Estimated blood loss and transfusion requirements of radical cystectomy

PURPOSE

Radical cystectomy has been associated with significant blood loss and/or transfusion requirement. We defined and characterized blood loss and transfusion parameters in this population.

MATERIALS AND METHODS

We reviewed the records of 304 consecutive patients who underwent radical cystectomy and urinary diversion between October 1995 and July 2000. Charts were examined, and univariate and multivariate logistic regression analysis was performed to evaluate estimated blood loss and the transfusion requirement.

RESULTS

Complete blood loss data were available in 297 cases. Overall 45% of patients had anemia preoperatively. Median estimated blood loss was 600 ml. (range 100 to 3,000). On univariate analysis increased estimated blood loss was related to patient age, American Society of Anesthesiologists score, longer operative time and paralytic ileus. Overall transfusion was done in 88 of 297 cases (30%) with a median requirement of 2 units (range 1 to 10). The transfusion rate in male and female patients was 26% and 40%, respectively (p <0.05). On univariate analysis female gender, ileal conduit diversion and lower preoperative hematocrit correlated with transfusion need (p = 0.04, <0.001 and <0.001, respectively). On multivariate logistic regression analysis lower preoperative hematocrit, increased estimated blood loss, major complications and ileal conduit diversion type correlated with a higher transfusion rate (odds ratio 8.34, 5.88 and 4.60, respectively).

CONCLUSIONS

Acute blood loss anemia is common in patients undergoing radical cystectomy, and predicting blood loss and transfusion requirements remains difficult. These data indicate the need for continued refinement in surgical techniques to decrease blood loss as well as for strategies designed to decrease the need for blood transfusion.

Health related quality of life assessment after radical prostatectomy in men with prostate specific antigen only recurrence

PURPOSE

The health related quality of life assessment is becoming increasingly important among patients with prostate cancer. Meanwhile, treatment of patients with increasing prostate specific antigen (PSA) after radical retropubic prostatectomy remains controversial. We attempt to define the impact of PSA recurrence on the health related quality of life of patients after radical retropubic prostatectomy.

MATERIALS AND METHODS

Of 604 consecutive patients who underwent radical retropubic prostatectomy between March 1991 and September 1998, 510 (84%) were available for followup. Each patient was mailed the RAND 36-Item Health Survey and University of California, Los Angeles, Prostate Cancer Index questionnaire. A total of 348 (70%) questionnaires were returned. Health related quality of life scores were then compared between patients with and without PSA recurrence. A multivariate analysis was also performed to elucidate further the cause of differences between the groups.

RESULTS

Overall, 88 (25%) patients had PSA recurrence. In regard to health related quality of life there were small (less than 10%) but statistically significant differences in 2 of 4 physical health domains (RAND 36-Item Health Survey). There was a significant decrease in only 1 category of the mental health domain for patients with PSA recurrence. Only sexual function was statistically lower on the University of California, Los Angeles, Prostate Cancer Index. This result reflects the lower incidence of nerve sparing in these patients, as confirmed by the multivariate analysis. Overall patient satisfaction was similar between those with and without PSA recurrence (76% and 79%, respectively).

CONCLUSIONS

Our study demonstrates small health related quality of life differences in patients with biochemical PSA recurrence versus those without. These findings provide a baseline assessment of general and disease specific health related quality of life domains among these patients. Future studies should focus on differences in the measure of cancer anxiety before and after administration of adjuvant therapy in these asymptomatic patients.

Comparison of three techniques to measure unsaturated-zone air permeability at Picatinny Arsenal, NJ

The purpose of this study is to compare three techniques to measure the air permeability of the unsaturated zone at Picatinny Arsenal, NJ and to examine the effects of moisture content and soil heterogeneity on air permeability. Air permeability was measured in three ways: laboratory experiments on intact soil cores, field-scale air pump tests and calibration of air permeability to air pressures measured in the field under natural air pressure conditions using a numerical airflow model. The results obtained from these three methods were compared and found to be similar. Laboratory experiments performed on intact cores measured air permeability values on the order of 10(-14) to 10(-9) m2. Low-permeability cores were found between land surface and a depth of 0.6 m. The soil core data were divided into two layers with composite vertical permeability values of 1.3 x 10(-13) m2 from land surface to a 0.6-m depth and 3.8 x 10(-10) m2 for the lower layer. Analyses of the field-scale pump tests were performed for two scenarios: one in which the entire unsaturated zone was open to the atmosphere and one assuming a cap of low permeability extending 0.6 m below land surface. The vertical air permeability values obtained for the open scenario ranged from 1.2 x 10(-9) to 1.5 x 10(-9) m2, and ranged from 3.6 x 10(-9) to 6.8 x 10(-9) m2 in the lower layer, assuming an upper cap permeability of 6.0 x 10(-14) m2. The results from the open scenario are much higher than expected and the possible reasons for this ambiguity are discussed. The results from the capped scenario matched closely with those from the other methods and indicated that it is important to have background information on the study site to correctly analyze the pump test data. The optimized fit of the natural subsurface air pressure was achieved with an intrinsic permeability value of 3.3 x 10(-14) m2. When the data were refitted to the model assuming two distinct layers of the unsaturated zone, the optimized fit was achieved with intrinsic air permeabilities of 1.6 x 10(-14) m2 for the upper, low-permeability region and 8.4 x 10(-9) m2 for the lower region. Vertical air-permeability predictions from the three methods are similar provided that soil cores are collected from all representative depths to account for heterogeneous layers and that the correct assumptions are made when analyzing field-scale pump test data.

beta-peptides as catalysts: poly-beta-leucine as a catalyst for the Juliá-Colonna asymmetric epoxidation of enones

Poly-beta-leucines have been evaluated as catalysts for the Juliá-Colonna asymmetric epoxidation of enones; the beta 3-isomer was found to be an effective catalyst for the epoxidation of chalcone (70% ee) and some analogues.

Keratitis caused by Candida glabrata in a patient with chronic granulomatous disease

PURPOSE

To report an unusual ocular presentation of Candida glabrata in a patient with chronic granulomatous disease.

METHODS

Interventional case report. A 15-year-old boy with chronic granulomatous disease presented with bilateral limbal infiltrates. He had been receiving broad-spectrum systemic antibiotics for recurrent liver abscesses. The keratitis did not respond to antibiotics and did not resolve after a course of topical steroids.

RESULTS

Corneal cultures revealed Candida glabrata. The same species was simultaneously isolated from the surgical drainage of the liver abscesses. The ocular and hepatic findings resolved on intravenous amphotericin B.

CONCLUSION

Candida glabrata has recently emerged as an important nosocomial pathogen. It may present as a limbal keratitis in the setting of systemic infection.

Safety of budesonide inhalation suspension (Pulmicort Respules) after up to 52 weeks of treatment in infants and young children with persistent asthma

Three open-label extension trials evaluated the safety of budesonide inhalation suspension (BIS; Pulmicort Respules) in 670 children (8 months-9 years of age) with mild-to-severe persistent asthma. Patients were randomized to receive either BIS or conventional asthma therapy (CAT) for 52 weeks. The percentage of patients who discontinued because of clinical adverse events was low and similar among the CAT (0.4%) and BIS (0.7%) groups. After adjusting for length of time in the studies, there were no clinically relevant differences between the BIS and CAT groups in the type, incidence, or intensity of adverse events; vital signs or physical examination outcomes; or changes in clinical laboratory evaluations or oral fungal cultures.

Acute biomechanical and histological effects of intradiscal electrothermal therapy on human lumbar discs

STUDY DESIGN

Human cadaver lumbar spines were used to assess the acute effects of intradiscal electrothermal therapy in vitro.

OBJECTIVE

To determine whether intradiscal electrothermal therapy produces acute changes in disc histology and motion segment stability.

SUMMARY OF BACKGROUND DATA

Intradiscal electrothermal therapy has been introduced as an alternative for the treatment of discogenic low back pain. Several hypothesized mechanisms for the effect of intradiscal electrothermal therapy have been suggested including shrinkage of the nucleus or sealing of the anulus fibrosus by contraction of collagen fibers, and thermal ablation of sensitive nerve fibers in the outer anulus.

METHODS

Intradiscal electrothermal therapy was performed with the Spinecath by Oratec on 19 fresh, frozen human lumbar cadaver specimens. In a separate study, eight specimens were tested biomechanically and instrumented to map the thermal distribution, whereas five specimens were tested only biomechanically, both before and after intradiscal electrothermal therapy. Six additional specimens were heated with intradiscal electrothermal therapy, and the resulting canal was backfilled with a silicone rubber compound to allow colocalization of the catheter and anular architecture.

RESULTS

A consistent pattern of increased motion and decreased stiffness was observed. For the specimens in which only biomechanical measurements were taken, a 10% increase in the motion, on the average, at 5 Nm torque was observed after intradiscal electrothermal therapy. No apparent alteration of the anular architecture was observed around the catheter site in the intradiscal electrothermal therapy-treated discs.

CONCLUSION

The data from this study suggest that the temperatures developed during intradiscal electrothermal therapy are insufficient to alter collagen architecture or stiffen the treated motion segment acutely.

Clinical outcome of trans-sacral interbody fusion after partial reduction for high-grade l5-s1 spondylolisthesis

STUDY DESIGN

A clinical retrospective study was conducted.

OBJECTIVE

To evaluate the clinical and radiographic outcome of reduction followed by trans-sacral interbody fusion for high-grade spondylolisthesis.

SUMMARY OF BACKGROUND DATA

In situ posterior interbody fusion with fibula allograft has improved the fusion rates for patients with high-grade spondylolisthesis. The use of this technique in conjunction with partial reduction has not been reported.

METHODS

Nine consecutive patients underwent treatment of high-grade (Grade 3 or 4) spondylolisthesis with partial reduction followed by posterior interbody fusion using cortical allograft. The average age at the time of surgery was 27 years (range, 8-51 years), and the average follow-up period was 43 months (range, 24-72 months). Before surgery, eight patients had low back pain, seven patients had radiating leg pain, and five patients had hamstring tightness. The average grade of spondylolisthesis by Meyerding grading was 3.9 (range, 3-5). Charts and radiographs were evaluated, and outcomes were collected by use of the modified SRS outcomes instrument.

RESULTS

Radiographic indexes demonstrated significant improvement with partial reduction and fusion. The slip angle, as measured from the inferior endplate of L5, improved from 41.2 degrees (range, 24-82 degrees ) before surgery to 21 degrees (range, 5-40 degrees ) after surgery. All the patients were extremely or somewhat satisfied with surgery. The two patients who underwent this operation without initial instrumentation experienced fractures of their interbody grafts. Both of these patients underwent repair of the pseudarthrosis with placement of trans-sacral pedicle screw instrumentation and subsequent fusion.

CONCLUSIONS

Partial reduction followed by posterior interbody fusion is an effective technique for the management of high-grade spondylolisthesis in pediatric and adult patient populations, as assessed by radiographic and clinical criteria. Pedicle screw instrumentation with the sacral screws capturing L5 is recommended when this technique is used for the treatment of high-grade spondylolisthesis. According to the clinical and radiographic results from this study, partial reduction and posterior fibula interbody fusion supplemented with pedicle screw instrumentation is an effective technique for select patients with high-grade spondylolisthesis at L5-S1.

Intraoperative nerve stimulation predicts postoperative potency

OBJECTIVES

Intraoperative nerve stimulation has been used to map the course of cavernosal nerve bundles to aid in nerve-sparing radical prostatectomy (RP). We sought to determine whether the intraoperative nerve stimulation response after removal of the prostate specimen predicts postoperative potency.

METHODS

We prospectively evaluated 63 consecutive patients undergoing RP. Among these 63 patients, 41 patients had a bilateral nerve-sparing procedure, and 22 underwent bilateral wide resection of the neurovascular bundles. Potency was determined at 1 year by direct patient interview.

RESULTS

Of the 22 patients with wide resection, 16 (73%) had no observed stimulated response, 4 (18%) had a measurable tumescence response, and 2 (9%) had detumescence. All 22 patients were impotent postoperatively. At a minimum follow-up of 1 year, of the 41 patients who underwent nerve-sparing RP, 27 (66%) had postoperative erections sufficient for penetration. Of the 30 men with an intraoperative stimulated tumescence response, 24 (80%) were potent; of the 6 with a detumescence response, 2 (33%) were potent; and of the 5 with no stimulated nerve response, 1 (20%) was potent. A tumescence response was significantly more predictive of postoperative potency than no intraoperative response (P = 0.017).

CONCLUSIONS

An intraoperative tumescence response with stimulation of the neurovascular bundles after prostate specimen removal is more likely to correspond to successful postoperative sexual function after nerve-sparing RP than is no response.

Management of fixed sagittal plane deformity: results of the transpedicular wedge resection osteotomy

STUDY DESIGN

Retrospective review of a consecutive clinical series.

OBJECTIVES

To evaluate the efficacy of the transpedicular wedge resection osteotomy as a technique for correction of sagittal and coronal deformity and to assess the clinical value of the procedure as assessed by patient satisfaction.

SUMMARY OF BACKGROUND DATA

The transpedicular wedge resection osteotomy is a well-established procedure for management of fixed sagittal deformity in ankylosing spondylitis. The utility of the procedure for applications in fixed deformity other than ankylosing spondylitis has not been demonstrated, and the efficacy of the procedure in the correction of coronal deformity has not been reported.

METHODS

A total of 13 consecutive cases undergoing transpedicular wedge resection osteotomy for the management of sagittal deformity of any etiology were reviewed. Radiographic studies, complications, and satisfaction assessment using the modified Scoliosis Research Society instrument were the outcome parameters measured.

RESULTS

Etiologies of deformity included postsurgical, ankylosing spondylitis, idiopathic, and infectious. Measurement of C7 sagittal plumb line to sacrum improved 63% at the most recent follow-up. Lumbar lordosis increased from -15.5 degrees to -45.4 degrees. Coronal balance was improved in all patients who had preoperative imbalance, with an average improvement of 60% maintained at follow-up. Patient satisfaction was high in all patients and not dependent on the etiology of deformity.

CONCLUSIONS

The transpedicular wedge resection osteotomy is an effective procedure for the management of fixed sagittal deformity and is generalizable for multiple etiologies. Simultaneous correction of coronal deformity is possible. The clinical value of the procedure is demonstrated in high rates of patient satisfaction.

The effect of the primary structure of the polypeptide catalyst on the enantioselectivity of the Juliá-Colonna asymmetric epoxidation of enones

Epoxidation of chalcone (1), using basic hydrogen peroxide, catalysed by polypeptides with defined primary structures demonstrates that the residues in the chain near to the N-terminus determine the stereochemical outcome of the reaction.

Development of a simplified, sensitive high-performance liquid chromatographic method using fluorescence detection to determine the concentration of UCN-01 in human plasma

UCN-01 is a naturally derived anticancer agent isolated in the culture broth of actinomyces streptomyces. We have developed a sensitive high-performance liquid chromatographic method for the determination of UCN-01 in human plasma. UCN-01 was isolated from human plasma after intravenous administration, by using 100% ice-cold acetonitrile liquid-liquid phase extraction. Liquid chromatographic separation was achieved by isocratic elution on a phenyl analytical column. The mobile phase consisted of acetonitrile-0.5 M ammonium acetate (45:55) with 0.2% triethylamine added as a modifier. The UCN-01 peak was identified from other peaks using fluorescence excitation energy and emission energy wavelengths of 310 and 410 nm, respectively. Retention time for UCN-01 was 4.2 +/- 0.5 min. The UCN-01 peak was baseline resolved, with nearest peak at 2.6 min distance. No interfering peaks were observed at the retention time of UCN-01. Peak area amounts from extracted samples were proportional over the dynamic concentration range used: 0.2 to 30 microg/ml. Mean recoveries of UCN-01 at concentrations of 0.5 and 25 microg/ml were 89 and 90.2%, respectively. Relative standard deviations for UCN-01 calibration standards ranged from 1.89 to 2.31%, with relative errors ranging from 0.3 to 11.6%. Assay precision for UCN-01 based on quality control samples of 0.50 microg/ml was +/- 4.86% with an accuracy of +/-5.7%. For drug extracted from plasma the lowest limit of detection was 0.1 microg/ml, with the lowest limit of quantitation being 0.2 microg/ml. This method is suitable for routine analysis of UCN-01 in human plasma at concentration from 0.2 to 30 microg/ml.

Relations between medical history, clinical findings and plasma N-terminal proatrial natriuretic peptide in patients in primary health care

BACKGROUND

recent studies indicate that measurement of natriuretic peptides may be a valuable tool to improve the quality of the diagnosis of heart failure in general practice.

AIM

the aim of the present study was to examine the relationship between the plasma level of the natriuretic peptide N-terminal proANP and symptoms and signs of heart failure in patients from general practice in the Oslo area.

METHODS AND RESULTS

we undertook a survey of 499 patients consecutively enrolled from the practice of 27 practitioners. One hundred and twenty-nine patients were classified as having possible or some degree of heart failure. The plasma concentration of N-terminal proANP increased with severity of heart failure as judged from clinical examination. In multivariate analysis age, history of heart disease, plasma creatinine, use of beta-blockers and digitalis, oedemas and atrial fibrillation were the main determinants of plasma N-terminal proANP.

CONCLUSION

while there was an overall increase in N-terminal proANP values with increasing symptoms and degree of heart failure, no single finding was closely related to N-terminal proANP. Treatment effects and diagnostic errors may both influence the relationship between N-terminal proANP and clinical findings. The current study has demonstrated the feasibility of using N-terminal proANP by general practitioners for the potentially improved diagnosis of heart failure. Further research is required to determine the precise role of this assay in clinical practice.

A phase I and pharmacologic study of 9-aminocamptothecin administered as a 120-h infusion weekly to adult cancer patients

PURPOSE

To define the toxicity profile and the recommended phase II doses of 9-aminocamptothecin (9-AC) administered as a weekly 120-h infusion.

METHODS

9-AC was administered over 120 h weekly to 55 adult cancer patients with solid tumors over doses ranging from 0.41 to 0.77 mg/m2 per day in a phase I and pharmacologic study. 9-AC formulated in dimethylacetamide/polyethylene glycol (DMA) was administered on a 3 of 4-week schedule, and the newer colloidal dispersion (CD) formulation was given on a 2 of 3-week schedule.

RESULTS

Overall, 193 courses of therapy were administered over 122 dose levels. On the 3 of 4-week schedule, 9-AC DMA infused at > or = 0.6 mg/m2 per day for 120 h weekly produced dose-limiting neutropenia, thrombocytopenia, and diarrhea, or resulted in 1-2-week treatment delays. Shortening treatments to 2 of 3 weeks resulted in dose-limiting neutropenia and fatigue at infusion rates > 0.72 mg/m2 per day. The ratio of 9-AC lactone to total (carboxylate + lactone) drug plasma concentrations at steady-state was 0.15 +/- 0.07. Clinical toxicities and drug pharmacokinetics were not substantially different between the DMA and CD formulations. One objective response was observed in a patient with bladder cancer and minor responses were observed in patients with lung and colon cancers. Plasma area under the concentration versus time curve for 9-AC lactone modestly correlated with the degree of thrombocytopenia (r=0.51) using a sigmoid Emax pharmacodynamic model.

CONCLUSION

The recommended phase II dose for the 9-AC DMA formulation is 0.48 mg/m2 per h over 120 h for 3 of 4 weeks and for the 9-AC CD formulation is 0.6 mg/m2 per day over 120 h for 2 of 3 weeks. Both regimens were well tolerated and feasible to administer.

Common discriminative stimulus properties in rats of muscarinic antagonists, clozapine and the D3 preferring antagonist PNU-99194a: an analysis of possible mechanisms

Dopamine D3 receptors have been implicated in the aetiology of schizophrenia and the actions of antipsychotic drugs. The initial studies reported here assessed the involvement of such receptors in the in vivo actions of the atypical antipsychotic clozapine and the putative D3-preferring antagonist PNU-99194A in drug discrimination assays. Rats trained to discriminate clozapine consistently generalized to PNU-99194A in two separate studies. However, four other putative D3-preferring antagonists (PD 152255, (+)-S14297, nafadotride and (+)-AJ 76) did not induce generalization to clozapine. In rats trained to discriminate PNU-99194A, which has been suggested to induce a stimulus mediated specifically by D3 antagonism, the D3-preferring antagonist (+)-UH 232 and clozapine both induced full generalization. However, the PNU-99194A-trained animals also generalized fully to the muscarinic antagonists scopolamine and trihexyphenidyl. A possible explanation for the symmetrical generalization observed between clozapine and PNU-99194A is that these drugs have common muscarinic antagonist actions, since muscarinic antagonists have been reported to substitute for clozapine in numerous prior studies. However, in vitro receptor binding studies with M1-M5 receptors indicated that (with the possible exception of the M4 receptor), no muscarinic receptor subtype had high affinity for both clozapine, PNU-99194A and scopolamine. In addition, other binding studies indicated that whereas clozapine and PNU-99194A had high affinity for the D3 receptor, scopolamine did not. It is therefore concluded that: (1) The generalization seen between clozapine, PNU-99194A and muscarinic antagonists may be mediated by common effects 'downstream' from either muscarinic or D3 receptors; (2) D3 antagonism does not play a critical role in the clozapine stimulus (since D3-preferring antagonists did not consistently induce generalization to clozapine); (3) although D3 antagonism plays a role in the PNU-91994A stimulus (since the D3-preferring antagonist (+)-UH 232 induced full generalization, in accord with results from prior studies with other D3-preferring antagonists, the PNU-99194A stimulus also has commonalities with that induced by muscarinic antagonists and clozapine. The in vivo differences observed between PNU-99194A and other D3-preferring antagonists should be borne in mind when this agent is used as a tool to study D3 receptor functioning in vivo. The similarities between the PNU-99194A and clozapine stimuli suggest tentatively that compounds with a profile like PNU-99194A may have antipsychotic actions similar to clozapine. Some preclinical data are suggestive of such effects of PNU-99194A.

Radical cystectomy is safe in elderly patients at high risk

PURPOSE

Radical cystectomy is standard treatment for bladder cancer in healthy individuals. We determined the safety of radical cystectomy in elderly patients at high risk.

MATERIALS AND METHODS

We reviewed the records of all patients who underwent radical cystectomy at our institution between January 1994 and June 2000. Of these 382 patients we identified 44 who were elderly and at high risk, as defined by age 75 years or greater and American Society of Anesthesiologists classification 3 or greater. We examined postoperative care, perioperative minor/major complications, the mortality rate and the need for rehospitalization.

RESULTS

Median age of the 44 patients was 77.5 years (range 75 to 87). American Society of Anesthesiologists class was 3 in 40 patients and 4 in 4. Median hospitalization was 7 days (range 4 to 20). Postoperatively 31 of the 44 patients (70%) were transferred directly to the general urology floor, while cardiac monitoring was required postoperatively in 30%. Nine of these patients were transferred to a step-down unit and the remaining 4 required surgical intensive care unit admission. Minor and major complications developed in 10 (22.7%) and 2 (4.5%) cases, respectively. No patients died in the perioperative period and 4 patients were hospitalized within 6 months of discharge home.

CONCLUSIONS

Our results support the safety of radical cystectomy in elderly patients at high risk. Acceptable perioperative morbidity and mortality may be achieved without routine intensive monitoring postoperatively.

Inhibition of export of fibroblast growth factor-2 (FGF-2) from the prostate cancer cell lines PC3 and DU145 by Anvirzel and its cardiac glycoside component, oleandrin

Anvirzel is an extract of Nerium oleander currently undergoing Phase I clinical evaluation as a potential treatment for cancer. Two of the active components of Anvirzel are the cardiac glycosides oleandrin and oleandrigenin. Previous studies have demonstrated that, in vitro, cardiac glycosides may inhibit fibroblast growth factor-2 (FGF-2) export through membrane interaction with the Na(+),K(+)-ATPase pump. In continuing research on the antitumor activity of this novel plant extract, the relative abilities of oleandrin and oleandrigenin to inhibit FGF-2 export from two human prostate cancer cell lines, DU145 and PC3, were examined. An ELISA assay was utilized to determine the FGF-2 concentration in the cell culture medium before and after exposure to cardiac glycosides or the parent extract material Anvirzel. Both cell lines were exposed to non-cytotoxic concentrations of oleandrin (0.05 and 0.1 ng/mL) for up to 72 hr. Studies also were conducted with Anvirzel and ouabain. Oleandrin (0.1 ng/mL) produced a 45.7% inhibition of FGF-2 release from PC3 cells and a 49.9% inhibition from DU145 cells. Non-cytotoxic concentrations (100 ng/mL) of Anvirzel produced a 51.9 and 30.8% inhibition of FGF-2 release, respectively, in the two cell lines. The decrease in FGF-2 release from cells required continuous incubation for 48--72 hr; shorter incubation times were not effective. These results demonstrate that Anvirzel, like oleandrin, inhibited FGF-2 export in vitro from PC3 and DU145 prostate cancer cells in a concentration- and time-dependent fashion and may, therefore, contribute to the antitumor activity of this novel treatment for cancer.

Development of a high-performance liquid chromatographic method to determine the concentration of karenitecin, a novel highly lipophilic camptothecin derivative, in human plasma and urine

Karenitecin is a novel, highly lipophilic camptothecin derivative with potent anticancer potential. We have developed a sensitive high-performance liquid chromatographic method for the determination of karenitecin concentration in human plasma and urine. Karenitecin was isolated from human plasma and urine using solid-phase extraction. Separation was achieved by gradient elution, using a water and acetonitrile mobile phase, on an ODS analytical column. Karenitecin was detected using fluorescence detection at excitation and emission wavelengths of 370 and 490 nm, respectively. Retention time for karenitecin was 16.2 +/- 0.5 min and 8.0 +/- 0.2 min for camptothecin, the internal standard. The karenitecin peak was baseline resolved, with the nearest peak at 3.1 min distance. Using normal volunteer plasma and urine from multiple individuals, as well as samples from the 50 patients analyzed to date, no interfering peaks were detected. Inter- and intra-day coefficients of variance were <4.4 and 7.1% for plasma and <4.9 and 11.6% for urine. Assay precision, based on an extracted karenitecin standard plasma sample of 2.5 ng/ml, was +4.46% with a mean accuracy of 92.4%. For extracted karenitecin standard urine samples of 2.5 ng/ml assay precision was +2.35% with a mean accuracy of 99.5%. The mean recovery of karenitecin, at plasma concentrations of 1.0 and 50 ng/ml, was 81.9 and 87.8% respectively. In urine, at concentrations of 1.5 and 50 ng/ml, the mean recoveries were 90.3 and 78.4% respectively. The lower limit of detection (LLD) for karenitecin was 0.5 ng/ml in plasma and 1.0 ng/ml in urine. The lower limit of quantification (LLQ) for karenitecin was 1 ng/ml and 1.5 ng/ml for plasma and urine, respectively. Stability studies indicate that when frozen at -70 degrees C, karenitecin is stable in human plasma for up to 3 months and in human urine for up to 1 month. This method is useful for the quantification of karenitecin in plasma and urine samples for clinical pharmacology studies in patients receiving this agent in clinical trials.

Clinical under staging of high risk nonmuscle invasive urothelial carcinoma treated with radical cystectomy

PURPOSE

The role of radical cystectomy in patients with nonmuscle invasive urothelial carcinoma of the bladder remains controversial. The risk of overtreatment must be balanced against the potential benefit of aggressive therapy. We reviewed our results in these patients with a particular emphasis on clinical under staging.

MATERIALS AND METHODS

We reviewed the records of 214 consecutive patients who underwent radical cystectomy for urothelial carcinoma between April 1995 and August 1999, focusing on those with nonmuscle invasive, stages T1 or less disease. We assessed clinical and pathological data as well as outcomes based on pathological disease extent.

RESULTS

A total of 78 patients (36%) underwent radical cystectomy for clinical stages T1 or less disease. Indications included disease refractory to intravesical therapy in 29 cases (37%), pathological findings reflective of high grade stage T1 or multifocal disease in 26 (33%), radiographic suspicion of invasive disease in 15 (20%) and severe symptoms in 8 (10%). Cancer was clinically under staged with stages pT2 or greater disease in 31 patients (40%) according to final pathology results. Under staging was most pronounced in the 10 patients (67%) with suspicious radiography and in the 18 (64%) with absent muscle in the biopsy specimen. Of the 78 patients with pathological stages pT1 disease or less 98% had no evidence of disease compared to 65% with stages pT2 or greater disease (p <0.01).

CONCLUSIONS

Despite the intent to perform early cystectomy a significant percent of patients harbored occult muscle invasive and/or metastatic disease. In clinical and pathological, superficial stages T1 or less cases disease-free survival was excellent. Due to these results, the selection of high risk superficial transitional cell carcinoma cases for continued bladder sparing treatment should include uninvolved muscle on biopsy and absent radiographic suspicion of invasion.

Increased acid-sensing ion channel ASIC-3 in inflamed human intestine

OBJECTIVES

Acid-sensing ion channels (ASICs) are expressed by rat sensory neurons and may mediate pain associated with tissue acidosis after inflammation or injury. Our aim was to examine the molecular forms and localization of ASICs in human intestine and dorsal root ganglia using immunochemical techniques, and to measure the effects of inflammation and injury.

DESIGN AND METHODS

Inflamed Crohn's disease intestine and injured human dorsal root ganglia, with appropriate controls, were studied by Western blotting and immunohistochemistry, using specific affinity-purified ASIC antibodies.

RESULTS

In the Western blot, there was a significant three-fold increase in the mean relative optical density of the ASIC-3 55-kDa band (but not ASIC-1 or ASIC-2) in full-thickness inflamed intestine, as well as in separated muscle and mucosal layers. There was a corresponding trend for an increased immunoreactive density and increased number of ASIC-3-positive neurons in the myenteric and sub-mucous plexus of inflamed intestine. In dorsal root ganglia, immunoreactivity for all ASICs was restricted to a sub-population (about 50%) of small-diameter (nociceptor) sensory neurons, and was generally less intense after injury.

CONCLUSIONS

Increased ASIC-3 in inflamed intestine suggests a role in pain or dysmotility, for which ASICs represent new therapeutic targets.

Nonprescription tinted eyewear optical accuracy study

BACKGROUND

Nonprescription tinted eyewear, commonly referred to as noncorrective sunglasses or plano sun eyewear, often induce measurable amounts of prismatic deviation. With high-wrap eyewear this effect becomes more pronounced. The purpose of this project was to assess the amount of horizontal and vertical prismatic deviation induced by some popular premium plano sun eyewear intended for use by athletes.

METHODS

Prismatic deviations for two identical pairs of high-wrap, steep base curve, plano sun eyewear from each of six prominent national brands were measured in both primary gaze and along a peripheral line of sight 30 degrees to the right of straight-ahead.

RESULTS

Most of the eyewear induced base-out and base-down prism in each lens in primary gaze. All eyewear induced base-in prism with temporal gaze and base-out prism with nasal gaze at 30 degrees laterally. Most eyewear induced base-down prism with lateral gaze as well.

CONCLUSIONS

Plano sun eyewear is often purchased for use in bright environments during visually demanding sports, such as golf, baseball, and volleyball. It is well-documented that athletes possess superior visual function as compared to nonathletes or lesser-level athletes. Further studies are indicated to determine the impact of this prism on the average wearer and the elite athlete.

Lung volume reduction surgery in emphysema: a systematic review

The aim of this study was to systematically review the literature regarding the safety and efficacy of lung volume reduction surgery (LVRS) in patients with emphysema. Studies on LVRS to August 2000 were identified using MEDLINE, Embase, Current Contents, and the Cochrane Library. Human studies of patients with upper, lower or diffuse distributions of emphysema were included. All types of bullous emphysema were excluded. A surgeon and researcher independently assessed the retrieved articles for their inclusion in the review. When LVRS was compared with medical management, at 2 years LVRS was associated with a higher FEV1 and at least equivalent survival. The use of staple excision of selected areas of lung appeared to be more efficacious than laser ablation. There is insufficient evidence to show preference for median sternotomy or videoscopically assisted thoracotomy, as the more safe and efficacious procedure. In highly selected patients with emphysema LVRS is deemed an acceptable treatment. To fully evaluate the safety and efficacy of LVRS, outcomes beyond 2 years must be included. The results of prospective randomized trials between medical management and LVRS, now in progress, are essential before a final assessment can be made.

Needs of carers of severely disabled people: are they identified and met adequately?

OBJECTIVE

To examine the unmet needs of informal carers of community dwelling disabled people and to compare their perspectives to those of disabled people and nominated professionals. It was hypothesised that a poor recognition of carers' needs could have implications for carers' well- being and thus their ability to maintain their caring role. Need was defined as a service or a resource that would confer a health or rehabilitation gain.

DESIGN

Face to face interviews with carers and disabled participants, telephone interviews with professionals (Southern England). Disabled participants had been selected randomly from two disability registers.

MAIN OUTCOME MEASURES

The Southampton Needs Assessment Questionnaire (carers version), SF-36 (carers' health status).

RESULTS

Carers experienced similar health status to people in the general population. The most frequently carer-reported unmet needs were for short breaks, domestic help and respite care. Carers who had reported unmet need for short breaks had significantly poorer levels of mental health and vitality (SF-36) than carers who had not reported this. Similar numbers of unmet carers' needs were reported by disabled participants, professionals and carers themselves. In terms of type of unmet needs, poor concordance between carers and disabled participants occurred in 52% of cases: carers reported more unmet needs than disabled participants for short breaks and domestic help. Poor concordance scores between carers and professionals occurred in 59% of cases: carers reported more unmet needs for short breaks than professionals and professionals reported more unmet needs for formal respite care.

CONCLUSION

In line with recent legislation, carers' needs must be independently addressed and services, especially for flexible community support such as short break services, must be developed specifically to meet the needs of carers. Further research is warranted to evaluate whether recent legislation for carers has any effect on carers' well-being and ability to cope with their caring role.

Activation of Toll-like receptor-2 by glycosylphosphatidylinositol anchors from a protozoan parasite

Glycosylphosphatidylinositol (GPI) anchors and glycoinositolphospholipids (GIPLs) from parasitic protozoa have been shown to exert a wide variety of effects on cells of the host innate immune system. However, the receptor(s) that are triggered by these protozoan glycolipids has not been identified. Here we present evidence that Trypanosoma cruzi-derived GPI anchors and GIPLs trigger CD25 expression on Chinese hamster ovary-K1 cells transfected with CD14 and Toll-like receptor-2 (TLR-2), but not wild-type (TLR-2-deficient) Chinese hamster ovary cells. The protozoan-derived GPI anchors and GIPLs containing alkylacylglycerol and saturated fatty acid chains or ceramide were found to be active in a concentration range of 100 nM to 1 microM. More importantly, the GPI anchors purified from T. cruzi trypomastigotes, which contain a longer glycan core and unsaturated fatty acids in the sn-2 position of the alkylacylglycerolipid component, triggered TLR-2 at subnanomolar concentrations. We performed experiments with macrophages from TLR-2 knockout and TLR-4 knockout mice, and found that TLR-2 expression appears to be essential for induction of IL-12, TNF-alpha, and NO by GPI anchors derived from T. cruzi trypomastigotes. Thus, highly purified GPI anchors from T. cruzi parasites are potent activators of TLR-2 from both mouse and human origin. The activation of TLR-2 may initiate host innate defense mechanisms and inflammatory response during protozoan infection, and may provide new strategies for immune intervention during protozoan infections.

Neuroprotective effects of pramipexole in young and aged MPTP-treated mice

This study examined the effect of pramipexole (PPX), a selective dopamine (DA) D(3)/D(2) agonist, on 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced damage to the nigrostriatal dopamine system in young (8-week-old) and aged (12-month-old) mice. Co-administration of PPX and MPTP to young or aged mice, followed by 2 or 14 days of additional PPX treatment, significantly attenuated MPTP-induced striatal DA loss. Pramipexole treatment also significantly attenuated the loss of tyrosine hydroxylase immunoreactive neurons (TH-IR) within the substantia nigra pars compacta (SNc) in both young and aged animals. Effects of PPX administration on dopaminergic cell survival were confirmed in Nissl-stained sections and by quantitation of retrogradely labeled Fluorogold-positive SNc neurons. Protective effects of PPX on striatal DA levels and SNc DA neuron survival were similar in young and aged animals, although the magnitude of these effects was significantly less in aged animals. These findings support the early initiation of PPX therapy in Parkinson's disease patients.

The impact of skin disease on the quality of life of adolescents

Though relatively well-investigated in adults, the impact of skin disease on the health-related quality of life (HRQL) of adolescents has only recently begun to be systematically evaluated. The primary goal of this article is to critically review previous research that has examined the relationship between HRQL and three types of skin disease commonly experienced by adolescents, namely acne vulgaris, alopecia areata, and atopic dermatitis. A secondary goal is to provide strategies to adolescent medicine physicians that will enable them to more effectively manage the psychological components of their patients dermatological conditions.

Laser treatment for invasive and noninvasive carcinoma of the bladder

Lasers are widely used in urologic surgery and have many well-developed applications. The use of lasers for the treatment of bladder cancer has been proven to be safe and minimally invasive. The neodymium:YAG laser is the most widely used instrument, although the holmium:YAG laser has also gained recent popularity. Noninvasive, small lesions are especially amenable to management with laser energy and have been treated with success rates that are at least as good as those of standard electrocautery resection. Complication rates are low. Laser therapy of invasive bladder cancer has significant limitations and should probably be restricted to stage T2 lesions.

Excision of hemivertebrae in the management of congenital scoliosis involving the thoracic and thoracolumbar spine

We present a study of ten consecutive patients who underwent excision of thoracic or thoracolumbar hemivertebrae for either angular deformity in the coronal plane, or both coronal and sagittal deformity. Vertebral excision was carried out anteriorly alone in two patients. Seven patients had undergone previous posterior spinal fusion. Their mean age at surgery was 13.4 years (6 to 19). The mean follow-up was 78.5 months (20 to 180). The results were evaluated by radiological review of the preoperative, postoperative and most recent follow-up films. The mean preoperative coronal curve was 78.2 degrees (30 to 115) and was corrected to 33.9 degrees (7 to 58) postoperatively, a mean correction of 59%. Preoperative coronal decompensation of 35 mm was improved to 11 mm postoperatively. Seven patients had significant coronal decompensation preoperatively, which was corrected to a physiological range postoperatively. There were no major complications and no neurological damage. We have shown that resection of thoracic and thoracolumbar hemivertebrae can be performed safely, without undue risk of neurological compromise, in experienced hands.

Disinhibition and expectancy in risk for alcohol use: comparing black and white college samples

OBJECTIVE

This study tested several predictions of the "acquired preparedness" model in both black and white samples of college students. The acquired preparedness model holds that trait disinhibition affects alcohol-related learning and, ultimately, alcohol use. This model maintains that the reward focus typical of disinhibited individuals increases the likelihood of forming overly positive expectancies about the effects of alcohol. Alcohol expectancy, then, acts as a mediator of the relationship of disinhibition and drinking behavior.

METHOD

Participants (N = 479, 341 women) were 279 white and 200 black college students. Self-reported alcohol expectancy, disinhibition and drinking behavior were assessed. Covariance structure analysis was used to test hypotheses separately for each sample, controlling for socioeconomic status.

RESULTS

Black participants scored significantly lower on disinhibition, expectancy and drinking. However, invariance testing indicated that the relationships between these variables were not different across groups. Results were consistent with the stated hypotheses in both samples--alcohol expectancy functioned as a mediator of the disinhibition-drinking relationship. Results did not differ across expectancy content.

CONCLUSIONS

These results provide support for the validity of the acquired preparedness model. Despite mean differences in risk and drinking levels between black and white samples, psychosocial learning appears to mediate the influence of disinhibition on drinking for both groups.

Column chromatography of antibodies and fragments

Since both size-exclusion (SE) chromatography (also known as gel filtration) and ion-exchange (IEX) chromatography are the fundamental methods on which antibody and fragment purifications are based, they are dealt with in detail in this appendix. The procedures for preparing the column matrix, for pouring the chromatography column, and for estimating the appropriate size of the column for the amount of antibody and fragment that are to be purified are all described.

Vascular response of the meniscus to injury: effects of immobilization

Failed meniscal healing may lead to degenerative osteoarthritis of the knee. Healing is thought to be dependent upon an adequate blood supply, yet "normal" vascular changes during healing are not well understood. In this study we have quantified vasoactive and angiogenic responses to medial meniscal injury in a rabbit model under clinically relevant conditions, and related these to histological criteria of healing. Twenty-six adult rabbits were given a standardized meniscal injury; 12 of these had the hind limb immobilized by pinning. Eight normal controls and 12 sham-operated animals were also studied. After 4 weeks, animals underwent either vascular volume (vascular index) determination, or blood flow measurement using coloured microspheres. Histological analysis was also performed to assess meniscal healing. In injured animals, blood flow to the menisci was increased fivefold 4 weeks post-operative; this increase was prevented by immobilization. The vascular index of the menisci was also increased threefold by injury, but not significantly reduced by immobilization. Histological examination of injured menisci showed examples of healing and non-healing tears in both mobile and immobile groups. Meniscal injuries are associated with characteristic changes in vascularity and perfusion, and these changes likely play a significant role in the healing process. Characterization of the vascular responses to meniscal injury may lead to techniques that can promote reliable healing of meniscal tears and thereby improve clinical outcomes.

Observation of exotic meson production in the reaction pi- p --> eta'pi- p at 18 GeV/c

An amplitude analysis of an exclusive sample of 5765 events from the reaction pi- p-->eta'pi- p at 18 GeV/c is described. The eta'pi- production is dominated by natural parity exchange and by three partial waves: those with J(PC) = 1(-+), 2(++), and 4(++). A mass-dependent analysis of the partial-wave amplitudes indicates the production of the a2(1320) meson as well as the a4(2040) meson, observed for the first time decaying to eta'pi-. The dominant, exotic (non- qq) 1(-+) partial wave is shown to be resonant with a mass of 1.597+/-0.010(+0.045)(-0.010) GeV/c2 and a width of 0.340+/-0.040+/-0.050 GeV/c2. This exotic state, the pi1(1600), is produced with a t dependence which is different from that of the a2(1320) meson, indicating differences between the production mechanisms for the two states.

Separation of human immunodeficiency virus type 1 replication from nef-mediated pathogenesis in the human thymus

Human immunodeficiency virus type 1 (HIV-1) is frequently attenuated after long-term culture in vitro. The attenuation process probably involves mutations of functions required for replication and pathogenicity in vivo. Analysis of attenuated HIV-1 for replication and pathogenicity in vivo will help to define these functions. In this study, we examined the pathogenicity of an attenuated HIV-1 isolate in a laboratory worker accidentally exposed to a laboratory-adapted HIV-1 isolate. Using heterochimeric SCID-hu Thy/Liv mice as an in vivo model, we previously defined HIV-1 env determinants (HXB/LW) that reverted to replicate in vivo (L. Su, H. Kaneshima, M. L. Bonyhadi, R. Lee, J. Auten, A. Wolf, B. Du, L. Rabin, B. H. Hahn, E. Terwilliger, and J. M. McCune, Virology 227:46-52, 1997). Here we further demonstrate that HIV-1 replication in vivo can be separated from its pathogenic activity, in that the HXB/LW virus replicated to high levels in SCID-hu Thy/Liv mice, with no significant thymocyte depletion. Restoration of the nef gene in the recombinant HXB/LW genome restored its pathogenic activity, with no significant effect on HIV-1 replication in the thymus. Our results suggest that in vitro-attenuated HIV-1 lacks determinants for pathogenicity as well as for replication in vivo. Our data indicate that (i) the replication defect can be recovered in vivo by mutations in the env gene, without an associated pathogenic phenotype, and (ii) nef can function in the HXB/LW clone as a pathogenic factor that does not enhance HIV-1 replication in the thymus. Furthermore, the HXB/LW virus may be used to study mechanisms of HIV-1 nef-mediated pathogenesis in vivo.

Effect of androgen deprivation therapy on local symptoms and tumour progression in men with metastatic carcinoma of the prostate

OBJECTIVE

To evaluate and compare the effects of medical or surgical castration combined with either nilutamide (Anandron) or placebo on symptoms of local tumour progression in men with carcinoma of the prostate.

METHODS

The results from twin, randomised, prospective, placebo-controlled trials were analysed. 434 patients received nilutamide 300 mg/day for 1 month and 150 mg thereafter, and 434 received a matched placebo from either the day of orchidectomy or the first leuprolide injection. Before treatment, and at months 1, 3, 6 and every 6 months thereafter, urinary obstruction and tumour volume were evaluated. Data on adverse or intercurrent events affecting the urological system were documented.

RESULTS

Before treatment, urinary obstructive symptoms and tumour volume were similar in both treatment groups. After treatment, improvement in urinary obstructive symptoms accompanied a decrease in prostate volume. The majority of men in both treatment groups reported an improvement in obstructive voiding symptoms. However, total adverse events secondary to local symptoms were significantly less frequent in the nilutamide-treated patients (20%) compared with the placebo-treated patients (35%). Only a small percentage of men in both treatment groups had disabling local symptoms and only 2% experienced problems with incontinence.

CONCLUSIONS

Local symptoms from primary tumour growth are relatively common in patients with metastatic carcinoma of the prostate and are favourably influenced by hormonal therapy. In these trials, the problems resulting from local tumour progression were significantly fewer in the group treated with castration plus nilutamide compared with the group treated with castration plus placebo.

Results of radical prostatectomy in men with locally advanced prostate cancer: multi-institutional pooled analysis

OBJECTIVE

We investigated the disease-specific and metastasis-free survival rates in men with locally advanced (clinical stage T3) prostate cancer who were treated surgically.

METHODS

A retrospective, multi-institutional pooled analysis of the results of surgical treatment in 345 men with clinical stage T3 disease was performed. Survival curves were generated using the Kaplan-Meier method.

RESULTS

Among 298 evaluable patients, pelvic lymphadenectomy alone was performed in 56 men (19%), while 242 men (81%) underwent node dissection and radical prostatectomy. In total, 122 of 298 patients (41%) had nodal metastases and/or seminal vesicle tumor spread. Pathologically organ-confined disease was noted in 27 men (9%). The actuarial 10-year disease-specific and metastasis-free survival rates for all patients managed surgically were 57 and 32%, respectively. For patients with well, moderately and poorly differentiated tumors, cancer-specific survival rates at 10 years were 73, 67 and 29%, respectively.

CONCLUSIONS

A large number of men with clinical stage T3 prostate cancer have advanced disease and are unlikely to achieve improved long-term survival with surgery alone. Although there may be a role for radical prostatectomy in selected patients with low to intermediate grade tumors, such treatment appears unlikely to result in long-term survival in men with high grade disease. A prospective study is necessary to determine the optimal treatment approach in men with locally advanced prostate cancer.

Fibrous contracture of muscles following intramuscular injections in adults

Periarticular fibrous muscle contractures in adults from repeated injections in the same site is predictable. The causes of joint contracture in children are many and complex, but in adults it seems certain that this phenomenon is the result of repeated injections of analgesics or other agents into 1 muscle area. Any drug if repeatedly injected locally may cause fibrosis of the muscle and subsequent joint contracture. Five cases of bilateral abduction contracture of the shoulder in adults including the first case of bilateral abduction contractures of shoulder and hip plus bilateral flexion contracture of elbow and extension contracture of a knee are reported. No underlying disease which might predispose to this fibrosis of muscles was noted. The frequency and period of injections were variable over several years. In all patients the interference in activtities of daily living were serious, but the deformities were corrected by release of the fibrous band with relief of discomfort and restoration of joint motion without recurrence. Noting the potential complication of repeated intramuscular injections in one area, this practice should be avoided whenever possible in adults, as well as in children.

Differential effects of a Toll-like receptor antagonist on Mycobacterium tuberculosis-induced macrophage responses

We previously showed that viable Mycobacterium tuberculosis (Mtb) bacilli contain distinct ligands that activate cells via the mammalian Toll-like receptor (TLR) proteins TLR2 and TLR4. We now demonstrate that expression of a dominant negative TLR2 or TLR4 proteins in RAW 264.7 macrophages partially blocked Mtb-induced NF-kappa B activation. Coexpression of both dominant negative proteins blocked virtually all Mtb-induced NF-kappa B activation. The role of the TLR4 coreceptor MD-2 was also examined. Unlike LPS, Mtb-induced macrophage activation was not augmented by overexpression of ectopic MD-2. Moreover, cells expressing an LPS-unresponsive MD-2 mutant responded normally to Mtb. We also observed that the lipid A-like antagonist E5531 specifically inhibited TLR4-dependent Mtb-induced cellular responses. E5531 could substantially block LPS- and Mtb-induced TNF-alpha production in both RAW 264.7 cells and primary human alveolar macrophages (AM phi). E5531 inhibited Mtb-induced AM phi apoptosis in vitro, an effect that was a consequence of the inhibition of TNF-alpha production by E5531. In contrast, E5531 did not inhibit Mtb-induced NO production in RAW 264.7 cells and AM phi. Mtb-stimulated peritoneal macrophages from TLR2- and TLR4-deficient animals produced similar amounts of NO compared with control animals, demonstrating that these TLR proteins are not required for Mtb-induced NO production. Lastly, we demonstrated that a dominant negative MyD88 mutant could block Mtb-induced activation of the TNF-alpha promoter, but not the inducible NO synthase promoter, in murine macrophages. Together, these data suggest that Mtb-induced TNF-alpha production is largely dependent on TLR signaling. In contrast, Mtb-induced NO production may be either TLR independent or mediated by TLR proteins in a MyD88-independent manner.

Conjunctival T-cell lymphoma caused by human T-cell lymphotrophic virus infection

PURPOSE

To examine the cause of adult T-cell leukemia/lymphoma.

METHODS

We examined a conjunctival biopsy from a 29-year-old Jamaican man who developed bilateral conjunctival masses. Adult T-cell leukemia/lymphoma was diagnosed using routine histology, immunohistochemistry, electron microscopy, microdissection, and the polymerase chain reaction.

RESULTS

Histopathologic examination revealed a conjunctival lymphoma. Clonality of the T-cell receptor gamma gene and human T-cell lymphotrophic virus gag gene were detected in the malignant cells. The demonstration of the human T-cell lymphotrophic virus gene and the rearrangement of the T-cell receptor gene in this neoplasm provide proof that human T-cell lymphotrophic virus is the cause of this conjunctival T-cell lymphoma.

CONCLUSION

Human T-cell lymphotrophic virus is the cause of adult T-cell leukemia/lymphoma, an aggressive malignancy of CD4+ lymphocytes.

Frosted branch angiitis in a child with HIV infection

PURPOSE

In adults with human immunodeficiency virus (HIV) infection, frosted branch angiitis is commonly associated with cytomegalovirus retinitis and responds to anti-cytomegalovirus therapy. We describe the first pediatric case of HIV-associated frosted branch angiitis.

METHODS

Case report.

RESULTS

A 7-year-old HIV-infected male with frosted branch angiitis was refractory to induction doses of intravenous ganciclovir and foscarnet over a 2-month period. Although cytomegalovirus antigenemia resolved, the angiitis only improved after subsequent treatment with systemic corticosteroids.

CONCLUSION

Frosted branch angiitis in this patient was not attributed to cytomegalovirus. The pathogenesis of HIV-associated frosted branch angiitis may differ between children and adults.

New corneal findings in human T-cell lymphotrophic virus type 1 infection

PURPOSE

Human T-cell lymphotrophic virus type 1 is a RNA retrovirus that primarily affects CD4+ T-cells. Human T-cell lymphotrophic virus type 1 infection is the established cause of adult T-cell leukemia/lymphoma, an aggressive malignancy of CD4+ T-cells, and two nonneoplastic conditions: human T-cell lymphotrophic virus type 1-associated myelopathy/tropical spastic paraparesis and human T-cell lymphotrophic virus type 1 uveitis. Other reported ophthalmic manifestations of human T-cell lymphotrophic virus type 1 infection include lymphomatous and leukemic infiltrates in the eye and ocular adnexa in patients with adult T-cell leukemia/lymphoma, retinal pigmentary degeneration, and neuro-ophthalmic disorders in patients with human T-cell lymphotrophic virus type 1-associated myelopathy/tropical spastic paraparesis and keratoconjunctivitis sicca, episcleritis, and sclerouveitis in asymptomatic human T-cell lymphotrophic virus type 1 carriers. This report describes the ocular findings in three Jamaican patients with human T-cell lymphotrophic virus type 1 infection and adult T-cell leukemia/lymphoma.

METHODS

The clinical records of three patients with human T-cell lymphotrophic virus type 1 infection and adult T-cell leukemia/lymphoma examined at the National Eye Institute were reviewed. Each patient had one or more complete ophthalmic evaluations.

RESULTS

All three patients had corneal abnormalities, including corneal haze and central opacities with thinning; bilateral immunoprotein keratopathy; and peripheral corneal thinning, scarring, and neovascularization. All three patients had elevated serum immunoglobulin levels.

CONCLUSIONS

We believe that the novel corneal findings in these patients are most likely a consequence of the hypergammaglobulinemia induced by the human T-cell lymphotrophic virus type 1 infection or the T-cell malignancy.

Ratio of free-to-total prostate specific antigen correlates with tumor volume in patients with increased prostate specific antigen

PURPOSE

We evaluated the relationship between the ratio of free-to-total prostate specific antigen (PSA) and prostate pathology, including grade, stage and tumor volume, among patients with prostate cancer who underwent radical prostatectomy.

MATERIALS AND METHODS

We prospectively analyzed 54 consecutive patients with prostate cancer who underwent radical prostatectomy and in whom frozen serum was available for assessment of free-to-total PSA ratio. Pathological review was done with whole mount sections, and total tumor volume was determined by planimetry. Comparison between free-to-total PSA ratio and pathological parameters was performed using the Pearson correlation coefficient.

RESULTS

Among the 54 patients mean total and free-to-total PSA ratio were 5.81 and 14.2 ng./ml., respectively, and free-to-total PSA ratio directly correlated with prostate volume (p = 0.037), and inversely correlated with Gleason score (p = 0.012) and extracapsular disease (p = 0.0074). Furthermore, there was a significant relationship between free-to-total PSA ratio and pathological stage pT2a/b in 39 cases versus pT3a/b in 15 (p = 0.005). Overall, there was no correlation between free-to-total PSA ratio and tumor volume. However, among 37 patients with an increased PSA, defined as greater than 4.0 ng./ml., a significant inverse relationship between free-to-total PSA ratio and tumor volume was identified (p = 0.01). Among this subset there was only a weak correlation with prostate volume (p = 0.049).

CONCLUSIONS

Our findings suggest that free-to-total PSA ratio may be predictive of tumor biology among those patients with a total PSA of greater than 4 ng./ml. as evidenced by good correlation with tumor grade and volume. This finding appears to be independent of prostate volume. These preliminary results suggest the need for additional studies among patients with an increased PSA designed to evaluate the potential role of free-to-total PSA ratio in combination with traditional clinical variables in the prediction of prostate cancer pathology.

Adenocarcinoma of the uterine cervix compared with squamous cell carcinoma: a 12-year study in Southampton and South-west Hampshire

In a 12-year study of the population of Southampton and South-west Hampshire (SSWH), there was no rise or fall in the incidence of adenocarcinoma of the uterine cervix, although the incidence of squamous cell carcinoma fell from 14 to 7.2 per 100000 women years and the overall fall in age-adjusted incidence of cervical carcinoma was commensurate with that of England and Wales. The majority (59%) of adenocarcinomas were seen in women aged less than 50, supporting the concept of a higher risk in young women. Screen-detected carcinomas accounted for 50% of adenocarcinomas and 41% of squamous cell carcinomas in women aged 20-64 (the difference was not significant). There were more screen-detected adenocarcinomas of less than 3 mm depth of invasion and 7 mm lateral extension during the third period of the study (1991-1993). The results are consistent with reports of an increased risk of cervical cancer in women born since 1940, and lesser effectiveness of screening in preventing adenocarcinoma compared with squamous cell carcinoma. High prevalence of early screen-detected carcinomas may have been a factor in recent reports of increased incidence of adenocarcinoma.

Intestinal disaccharidase deficiency without villous atrophy may represent early celiac disease

BACKGROUND

Intestinal disaccharidase activities are decreased in untreated celiac disease and also in other conditions without villous atrophy. Of 908 patients examined for suspected malabsorption, 37 (4.1%) had generalized disaccharidase deficiency without villous atrophy. The aim was to determine if generalized disaccharidase deficiency without villous atrophy represented latent celiac disease.

METHODS

Case notes and histology of the 37 patients were reviewed. History and blood investigations including antigliadin and endomysial antibodies were checked. Where celiac disease was suspected, endoscopic duodenal biopsies for histology and disaccharidase estimation were repeated.

RESULTS

Of the initial 37 patients, 6 patients had had repeat endoscopic biopsies; one having celiac disease. A further 18 patients were reviewed. The remainder declined further investigation. Eight had repeat endoscopic duodenal biopsies; one had celiac disease. Two with positive celiac serology also had enteroscopy with jejunal biopsies; both had celiac disease.

CONCLUSIONS

At least 11% of patients with generalized disaccharidase deficiency without villous atrophy develop celiac disease. Enteroscopic biopsies from distal duodenum and proximal jejunum should be considered as the next investigation if endomysial or antigliadin antibodies are positive.

Immunolocalisation of adenosine A(1) receptors in the rat kidney

The location of adenosine A(1) receptors in the rat kidney was investigated using immunolabelling with antibodies raised to a 15-amino-acid sequence near the C-terminus of the receptor (antibody I) and to a 14-amino-acid sequence in the second extracellular loop (antibody II). In the cortex, antibody I bound to adenosine A(1) receptors in mesangial cells and afferent arterioles, whilst antibody II bound to receptors in proximal convoluted tubules. In the medulla, both antibodies bound to receptors in collecting ducts and the papillary surface epithelium. These observations provide support for the diverse functional roles previously proposed for the adenosine A(1) receptor in the kidney. The labelling of distinct but different structures in the cortex by antibodies raised to different amino acid sequences on the A(1) receptor protein suggests that differing forms of the receptor are present in this region of the kidney.

Developing performance indicators for cardiac surgery: A demonstration project in Victoria

Six Victorian cardiac surgical units pooled data in order to undertake a demonstration project aimed at developing performance indicators to assess outcomes following cardiac surgery. The outcome of the project was an indicative report for the purpose of monitoring surgical performance indicators in a format suitable for: (i) the general public; (ii) the Victorian State Government; and (iii) the participating units and surgeons. Each participating cardiac surgical unit had an existing database used for recording information from each procedure. A request was made to each unit to extract a subset of data from all cases entered over the past 5 years. The proposed list of performance indicators included surgical mortality (within the period of admission for surgery), complication rates (including sternal infection, postoperative myocardial infarction, postoperative stroke, haemorrhage requiring return to theatre), and length of hospital stay. A model was developed from the data and used to provide risk-adjusted measures of hospital performance. Cases from five cardiac surgical units (n = 10 715) were included in the final analysis. A risk-adjusted model (including age, sex, diabetes, hypertension, smoking, procedure type, urgency of procedure) was developed for surgical mortality. Performance indicators for coronary artery bypass graft surgery, including mortality, sternal infection rate and length of hospital stay are presented. From the available data, performance indicators for cardiac surgery in Victorian hospitals compared favourably with international benchmarks. This project has demonstrated that prospective data collection using a standardised system could readily produce local risk-adjustment models for cardiac surgery to aid in developing appropriate performance indicators.

The feasibility of remote-controlled assistance as a search tool for patient education

Patients often desire more information about their conditions than they receive during a physician office visit. To address the patient's information needs, a touchscreen information kiosk was implemented. Results from the first prototype identified interface, security, and technical issues. Misspelling of search terms was identified as the most observable cause of search failure. An experimental remote control assistance feature was added in the second prototype. The feature allowed a medical librarian to provide real-time remote help during searches by taking control of the patient's computer. Remote assistance improved patient satisfaction, increased ease of use, and raised document retrieval rate (86.7% vs. 56.7%). Both patients and librarians found the application useful. Reasons included its convenience and flexibility, opportunity for direct patient contact, ability to teach through direct demonstration, and complementing the librarian's role as an information gateway. The project demonstrated the feasibility of applying remote control technology to patient education.

Bone-targeted Src SH2 inhibitors block Src cellular activity and osteoclast-mediated resorption

Src, a nonreceptor tyrosine kinase, is an important regulator of osteoclast-mediated resorption. We have investigated whether compounds that bind to the Src SH2 domain inhibit Src activity in cells and decrease osteoclast-mediated resorption. Compounds were examined for binding to the Src SH2 domain in vitro using a fluorescence polarization binding assay. Experiments were carried out with compounds demonstrating in vitro binding activity (nmol/L range) to determine if they inhibit Src SH2 binding and Src function in cells, demonstrate blockade of Src signaling, and lack cellular toxicity. Cell-based assays included: (1) a mammalian two-hybrid assay; (2) morphological reversion and growth inhibition of cSrcY527F-transformed cells; and (3) inhibition of cortactin phosphorylation in csk-/- cells. The Src SH2 binding compounds inhibit Src activity in all three of these mechanism-based assays. The compounds described were synthesized to contain nonhydrolyzable phosphotyrosine mimics that bind to bone. These compounds were further tested and found to inhibit rabbit osteoclast-mediated resorption of dentine. These results indicate that compounds that bind to the Src SH2 domain can inhibit Src activity in cells and inhibit osteoclast-mediated resorption.

Towards a statewide cardiac surgery database: The Victorian initiative

The establishment of the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) at the beginning of the 1990s gave rise to an early proposal for the development of a cardiac surgical database. The Victorian Government gave its in-principle backing to a statewide database project from late 1997. Release of a promised dollar 200,000 grant for development was contingent on the ASCTS being able to fulfil several initial requirements. These were: (i) the provision of an indicative annual report outlining performance against a series of clinical indicators; (ii) an indicative peer-review process; and (iii) the addressing of issues surrounding intellectual property and ownership of any database that was developed. In outlining a strategy to be used in developing and implementing the project plan, it was determined by the project development team that all Victorian cardiac surgical units were, in fact, collecting similar data, but were using different software and analytical tools. The Cardiovascular Disease Prevention Unit at the Baker Medical Research Institute in Melbourne has developed a model of mortality and risk-adjusted complications out of the pooled Victorian data. This, it is hoped, will be a forerunner of a major achievement in the monitoring of cardiac surgery procedures nationally, and the attainment of national and international best practice.