A review of results in a series of 113 laparoscopic colposuspensions

The case records of 113 women having laparoscopic retropubic colposuspensions (Burch procedure) performed for the treatment of genuine urinary stress incontinence between December, 1992 and April, 1995 were retrospectively reviewed. The mean age of the group was 49.4 (30-80) years, mean weight 72.1 (44.5-114) kg, and mean parity 2.7 (0-8). All patients had preoperative urodynamic study to confirm genuine stress incontinence (GSI). Sixteen patients (14%) had dual pathology (GSI and detrusor instability). A transperitoneal approach was used in 93 operations and extraperitoneal in 20. The mean operating time was 108 (30-320) minutes and mean hospitalization 3.3 (1-10) days. In 13 women the operation was converted to laparotomy; 10 due to adhesions and diminished bladder mobility, 1 for inferior epigastric vessel injury, 1 for an ovarian tumour discovered incidentally at the procedure and 1 for equipment problems. Operative complications included 10 cystotomies (5 repaired laparoscopically), 2 extraperitoneal cases converted to transperitoneal, 1 inferior epigastric vessel injury, 1 vaginal tear, 1 suture through the bladder and 1 case of possible enterotomy oversewn at laparoscopy. The mean follow-up period was 8.4 (1-28) months. All patients were reviewed postoperatively and then contact was attempted either by telephone or in consultation. There was an overall 87% subjective success rate. Two patients felt sutures tear out at 4 and 6 months and were deemed failures; 4 felt their incontinence was improved but had ongoing stress incontinence of urine; 9 had symptoms of detrusor instability and one developed an enterocele 9 months after surgery.

Intrahepatic bile duct dilatation and cholestasis in autosomal recessive polycystic kidney disease. Demonstration with hepatobiliary scintigraphy

Fifteen patients with the clinical and radiologic features of autosomal recessive polycystic kidney disease were investigated with radionuclide hepatobiliary scintigraphy. In nine patients (60%), cholestasis and intrahepatic bile duct dilatation were demonstrated. A 10th child had scintigraphic evidence of cholestasis, but the bile ducts were not dilated. The other five children has normal h hepatobiliary scans. The authors conclude that intrahepatic bile duct dilatation with cholestasis (Caroli's disease) is part of the clinical spectrum of autosomal recessive polycystic kidney disease and that hepatobiliary scintigraphy can be of value in determining the extent of hepatobiliary disease in this group of patients.

Inferior vena cava thrombosis as a complication of femoral vein catheterisation

Indwelling femoral venous catheters were prospectively studied by ultrasonography to define the frequency and evolution of inferior vena cava (IVC) thrombosis. IVC thrombosis was identified in six of 56 catheters (54 children). Only one patient with a positive ultrasound scan had clinical signs of thrombosis. All children with IVC thrombosis had had catheters in place for over six days. It is recommended that either the femoral central venous catheters are routinely changed at six days or ultrasound studies are routinely performed twice a week in all patients with catheters in situ for six or more days and that the catheter is removed immediately if evidence of thrombosis appears.

Effect of the Valsalva maneuver on intracranial hypertension

We describe a case of intracranial hypertension in a previously healthy 25-year-old man who sustained a head injury in a motor vehicle accident, in whom a Valsalva maneuver resulted in parallel reductions in mean arterial blood pressure, cerebral blood flow velocity in the middle cerebral artery, and intracranial pressure. The effects of raising intrathoracic pressure in patients with intracranial hypertension are discussed.

Comparison of flow and velocity during dynamic autoregulation testing in humans

BACKGROUND AND PURPOSE

We compared relative changes in middle cerebral artery velocity and internal carotid artery flow during autoregulation testing to test the validity of using transcranial Doppler recordings of middle cerebral artery velocity to evaluate cerebral autoregulation in humans.

METHODS

Seven human volunteers had dynamic autoregulation tested during surgical procedures that included exposure of the internal carotid artery. The mean arterial blood pressure and middle cerebral artery velocity spectral outline (Vmax), using transcranial Doppler, and ipsilateral internal carotid artery flow, using an electromagnetic flowmeter, were continuously and simultaneously recorded during transient sharp decreases in blood pressure that were induced by rapid deflation of thigh blood pressure cuffs. The resulting responses of velocity in the middle cerebral artery and flow in the internal carotid artery were compared.

RESULTS

Moderate decreases in blood pressure evoked responses in cerebral autoregulation. There were no significant (P = .97) differences between the responses in middle cerebral artery velocity and internal carotid artery flow to the blood pressure decreases.

CONCLUSIONS

Relative changes in Vmax accurately reflect relative changes in internal carotid artery flow during dynamic autoregulation testing in humans. Therefore, alterations in middle cerebral artery diameter do not occur to the extent that they introduce a significant error in making these comparisons.

Expression cloning of neurotrophic factors using Xenopus oocytes

We have explored the potential for cloning novel neurotrophic factor cDNAs via assay of neurotrophic activities following expression in Xenopus oocytes. In this report, we describe the successful application of the method to tract rat ciliary neurotrophic factor (CNTF) activity from mRNA purified from cultured cells and from mRNA synthesized by in vitro transcription of a cDNA library. Rat C6 glioma cells, which had been previously shown to have CNTF-like activity (Westermann et al., 1988), were used as source material. We tested protein extracts of C6 cells using an in vitro assay of primary neurons from the chick ciliary ganglion (CCG assay) and detected a CNTF-like activity. RNA isolated from C6 cells was shown to direct the synthesis of the activity following microinjection into Xenopus oocytes and one-step fractionation of Xenopus extract. C6 mRNA was size-fractionated, and fractions encoding CNTF-like activity were cloned into a lambda phage vector at a site distal to a T7 promoter. Synthetic RNA transcribed from total library DNA was injected into Xenopus oocytes, and a CNTF-like activity in the oocyte extract was detected by the CCG assay. Further fractionation of library clones narrowed the presence of the clone encoding the CNTF-like activity to a pool containing 20,000 members. The presence of a full-length CNTF cDNA clone in this pool and partial clones in other pools was confirmed by Polymerase Chain Reaction (PCR) using oligonucleotides from the rabbit CNTF cDNA (Lin et al., 1989) as primers.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of therapy in X-linked hypophosphatemic rickets

BACKGROUND

Patients with X-linked hypophosphatemic rickets, which is clinically manifested by growth failure and bowing of the legs, are usually treated with phosphate and a vitamin D preparation. However, the efficacy of this treatment has been disputed, and nephrocalcinosis is a recognized complication of therapy.

METHODS

We studied 24 patients with X-linked hypophosphatemic rickets (9 boys and 15 girls) ranging in age from 1 to 16 years (median, 5.3). The duration of combination therapy ranged from 0.3 to 11.8 years (median, 3.0). We measured height as a standard-deviation (SD) score (the number of SDs from the mean height for chronologic age). Measurements made before the age of two years or after the onset of puberty were excluded. We compared the results with those reported in 1971 for 16 untreated prepubertal Australian patients. We also determined the severity of nephrocalcinosis (on a scale of 0 to 4, with 0 indicating no abnormalities and 4 stone formation) with renal ultrasonography and whether it could be related to the dosage of phosphate or vitamin D or to other factors.

RESULTS

Patients treated for at least two years before the onset of puberty (n = 19) had a mean height SD score of -1.08, as compared with -2.05 in the untreated historical controls. The 13 patients who had been treated with calcitriol and phosphate for at least two years had an increase in the mean height SD score of 0.33, from -1.58 to -1.25 (95 percent confidence interval, 0 to 0.67; P = 0.05). Nineteen of the 24 patients (79 percent) had nephrocalcinosis detected on renal ultrasonography. The grade of nephrocalcinosis was significantly correlated with the mean phosphate dose (r = 0.60, P = 0.002), but not with the dose of vitamin D or the duration of therapy. All patients had normal serum creatinine concentrations.

CONCLUSIONS

Therapy with calcitriol and phosphate may increase the growth of children with X-linked hypophosphatemic rickets. Nephrocalcinosis in these children represents a complication of therapy and is associated with the dose of phosphate received.

Epinephrine-containing test dose during beta-blockade

Epinephrine is routinely used as a marker for intravascular injection during administration of regional anesthesia. The cardiovascular response of patients on beta-blockers to such a test dose has been reported to be unpredictable. We investigated this interaction by administering 15 micrograms of epinephrine intravenously to 6 healthy volunteers 39 to 48 years old before and after beta-blockade, accomplished by intravenous injection of propranolol, 0.04 mg/kg. Epinephrine administration caused a 20 +/- 4% (mean +/- SEM) increase in heart rate before beta-blockade but a 38 +/- 3% reduction after beta-blockade. The lowest heart rate recorded was 28 beats/min. We conclude that, in middle-aged beta-blocked men, intravenous injection of a standard epinephrine-containing test dose will predictably cause significant hypertension followed by marked bradycardia.

Sequence and structural organization of the human gene encoding ciliary neurotrophic factor

Ciliary neurotrophic factor (CNTF) is a potent polypeptide hormone whose actions appear to be restricted to the nervous system where it promotes survival, neurotransmitter synthesis and neurite outgrowth in certain neuronal populations. We have cloned the gene encoding human CNTF (hCNTF) and have characterized its structure and organization. The hCNTF gene appears to be a unique-copy gene with a simple genetic organization, since only a single intron interrupts the coding domain. The hCNTF gene is located on chromosome 11, as determined using human-hamster somatic cell hybrids. The CNTF protein is highly conserved in evolution. The amino acid (aa) sequences of rat and rabbit CNTF translated from cDNAs display approx. 85% homology with the deduced aa sequence encoding hCNTF.

Arterial desaturation during induction in healthy adults: should preoxygenation be a routine?

We studied the haemoglobin saturation of one hundred healthy patients equally divided into two groups. Group 1 patients received three minutes of preoxygenation prior to thiopentone induction followed by inhalational anaesthetics. Group 2 patients breathed room air prior to induction. None of the patients in Group 1 showed any arterial oxygen desaturation during the five minutes of the induction period, whereas 21 patients in Group 2 showed definite desaturation (P less than 0.005), of which fifteen patients had a saturation of 90% or less (P less than 0.005) and six had a saturation of 85% or less. Since those were healthy patients and the anaesthetics were given by experienced anaesthetists, we concluded that some form of preoxygenation should be used in all patients receiving general anaesthesia.

Management of asthma and chronic airflow limitation: are methylxanthines obsolete?

The widespread popularity of methylxanthine derivatives should be reassessed in light of current evidence. These drugs are relatively weak bronchodilators, respiratory muscle stimulants and inotropic agents and adverse effects, sometimes life threatening, occur fairly frequently. In contrast, beta-2 adrenergic and anticholinergic bronchodilator aerosols used in asthma or chronic obstructive lung disease, and the prophylactic anti-inflammatory aerosols of corticosteroids and cromolyn provide a spectrum of therapeutic choices which address both the inflammatory and bronchoconstrictor components of acute and chronic airflow limitation. Aerosol bronchodilators, in general, are more potent, are virtually free of important side effects, and do not require costly serum level monitoring. Adrenoceptor agonists, together with inhaled steroids, should be considered first-line drugs of choice in managing patients with reversible airflow obstruction associated with asthma or COPD, while methylxanthines should be relegated to the position of third or fourth line drugs, if they are to be used at all. If they are, they should be used with great caution and close patient supervision and, even then, only if benefit, over and above the aerosol bronchodilators and inhaled anti-inflammatory agents can be demonstrated objectively.

Management of asthma and chronic airflow limitation. Are methylxanthines obsolete?

After almost 50 years as first-line drugs in the management of asthma and COPD, methylxanthines have been largely superceded by inhaled adrenoceptor agonist and anticholinergic bronchodilators which are more potent and far less toxic. Accumulating evidence indicates that intravenous theophylline contributes side effects, but is rarely of benefit in acute exacerbations of asthma or COPD. In the maintenance therapy of asthma, first-line therapy is dose-optimized inhaled steroids, reducing the need for bronchodilators. Inhaled adrenoceptor agonists are second line medications, anticholinergic aerosols third line, and theophylline, if needed at all, may fulfill a minor systemic steroid-sparing function in severe asthmatics on maximum doses of the inhaled medications. In the maintenance therapy of some patients with COPD, theophylline sometimes may be useful but these responders should be identified by objectively establishing therapeutic benefit. Since many patients have side effects from the methylxanthines, while their therapeutic benefit over and above dose-optimized inhaled therapy is marginal, their continued almost routine use in the management of reversible airflow obstruction is hard to justify, although this class of drugs may be useful in selected patients in whom both subjective and objective benefit can be demonstrated. In COPD, theophylline may improve exercise capacity in some patients by still incompletely understood mechanisms probably unrelated to bronchodilation.

Neonatal echoencephalography

The recent development of high-resolution real-time ultrasound scanners has coincided with the awareness of the high incidence of intracranial haemorrage in low birthweight babies, resulting in a considerable expansion in the use of echoencephalography in newborns in recent years. The uses are now further expanded and an overview of the subject is presented.

Isolation of a new plasmid pIRL19: its use in construction of small vectors and detection of specific sequence in a foreign DNA

A new plasmid, pIRL19, was constructed by ligating a 1875-bp HaeII fragment carrying the ampicillin-resistance (Apr) gene to a 370-bp HaeII fragment containing the replication origin of the plasmid pBR322. The plasmid essentially contains only the basic replicator and the Apr gene. This basic replicator provides a valuable initial building block for in vitro construction of other very small vectors with antibiotic-resistance determinants. To illustrate this potential, we have transferred the chloramphenicol-resistance (Cmr) gene and a part of the Apr gene from the plasmid pBR329 into pIRL19 such that the new plasmid pIRL20 acquired the Cmr gene and maintained the integrity of its Apr structural gene.

Construction of a broad-host-range kanamycin-resistant plasmid vector

A new 10.2-kb plasmid, pIRL2, was constructed by using a 2140-bp DNA fragment carrying the Kmr gene and BamHI cohesive ends. These BamHI cohesive ends were used to trap the replicating DNA fragment from a partial Sau3A digest of the plasmid R300B. The plasmid contains unique EcoRI, SstI, HindIII, SmaI, SalI, and XhoI sites. These sites can be used as cloning sites without the loss of Kmr. A unique BglII site can be used as a cloning site by insertional inactivation of the Kmr structural gene, coding for neomycin phosphotransferase type II. The new plasmid carries the Sur and Smr genes of R300B. The direction of transcription from the neo promoter is clockwise, the same as that from the sul promoter. The plasmid retains the broad-host-range function of R300B, and thus it may be used for gene cloning in Rhizobium and Agrobacterium for genetic engineering of plant cells.

Characterization of the hormone-sensitive Ca2+ uptake activity of the hepatic endoplasmic reticulum

The characteristics and kinetics of calcium uptake activity were studied in isolated hepatic microsomes. The sustained accumulation of calcium was ATP- and oxalate-dependent. Glucagon increased microsomal Ca2+ uptake upon either in vivo injection, or in vitro perfusion of the hormone in the liver. In contrast, the effect of insulin depended on the route of administration. Calcium accumulation by subsequently isolated hepatic microsomes increased when insulin was injected intraperitoneally whereas it decreased when the hormone was perfused directly into the liver. These effects of glucagon and insulin were dose dependent. When insulin was added to the perfusate prior to the addition of glucagon, insulin blocked the glucagon-stimulated increase in microsomal Ca2+ uptake. Cyclic AMP mimicked the effect of glucagon on microsomal Ca2+ accumulation when the cyclic nucleotide was perfused into the liver. The effects of glucagon and insulin on the kinetics of hepatic microsomal Ca2+ uptake were investigated. In microsomes isolated from perfused rat livers treated with glucagon the V of the uptake was significantly increased over the control values (12.2 vs. 8.6 nmol Ca2+ per min per mg protein, P less than 0.02). In contrast, the addition of insulin to the perfusate significantly decreased the V of Ca2+ uptake by subsequently isolated microsomes (6.8 vs. 8.3 nmol Ca2+ per min per mg protein, P less than 0.05). However, neither hormone had an effect on the apparent Km for Ca2+ (4.1 +/- 0.5 microM) of the reaction. The effect of these hormones on the activity of Ca2+-stimulated ATPase was also studied. No significant changes in either V or Km for Ca2+ of the enzymatic reaction were detected.

Cystic lymphangioma of the cecum with ileocecal intussusception: Case report

A rare case of cystic lymphangioma of the cecum presenting as a leading point for ileocecal intussusception is described. Local resection is recommended.

Arterialization of the liver in combination with a portacaval shunt in the dog

A dog preparation has been developed combining an end-to-side portacaval shunt with arterialization of the hepatic portion of the portal vein through an anastomosis between the inferior branch of the splenic artery and the stump of the portal vein. In this dog preparation, total hepatic blood flow, perfusion of the intrahepatic portal vein, and sinusoidal pressure remained within the preoperative range in the majority of the dogs. The data presented indicate that arterialization of the liver, under those conditions, resulted in no histologic damage or atrophy of the parenchyma of the liver and was effective in achieving significant prolongation of life and prevention of most of the adverse metabolic sequelae that follow a portacaval shunt in dogs. The indocyanine green extraction was restored to normal. The extraction of ammonia was impaired in all dogs with shunts; however, a significantly better ammonia extraction was seen in dogs with arterialization of the liver. It is being postulated that the dual perfusion of the liver through the hepatic artery and the portal vein is essential for the maintenance of the normal morphologic and functional states of the liver in dogs. The avoidance of hyperfusion of the sinusoidal bed with arterial blood is the most critical factor in preventing morphologic damage of the liver if arterialization of the portal vein is used.

Coagulation studies in ulcerative colitis and Crohn's disease

Thromboembolic disease is a known complication of ulcerative colitis, but is rarely reported in Crohn's disease. In this study, we have tried to determine if there are indeed coagulation abnormalities associated with these two diseases. Four groups of patients were studies: (1) patients with ulcerative colitis; (2) patients with Crohn's disease; (3) patients with other diseases; (4) healthy control subjects. In both disease groups, platelet counts, factor V, factor VIII, and fibrinogen levels were found to be elevated, while antithrombin III levels were decreased.