinogen-III: Novel Probes for the Active Site of Coproporphyrinogen Oxidase

Coproporphyrinogen oxidase (copro'gen oxidase) catalyses the oxidative decarboxylation of two propionate side chains on coproporphyrinogen-III to produce protoporphyrinogen-IX. This process is very poorly understood at a molecular level, and copro'gen oxidase remains one of the least well-characterized enzymes in the heme biosynthetic pathway. To provide a rigorous test for a proposed model for substrate recognition and binding by this enzyme, two tripropionate analogues of copro'gen-III were prepared where an ethyl group replaced one of the usual propionate residues on positions 13 or 17. Although the required substrate probes are porphyrinogens (hexahydroporphyrins), the corresponding porphyrin methyl esters were initially synthesized via tripyrrene and a,c-biladiene intermediates. These were hydrolyzed and reduced with 3% sodium-amalgam to give the unstable porphyrinogens needed for the biochemical investigations. The modified structure with a 13-ethyl moiety was metabolized by avian preparations of copro'gen oxidase to give a monovinylic product, but the isomeric 17-ethylporphyrinogen afforded a divinylic product, albeit with poorer overall conversion. These results strongly support the proposed model for substrate binding at the active site of copro'gen oxidase.

Solute-binding protein-dependent ABC transporters are responsible for solute efflux in addition to solute uptake

The ATP-binding cassette (ABC) transporter superfamily is one of the most widespread of all gene families and currently has in excess of 1100 members in organisms ranging from the Archaea to manQ1. The movement of the diverse solutes of ABC transporters has been accepted as being strictly unidirectional, with recent models indicating that they are irreversible. However, contrary to this paradigm, we show that three solute-binding protein-dependent (SBP) ABC transporters of amino acids, i.e. the general amino acid permease (Aap) and the branched-chain amino acid permease (Bra) of Rhizobium leguminosarum and the histidine permease (His) of Salmonella typhimurium, are bidirectional, being responsible for efflux in addition to the uptake of solutes. The net solute movement measured for an ABC transporter depends on the rates of uptake and efflux, which are independent; a plateau is reached when both are saturated. SBP ABC transporters promote active uptake because, although the Vmax values for uptake and efflux are not significantly different, there is a 103-104 higher affinity for uptake of solute compared with efflux. Therefore, the SBP ABC transporters are able to support a substantial concentration gradient and provide a net uptake of solutes into bacterial cells.

Variation in shoulder position sense at mid and extreme range of motion

OBJECTIVE

To determine the effect of different joint positions on position sense of asymptomatic shoulders.

DESIGN

Repeated-measures design.

SETTING

Laboratory in an educational institution.

PARTICIPANTS

Thirty-four asymptomatic, right-handed men.

INTERVENTIONS

The ability of subjects to replicate 3 criterion positions was examined on subjects' right shoulders by using an isokinetic dynamometer. Three criterion positions were the 50th, 75th, and 90th percentiles of each individual's total passive shoulder rotation range measured from the full internal rotation position.

MAIN OUTCOME MEASURE

Repositioning accuracy, indicating the difference in degrees between the criterion and matching positions.

RESULTS

All subjects were able to reproduce the criterion position near the end of external rotation range more accurately and consistently than in the middle range of motion (ROM).

CONCLUSIONS

Position sense acuity at the shoulder complex varied across the ROM and may be enhanced near the end of rotation range where there is more tension on the restraints to movement. Therefore, an individual's ROM should be factored into any attempt to assess or rehabilitate shoulder proprioception.

Mortality in rheumatoid arthritis: relationship to single and composite measures of disease activity

BACKGROUND

Rheumatoid arthritis (RA) is a heterogeneous disease characterized by a variable course of remissions and relapses. Single measures of disease activity at only one point in time may not reflect the overall control of disease activity.

OBJECTIVE

The aim was to determine (i) the predictive value of 20 baseline demographic and disease variables on mortality, and (ii) the relationship between serial measures of the Stoke index (SI; a validated index of disease activity in RA) and mortality in RA.

METHODS

Mortality in 309 RA patients followed up for a median of 14 yr was analysed retrospectively. The standardized mortality ratio (SMR) was calculated for all causes of death. The predictive values of baseline and time-integrated variables were assessed using multivariate Cox proportional hazards regression analysis.

RESULTS

The SMR was 1.65. At baseline, only nodules, erosions, RA latex titre, white cell count and globulin level were predictive of mortality after correction for age, sex and disease duration. Using a stepwise Cox proportional hazards regression model, the most powerful predictors of mortality were age, nodules and RA latex titre. Individual measures of disease activity and the SI at baseline were not predictive of mortality. However, the mean level of the SI over 12 months was related to mortality (P=0.039).

CONCLUSIONS

At baseline, the demographic and disease variables most significantly related to mortality in RA are age, nodules and RA latex titre. Individual measures of disease activity at a single point in time are poor predictors of mortality in RA. However, measurement of the mean level of disease activity over time using the composite SI has a significant relationship with mortality. A high level of sustained inflammation appears to be an important predictor of premature death.

Vaginal metastases from renal cell carcinoma: report of four cases and review of the literature

Between 1987 and 1997, four patients presented with gynecologic symptoms that on evaluation revealed vaginal metastases from renal cell carcinoma. Two patients had isolated metastases and were treated with nephrectomy, local excision of the vaginal lesion and post-operative radiotherapy. Both are alive without evidence of disease at 24 and 30 months, respectively. The other two patients had widespread disease and died within a year of diagnosis. Seventy-one cases of vaginal metastases from renal cell carcinoma have been reported in the literature.

Improved survival after endoluminal repair with second-generation prostheses compared with open repair in the treatment of abdominal aortic aneurysms: a 5-year concurrent comparison using life table method

PURPOSE

The aim of this study was to compare the outcome of consecutive patients with abdominal aortic aneurysm (AAA) treated concurrently by means of open repair (OR) and endoluminal repair (ER) with second-generation prostheses by the same surgeons during a defined interval.

METHODS

Between May 1995 and December 1998 second-generation (low profile, fully supported, modular) endoprostheses were implanted in 148 patients. These patients, together with 135 patients treated concurrently with OR during the same period, comprised the study group of 283 patients. Patient selection was based on aneurysm morphology. Those patients who were anatomically suitable for ER were treated with this method. The ER and OR groups were similar with regard to age, sex, and size of AAA. The ER group contained high-risk patients considered unfit for OR (n = 46), and the OR group contained high-risk patients who were anatomically unsuitable for ER (n = 19). Outcome criteria in both groups were survival and successful aneurysm repair. Success in the ER group was defined as exclusion of the aneurysm sac and stability or reduction in AAA maximum transverse diameter. Persistent endoleaks were classified as failures, regardless of whether they were subsequently corrected with secondary endovascular intervention. Data were analyzed with the life table method. The minimum period of follow-up for all patients was 18 months.

RESULTS

The perioperative mortality rate was 5.9% in the OR group and 2.7% in the ER group (not significant). There was a statistically significant difference between the survival curves of the two groups in favor of the ER group when analyzed with the log-rank test (P =.004). The Kaplan-Meier curve for graft failure for the ER group revealed a 3-year graft success probability of 82%. Survival probability with successful repair in the OR group at 3 years was 85%.

CONCLUSIONS

A concurrent comparison of ER with second-generation prostheses versus OR demonstrated a significant difference in survival in favor of the ER group. The probability of survival with successful repair at 3 years was similar in both groups.

Nitric oxide is a downstream mediator of agrin-induced acetylcholine receptor aggregation

The synaptic basal lamina protein, agrin, is required for the formation of the neuromuscular junction. Agrin signals through a muscle-specific receptor tyrosine kinase (MuSK) initiating a cascade of events that lead to the aggregation of acetylcholine receptors (AChR) at the postsynaptic site. Another important synaptic signalling molecule is nitric oxide (NO), which is produced by the enzyme, nitric oxide synthase (NOS). We investigated the interaction between the agrin signalling cascade and the NO signalling cascade by treating cultured myotubes with agrin, NOS inhibitors, and NO donors. NOS inhibitors prevented agrin induced AChR aggregation and phosphorylation of the AChR beta subunit. Furthermore, NO donors induced AChR aggregation in the absence of agrin, as well as phosphorylation of the AChR beta subunit. These results demonstrate a role for NO as a downstream mediator of agrin induced AChR aggregation and AChR beta subunit phosphorylation at the neuromuscular junction.

The secreted effector protein of Salmonella dublin, SopA, is translocated into eukaryotic cells and influences the induction of enteritis

Salmonella-induced enteritis is associated with the induction of an acute intestinal inflammatory response and net fluid secretion into the lumen of infected mucosa. Proteins secreted by the Inv/Spa type III secretion system of Salmonella play a key role in the induction of these responses. We have demonstrated recently that the Inv/Spa-secreted SopB and SopD effector proteins are translocated into eukaryotic cells via a Sip-dependent pathway and act in concert to mediate inflammation and fluid secretion in infected ileal mucosa. Mutations of both sopB and sopD significantly reduced, but did not abrogate, the enteropathogenic phenotype. This indicated that other virulence factors are involved in the induction of enteritis. In this work, we characterize SopA, a secreted protein belonging to the family of Sop effectors of Salmonella dublin. We demonstrate that SopA is translocated into eukaryotic cells and provide evidence suggesting that SopA has a role in the induction of enteritis.

Mortality in a cohort of Norwegian patients with rheumatoid arthritis followed from 1977 to 1992

This study aimed to describe the mortality pattern of Norwegian patients with rheumatoid arthritis (RA). The subjects were 149 patients (52 males(M)) who were discharged from a Norwegian rheumatology hospital in 1977 after their first admission for RA. 126 patients (85%) met the 1958 criteria for definite or classical RA. By the end of 1992, 2 patients, both with definite/classical RA, were lost to follow-up. Of the remaining 147 patients (51M), 68 (25M) had died. The overall standardised mortality ratio (SMR) was 149 (95% CI: 115-188). The mortality was significantly raised for females with SMR= 168 (120-223). The moderate increase in the male SMR of 126 (81-181) was restricted to the early years of follow up. Patients with definite/classical RA had a somewhat higher SMR (159 (120-202)). Excess deaths were due to malignant disease in males and cardiovascular disease in females. RA was mentioned on one third of the death certificates. This study supports previous findings that patients with RA have a reduced long term survival, most prominent in females.

EMG and strength correlates of selected shoulder muscles during rotations of the glenohumeral joint

OBJECTIVE

To identify activation patterns of several muscles acting on the shoulder joint during isokinetic internal and external rotation.

DESIGN

Combined EMG and isokinetic strength analysis in healthy subjects.

BACKGROUND

EMG studies of the shoulder region revealed intricate muscular activation patterns during elevation of the arm but no parallel studies regarding pure rotations of the joint could be located.

METHODS

Fifteen (n=30 shoulders) young, asymptomatic male subjects participated in the study. Strength production during isokinetic concentric and eccentric internal and external rotations at 60 and 180 degrees /s was correlated with the EMG activity of the rotator cuff, biceps, deltoid and pectoralis major. Analysis of the smoothed EMG related to the timing of onset of the signal and to the normalized activity at the angle of the peak moment. Determination of the association between the EMG and the moment was based on strength ratios.

RESULTS

Findings indicated that for both types of rotations, the rotator cuff and biceps were active 0.092+/-0.038-0.215+/-0.045 s prior to the initiation of the actual movement and 0.112-0.034 s prior to onset of deltoid and pectoralis major activity. These differences were significant in all of the eight conditions (P<0.05). In terms of the strength ratios, strong association was found between electrical activity and moment production in the subscapularis and infraspinatus (r(2)=0.95 and 0. 72, respectively) at the low and high angular velocities.

CONCLUSIONS

Prior to actual rotation of the shoulder joint, normal recruitment of the rotator cuff and biceps is characterized by a non-specific presetting phase which is mainly directed at enhancing the joint 'stiffness' and hence its stability. Once movement is in progress, the EMG patterns of these muscles become movement specific and are correlated with the resultant moment.

RELEVANCE

Muscular dysfunction relating to delayed onset activity or altered activation patterns, due to pain, perturbed mechanics or disturbed neural activation have been implicated as concomitant factors in other joint associated pathologies. Through highlighting the role of the rotator cuff in shoulder joint rotations, this study lends further support to the argument that a parallel situation may prevail with respect to shoulder joint dysfunction. This could lead to the development of rehabilitation protocols aimed specifically at redressing such dysfunction.

The importance of considering biological maturity when assessing physical fitness measures in girls and boys aged 10 to 16 years

It is widely considered that biological maturity influences physical fitness test performance, children can be advantaged/disadvantaged in physical fitness tests by being more or less mature than counterparts of the same chronological age. The current study sought to investigate the effect sexual maturity had upon performance in physical fitness tests. A cross-sectional study involving 161 girls and 152 boys was carried out. Each subject was assessed for stature, mass, self-assessment of sexual maturity, vertical jump, hand grip strength and the 20 m shuttle run test, all procedures were standardized. Spearman's rank correlation coefficients were developed to assess the relationship between maturity and physical fitness measures. ANCOVA inferential statistics were performed to investigate if performance in physical fitness tests differed between children of different sexual maturity stages irrespective of mass and stature. Significance was set at p < 0.05. Stage of sexual maturity was significantly correlated with all physical fitness measures (boys: r=0.56 to 0.73; girls: r=0.24 to 0.46). ANCOVA revealed that when stature and mass were taken into account significant differences were evident between sexual maturity stages in boys but not girls. This suggests that increases in mass and stature are primarily responsible for variation in girls' physical performance throughout maturation, whereas in boys there are some qualitative differences in performance due to other factors. It was concluded that sexual maturity has a large influence on physical fitness measures in boys but less effect in girls. Rating of physical fitness, particularly for boys should take into account biological maturity.

Ultrasonographic differential diagnosis and neurodevelopmental outcome of cerebral white matter lesions in premature infants

OBJECTIVE

To determine the clinical usefulness of recently published ultrasonographic criteria for the differential diagnosis of periventricular hemorrhagic venous infarction (PHVI) versus periventricular leukomalacia (PVL), and its relevance to neurodevelopmental outcome.

STUDY DESIGN

From 1992 to 1995, we evaluated 998 very low birth weight infants of which 111 developed cerebral white matter lesions on cranial ultrasonogram examination. An attempt was made to differentiate the lesions into either PHVI or PVL using specific ultrasonographic criteria (Volpe JJ. Brain inury in the premature infant: is it preventable? Pediatr Res 1990; 6:S28-33). Seventy-six patients who survived to discharge constituted the study group. Survivors were followed prospectively with neurologic examinations, visual and auditory screening, and developmental testing.

RESULTS

PHVI was diagnosed in 23 patients (30%), PVL in 36 (47%), characteristics of both PHVI and PVL (mixed lesions) in 8 (11%), and persistent periventricular echodensity without cystic change in 9 (12%). Two-year follow-up data were obtained on 57 of 76 (75%) patients. Neurodevelopmental deficits were common in all groups; however, infants with localized PHVI had a mean developmental quotient in the normal range.

CONCLUSION

The majority of white matter lesions (77%) can be differentiated as either PHVI or PVL by ultrasonographic criteria, with coexisting features in only 11% of patients. In addition to these lesions, persistent periventricular echodensity was also associated with a high risk of subsequent neurodevelopmental deficit. However, normal development was seen in a subgroup of patients with localized periventricular hemorrhagic venous infarction.

Aggregates of acetylcholine receptors are not observed under anti-agrin staining schwann cell processes at the frog neuromuscular junction

The frog neuromuscular junction offers a unique structure in which to observe fine details in the relationship between the motor neuron, muscle, and Schwann cell, which together comprise the neuromuscular junction. Schwann cell processes that extended from the synapse stained positively with anti-agrin antibodies. Immunocytochemistry revealed strong anti-agrin staining of the extracellular matrix surrounding the entire Schwann cell and the Schwann cell processes come in close contact with the muscle fiber. Dual-labeling experiments revealed a lack of acetylcholine receptor (AChR) aggregates on the surface of the muscle fiber directly under these anti-agrin-staining Schwann cell processes. The cDNA that codes for the C-terminal portion of agrin in frog (Rana pipiens) was cloned and sequenced. Polymerase chain reaction of frog brain, nerve, and muscle cDNA revealed that like other species, agrin transcripts that contain the B8, B11, or B19 inserts were observed only in brain tissue. Unlike other species, the exact site of the B inserts in frog was slightly altered, with the B insertion site occurring within a codon sequence. Our data are consistent with the hypothesis that Schwann cells produce agrin which lacks inserts at the B region, and that agrin lacking B inserts does not direct the aggregation of AChRs in vivo under physiological conditions and concentrations.

The re-use of irrigating equipment for flexible cystoscopy is not safe

OBJECTIVE

To determine the incidence of fluid reflux from the lower urinary tract into the connecting tubing used for irrigation in patients undergoing flexible cystoscopy.

PATIENTS AND METHODS

The study was conducted in 94 consecutive male and female patients attending routine outpatient flexible cystoscopy lists. A sensor was designed and constructed to determine the presence of any retrograde flow of irrigating fluid, and the volume of any reflux through the connecting tubing. The mean (sd) cystoscope internal channel volume was 2.56 (0.25) mL; the level of significant reflux was set at >/=2. 25 mL.

RESULTS

Reflux of irrigating fluid occurred in 11 males (17%) and was significant in six (9%) of 65 male patients, with the irrigating fluid reservoir set at a height of 0.78 m above the patient's mid-coronal level. No reflux occurred in the 29 females studied.

CONCLUSIONS

Significant reflux can occur in males and hence the connecting tubing should be regarded as contaminated. Infection-control measures must include the prevention of transmission of blood-borne infections, e.g. hepatitis B and C viruses, and human immunodeficiency virus, because of the risk that blood may contaminate urine, and they should be implemented in all cases regardless of patient risk factors. From the available evidence, flexible cystoscopy should always be performed with single-use irrigation systems.

Utilization of psychotherapy by lesbians, gay men, and bisexuals: findings from a nationwide survey

Based on a survey of the psychotherapy histories of 600 lesbians, gay men, and bisexuals, the number, duration, and circumstances of each therapy episode, and respondents' views of their therapists and of therapy, are reported. Findings suggest that lesbians and gay men are among the most active and satisfied--but least acknowledged--consumers of psychotherapy. Routine inclusion of sexual orientation as a demographic variable in mental health services research is proposed.

Protection of Escherichia coli cells against extreme turgor by activation of MscS and MscL mechanosensitive channels: identification of genes required for MscS activity

Mechanosensitive channels are ubiquitous amongst bacterial cells and have been proposed to have major roles in the adaptation to osmotic stress, in particular in the management of transitions from high to low osmolarity environments. Electrophysiological measurements have identified multiple channels in Escherichia coli cells. One gene, mscL, encoding a large conductance channel has previously been described, but null mutants were without well-defined phenotypes. Here, we report the characterization of a new gene family required for MscS function, YggB and KefA, which has enabled a rigorous test of the role of the channels. The channel determined by KefA does not appear to have a major role in managing the transition from high to low osmolarity. In contrast, analysis of mutants of E.coli lacking YggB and MscL shows that mechanosensitive channels are designed to open at a pressure change just below that which would cause cell disruption leading to death.