Balanitis xerotica obliterans with urethral stricture after hypospadias repair

Three cases of urethral stricture due to balanitis xerotica obliterans (BXO) after hypospadias repair are reported. The first patient showed white, dense scarring on the prepuce before the hypospadias repair and developed a stricture of the urethra after the operation. The second and the third were uneventful for 6 and 2 years, respectively, after the hypospadias repair, and then developed urethral strictures. Pathologic diagnosis of the stenotic lesion is essential. Complete excision of the affected urethra with topical steroid ointment or sublesional triamcinolone injection is recommended for this condition. Although the complication of BXO after hypospadias repair is rare (3 out of 796 cases with hypospadias in our series), surgeons need to be aware of this condition as a cause for late onset of urethral problems.

The epithelial Na(+)/H(+) exchanger, NHE3, is internalized through a clathrin-mediated pathway

Trafficking of the Na(+)/H(+) exchanger isoform 3 (NHE3) between sub-apical vesicles and apical membrane of epithelial cells is a suggested mechanism of regulation of NHE3 activity. When epitope-tagged NHE3 was stably expressed in NHE-deficient Chinese hamster ovary cells, a sizable fraction was found in recycling endosomes. This system was used to analyze the mechanism of endocytosis of NHE3. Immunofluorescence and radiolabeling experiments showed that inhibition of clathrin-mediated endocytosis using hypertonicity, acid treatment, or K(+) depletion inhibited internalization of NHE3. Moreover, transient transfection of an inhibitory mutant of dynamin (DynS45N) blocked the clathrin-mediated uptake of transferrin, as well as the endocytosis of NHE3. In ileal villus cells, endogenous NHE3 was also found to co-purify with isolated clathrin-coated vesicles, thereby confirming their association in native tissues. The role of COP-I subunits in the intracellular traffic of NHE3 was evaluated using ldlF cells, which bear a temperature-sensitive mutation in the epsilon-COP subunit. At the permissive temperature, NHE3 distributed normally, whereas at the restrictive temperature, which induces rapid degradation of epsilon-COP, NHE3 was still internalized, but its subcellular distribution was altered. These results indicate that endocytosis of NHE3 occurs primarily via clathrin-coated pits and vesicles and that normal intracellular trafficking of NHE3 involves an epsilon-COP-dependent step.

Increasing the effectiveness of resource deployment in healthcare organizations

This article suggests ways to enhance the effectiveness with which healthcare organizations deploy their resources. Specifically, the article: (1) reviews research findings from the academic literature that managers often continue, or even increase, resource allocation to unprofitable courses of action; (2) reports the results of a case study with hospital administrations that suggests that this tendency may exist in healthcare organizations; and (3) suggests ways for healthcare organizations to control the occurrence of such suboptimal actions, thereby increasing the effectiveness and timeliness of their resource deployment.

Bifunctional 2-naphthyl propargylic sulfones exhibiting high DNA intercalating and alkylating activity

A number of novel 2-naphthyl propargylic sulfones were synthesized as nucleic base alkylating agents. Extremely high DNA cleavage activity was observed for the sulfones with a free omega-hydroxyl group in the carbon chain in contrast to the ester conjugates possessing an additional intercalating unit.

Regulation and intracellular localization of the epithelial isoforms of the Na+/H+ exchangers NHE2 and NHE3

The Na+/H+ exchangers (NHE) are a ubiquitous family of membrane proteins that catalyze the counter-transport of extracellular Na+ for intracellular H+ and are important for intracellular pH and cell volume regulation. The major epithelial isoforms, NHE2 and NHE3, are thought to have more specialized roles in regulating Na+ and water absorption and are differentially expressed in epithelial tissues. NHE2 and NHE3 not only differ with respect to their response to various endogenous and exogenous factors but exhibit different intracellular localization as well. NHE2 is primarily located at the plasma membrane, whereas NHE3 is mostly sequestered in an intracellular compartment corresponding to the recycling endosome. Furthermore, NHE3 is localized to the apical pole, whereas polar localization of NHE2 has been controversial. The author has recently localized NHE2 to the apical membrane of a renal epithelial cell line and identified a 45-residue-long region of the cytosolic domain (corresponding to residues 731-777 of the rat NHE2) to be critical for apical targeting. Although SH3 domains of various proteins were found to bind to this and a more carboxy-terminal proline-rich region in vitro, the functional significance of these interactions appears inconsequential. Deletion of both proline-rich regions did not affect Na+/H+ exchange nor its response to hypertonicity and metabolic depletion. However, loss of residues 731-777, which bound specifically in vitro to the SH3 domain of the cytoskeletal protein, alpha-spectrin, mistargets NHE2 to the basolateral surface.

Case report: Colonic duplication: a rare cause of obstruction

Complete duplication of the entire large bowel with partial ileal involvement is very rare and diagnosis can often be difficult as illustrated by this case report. We also review the other clinical associations of this rare condition and briefly discuss the embryology of duplications of the gastrointestinal tract.

Testicular and paratesticular tumours in children: 30 years' experience

BACKGROUND

Testicular or paratesticular tumours in children are rare, making it difficult to achieve the best management for these life-threatening diseases. The aim of this study is to review patients during a 30-year period with these tumours and assess clinical aspects to improve management.

METHODS

The records of 68 patients from 1967 to 1996 were reviewed with respect to age at diagnosis, affected sites, presentation, clinical diagnosis, operation, pathology and prognosis.

RESULTS

The most common presentation was a painless scrotal mass (84%). The most common testicular tumour was mature teratoma (n = 27) followed by yolk sac tumour (n = 17). Thirteen patients had paratesticular rhabdomyosarcoma. Two teratocarcinomas, three leydig cell tumours, two sertoli cell tumours, one granulosa cell tumour, one fibroma, one gonadoblastoma, and one secondary tumour from acute myeloid leukaemia were found also. Testis-sparing surgery was performed in 21 of 33 patients with benign tumours (27 teratoma, three leydig cell tumours, two sertoli cell tumours, one fibroma), which caused no recurrence. Only two patients with rhabdomyosarcoma and one with mixed germ cell tumour died of their disease.

CONCLUSION

Recent combined therapy with surgery and chemotherapy against primary testicular and paratesticular tumours has improved prognosis. Testis-sparing surgery should be considered for benign tumours.

Slow-transit constipation in childhood

BACKGROUND/PURPOSE

Intestinal neuronal dysplasia (IND) as a cause for severe chronic constipation remains controversial. The authors have identified a deficiency of substance P (SP) immunoreactivity in the colonic nerve fibres of some children with severe constipation, and aim to correlate this with clinical features and transit studies.

METHODS

Over 100 children with intractable constipation with or without soiling have been assessed by clinical questionnaire, nuclear transit study, and laparoscopic seromuscular biopsy of the colon labelled with antibodies to SP and vasoactive intestinal peptide (VIP) using immunofluorescence.

RESULTS

More than 30% of children had delayed passage of meconium, and symptoms of constipation appeared by the age of 1 year in 63%. More than 80% had significant delay in colonic transit, and of these, about 80% had reduced SP immunoreactivity in the axons of the colonic circular muscle. A further 6% had heterotopic ganglion cells or hypoplastic ganglia on routine histology.

CONCLUSIONS

In children with intractable constipation, features of early onset and delayed colonic transit correlated with deficiency of SP in myenteric axons. The authors propose that deficient SP immunoreactivity may be used as a histological marker for severe constipation. Defective excitatory neuromuscular transmission may be the cause of slow colonic transit.

Proline-rich motifs of the Na+/H+ exchanger 2 isoform. Binding of Src homology domain 3 and role in apical targeting in epithelia

The NHE2 isoform of the Na+/H+ exchanger (NHE) displays two proline-rich sequences in its C-terminal region that resemble SH3 (Src homology 3)-binding domains. We investigated whether these regions (743PPSVTPAP750, termed Pro-1, and 786VPPKPPP792, termed Pro-2) can bind to SH3 domains and whether they are essential for NHE2 function and targeting. A fusion protein containing the Pro-1 region showed promiscuous binding to SH3 domains of several proteins in vitro, whereas a Pro-2 fusion bound preferentially to domains derived from kinases. In contrast, cytoplasmic regions of NHE1, NHE3, or NHE4 failed to interact. When expressed in antiporter-deficient cells, truncated NHE2 lacking both Pro-rich regions catalyzed Na+/H+ exchange, retained sensitivity to intracellular ATP, and was activated by hyperosmolarity, resembling full-length NHE2. The role of the Pro-rich regions in subcellular targeting was examined by transfection of epitope-tagged forms of NHE2 in porcine renal epithelial LLC-PK1 cells. Both full-length and Pro-2-truncated NHE2 localized almost exclusively to the apical membrane. By contrast, a mutant devoid of both Pro-1 and Pro-2 was preferentially sorted to the basolateral surface but also accumulated intracellularly. These observations indicate that the region encompassing Pro-1 is essential for appropriate subcellular targeting of NHE2.

Improving subjective decision making in health care administration

Managing a health care institution typically requires the consideration of many nonquantifiable factors, such as community relations, quality of service, and employee morale. As a result, subjective judgments are an inevitable, and often major, part of decision making in health care financial management. A large body of scientific research has shown that people's subjective, or intuitive, judgments tend to be biased and inaccurate. This article reviews the major types of errors typically found in four phases of decision making: defining the problem, estimating the effects of different alternatives, choosing an alternative, and evaluating the outcomes as the basis for subsequent action. In addition to alerting health care administrators to these potential judgment errors, several methods to improve subjective decision making are explained.

Requirement for transcription factor NFAT in interleukin-2 expression

The nuclear factor of activated T cells (NFAT) transcription factor is implicated in expression of the cytokine interleukin-2 (IL-2). Binding sites for NFAT are located in the IL-2 promoter. Furthermore, pharmacological studies demonstrate that the drug cyclosporin A inhibits both NFAT activation and IL-2 expression. However, targeted disruption of the NFAT1 and NFAT2 genes in mice does not cause decreased IL-2 secretion. The role of NFAT in IL-2 gene expression is therefore unclear. Here we report the construction of a dominant-negative NFAT mutant (dnNFAT) that selectively inhibits NFAT-mediated gene expression. The inhibitory effect of dnNFAT is mediated by suppression of activation-induced nuclear translocation of NFAT. Expression of dnNFAT in cultured T cells caused inhibition of IL-2 promoter activity and decreased expression of IL-2 protein. Similarly, expression of dnNFAT in transgenic mice also caused decreased IL-2 gene expression. These data demonstrate that NFAT is a critical component of the signaling pathway that regulates IL-2 expression.

An unusual cause of rectal bleeding in a patient with cystic fibrosis

Here we identify a previously unreported cause of rectal bleeding (juvenile polyposis) in a patient with cystic fibrosis (CF). We believe this patient most likely has two coexisting genetic diseases. It also raises many issues about organ transplantation in a patient with medical conditions that individually increase the risk of gastrointestinal malignancy and stresses the diagnostic value of endoscopy in CF patients with rectal bleeding.

Expression of MAGE and GAGE in high-grade brain tumors: a potential target for specific immunotherapy and diagnostic markers

The mRNA expression of the tumor-associated antigens MAGE and GAGE was examined in 60 high-grade brain tumors. This analysis was performed by using reverse transcription-PCR, Southern blotting, and sequencing. It was demonstrated that, of the eight GAGE genes, GAGE-2 and -7 were expressed in five of seven normal brains. Four groups of tumors--adult glioblastoma multiforme (n = 20), pediatric glioblastoma multiforme (n = 9), medulloblastomas (n = 15), and ependymomas (n = 14)--were analyzed for mRNA expression. The following frequencies were observed: MAGE-1, 0, 0, 13, and 0%, respectively; MAGE-2, 5, 11, 60, and 57%; MAGE-3 & -6, 0, 0, 13, and 0%; GAGE-1, 65, 11, 13, and 43%; and GAGE-3-6 and -8: 75, 78, 47, and 93%, respectively. Two unclassified tumors expressed GAGE-3-6 and -8 only. The absence of GAGE-1 expression in normal brain, its relatively high frequency of expression in high-grade brain tumors, and its unique 3' sequence, suggest it may represent a useful target for specific immunotherapy. The detection method of reverse transcription-PCR and Southern blotting may also be useful for rapid screening of biopsy specimens both for diagnostic purposes and to determine a patient's eligibility for specific immunotherapy.

An anchored framework BAC map of mouse chromosome 11 assembled using multiplex oligonucleotide hybridization

Despite abundant library resources for many organisms, physical mapping of these organisms has been seriously limited due to lack of efficient library screening techniques. We have developed a highly efficient strategy for large-scale screening of genomic libraries based on multiplex oligonucleotide hybridization on high-density genomic filters. We have applied this strategy to generate a bacterial artificial chromosome (BAC) anchored map of mouse chromosome 11. Using the MIT mouse SSLP data, 320 pairs of oligonucleotide probes were designed with an "overgo" computer program that selects new primer sequences that avoid the microsatellite repeat. BACs identified by these probes are automatically anchored to the chromosome. Ninety-two percent of the probes identified positive clones from a 5.9-fold coverage mouse BAC library with an average of 7 positive clones per marker. An average of 4.2 clones was confirmed for 204 markers by PCR. Our data show that a large number of clones can be efficiently isolated from a large genomic library using this strategy with minimal effort. This strategy will have wide application for large-scale mapping and sequencing of human and other large genomes.

Distributions of substance P- and VIP-immunoreactive nerve fibres in the colonic circular muscle in children

In children with severe chronic constipation, abnormal distribution of substance P (SP) and vasoactive intestinal peptide (VIP), which represent excitatory and inhibitory nerves, respectively, has been reported. The normal distribution of these neuropeptides, however, is not well known. The aim of this study was to determine the populations of SP- and VIP-immunoreactive nerve fibres in the circular muscle of the colon in children. Surgically resected specimens were collected from a 6-year-old girl with familial polyposis coli (total colon) and nine patients with anorectal malformations aged 0-4 years (sigmoid colon). Double-labelling immunofluorescence was employed using neuron-specific enolase (NSE) with SP and NSE with VIP to count the percentage of SP- or VIP-labelled nerve fibres. These specimens showed normal submucous and myenteric plexuses stained with NSE. The population of SP- immunoreactive fibres was 15%-21% throughout the colon, and VIP was 39% in the caecum and 63%-65% in the transverse, descending, and sigmoid colon. In the four neonatal specimens (day 1 to 4), the SP population was only 1%-6% and the VIP population was also low (22%-33%). After 3 weeks of age, the populations had stabilised at 18%-26% for SP and 52%-62% for VIP. SP-immunoreactive nerve fibres were scarce in the neonatal period, and showed a rapid increase by 3 weeks and a similar though less dramatic increase in VIP-immunoreactive fibres. VIP-immunoreactive fibres were fewer in the caecum that at other colonic levels, where they accounted for 60% of NSE-labelled fibres; the SP population, however, was comparable at all levels of the colon at about 20% of NSE-labelled fibres.

Multiple leiomyosarcomas of both donor and recipient origin arising in a heart-lung transplant patient

The occurrence of Epstein-Barr virus-associated smooth-muscle tumors in immunocompromised patients has been reported, particularly in the pediatric population. In posttransplantation tumors, the tissue of origin has been either donor or recipient. Mixed-genotype sarcomas within the same patient have not yet been reported. We describe the occurrence of multiple leiomyosarcomas of both donor (arising in the lung allograft) and recipient (arising in the host liver) origin in a 15-year-old boy 3 years after heart-lung transplantation. Analysis of premortem lung tumors demonstrated the presence of Epstein-Barr virus DNA. Despite decreasing immunosuppression and commencing acyclovir, the patient died of systemic Pseudomonas infection. Immunohistochemical analysis revealed that both lung and liver tumors were negative for the Epstein-Barr virus receptor (CD21), and suggests that Epstein-Barr virus entry into the cells was not via this receptor but via an alternate mechanism such as cell fusion.

Multiple domains for initiator binding proteins TFII-I and YY-1 are present in the initiator and upstream regions of the rat XDH/XO TATA-less promoter

We previously reported that the TATA-less rat xanthine dehydrogenase/oxidase (XDH/XO) promoter is organized with multiple initiator elements (Inr 1, 2, 3 and 4). Additionally, we identified six factor binding footprints in the upstream region of this promoter (FP 1-FP 6), two of which (FP 2 and FP 4) we showed to be C/EBP binding sites. In this report we continue our characterization of the XDH/XO promoter, detailing other cis elements which comprise the Inr and upstream binding factors. Interestingly, multiple binding domains for known initiator binding proteins, YY-1 and USF-related factor/TFII-I, have been identified which potentially play an important role in transcription initiation.

The balanced scorecard: a potent tool for energizing and focusing healthcare organization management

The current environment for healthcare organizations contains many forces demanding unprecedented levels of change. These forces include changing demographics, increased customer expectations, increased competition, and intensified governmental pressure. Meeting these challenges will require healthcare organizations to undergo fundamental changes and to continuously seek new ways to create future value. This article provides explanation of a potent new management tool-the balanced scorecard-that can be used by healthcare organizations to meet these challenges. The article also presents the opinions of many high-level healthcare administrators that the balanced scorecard can be highly beneficial to healthcare organizations. It also summarizes these administrators' suggestions regarding the goals and measures that can make up an effective scorecard for a hospital as a whole, as well as for a specific subunit of a hospital. Interestingly, while no published report of balanced scorecard implementations in healthcare organizations exists, a number of administrators stated that they had fully implemented systems similar to the scorecard. These actions can be considered support for the scorecard's potential usefulness; at the same time, they suggest that some sharing of experiences will likely be available in the future. As all administrators are well aware, moving from concept to practice is often difficult. While the article includes some suggestions for scorecard development and implementation, each organization must engage in the full range of activities, from defining its mission to the selection of goals and strategies, and develop its own unique scorecard to assist progress toward the selected goals. As a starting point, Table 3 provides a timeline of some general events that may be common to all organizations during this process.

The beta2-adrenergic receptor interacts with the Na+/H+-exchanger regulatory factor to control Na+/H+ exchange

Stimulation of beta2-adrenergic receptors on the cell surface by adrenaline or noradrenaline leads to alterations in the metabolism, excitability, differentiation and growth of many cell types. These effects have traditionally been thought to be mediated exclusively by receptor activation of intracellular G proteins. However, certain physiological effects of beta2-adrenergic receptor stimulation, notably the regulation of cellular pH by modulation of Na+/H+ exchanger (NHE) function, do not seem to be entirely dependent on G-protein activation. We report here a direct agonist-promoted association of the beta2-adrenergic receptor with the Na+/H+ exchanger regulatory factor (NHERF), a protein that regulates the activity of the Na+/H+ exchanger type 3 (NHE3). NHERF binds to the beta2-adrenergic receptor by means of a PDZ-domain-mediated interaction with the last few residues of the carboxy-terminal cytoplasmic domain of the receptor. Mutation of the final residue of the beta2-adrenergic receptor from leucine to alanine abolishes the receptor's interaction with NHERF and also markedly alters beta2-adrenergic receptor regulation of NHE3 in cells without altering receptor-mediated activation of adenylyl cyclase. Our findings indicate that agonist-dependent beta2-adrenergic receptor binding of NHERF plays a role in beta2-adrenergic receptor-mediated regulation of Na+/H+ exchange.

Correct usage of multiple transcription initiation sites and C/EBP-dependent transcription activation of the rat XDH/XO TATA-less promoter requires downstream elements located in the coding region of the gene

In the present study, we have shown that a downstream element located in the coding region of the TATA-less rat xanthine dehydrogenase/oxidase (XDH/XO) gene (-7 to +42) plays an important role in transcription initiation and C/EBP transcriptional activation. Previous work from our laboratory has shown that the promoter is organized with multiple initiator elements (Inr 1, 2, 3 and 4) which are important for transcription initiation. Additionally, we had identified two C/EBP binding sites upstream of this promoter. Deletional and mutational studies revealed that C/EBP binding was not essential for the basal level of transcriptional initation. However when XO-luciferase constructs include downstream sequence extending to +42 there is development of C/EBP sensitivity as well as a shift in the initiator usage. In the absence of the downstream element, primer extension analyses reveals Inr 3 and 4 to be the major start sites but in the presence of this additional sequence the usage is shifted to Inr 1 and 2. This shift in Inr usage more closely resembles that seen in intact macrophages or liver cells. Gel mobility shift assays indicate the presence of several binding factors located in this downstream region, one of which has been identified as YY-1. We postulate that YY-1 allows DNA bending which permits the upstream C/EBP elements to exhibit a transcriptional activation which is not seen when the downstream element is absent. This study presents a potential model for regulation of the XDH/XO promoter.

Remarkable tethering effect on DNA cleavage of propargylic sulfone conjugates with intercalating moieties

A number of novel propargylic sulfone conjugates 3 and 4 with intercalating moieties were synthesized and evaluated for DNA cleavage activity through nucleic base alkylation. A remarkable enhancement in DNA cleaving potency was observed with those conjugates 3 possessing a suitable spacer, a right attachment point at the aromatic ring, and a good intercalator.

Characterization of a t(8;13)(p11;q11-12) in an atypical myeloproliferative disorder

Fourteen cases of an atypical myeloproliferative disorder associated with consistent translocations involving 8p11-12 have previously been described. A t(8;13)(p11;q11-12) was the most common, but variant t(8;9)(p11-12;q32-34) and t(6;8)(q27;p12) were also reported. Here we have used a series of yeast artificial chromosomes (YACs) derived from the 8p11 and 13q11-12 regions to analyse one of the t(8;13) cases by fluorescence in situ hybridization (FISH). YACs flanking the 13q11-12 breakpoint and spanning the 8p11 breakpoint have been isolated. These YACs will facilitate characterization of the genes involved in this rearrangement.

Myocarditis in children with dilated cardiomyopathy: incidence and outcome after dual therapy immunosuppression

BACKGROUND

The true incidence and prognosis of myocarditis in children with acute dilated cardiomyopathy (DCM) at presentation remains uncertain. This study examines the incidence of lymphocytic myocarditis in a consecutive cohort of children with acute DCM at presentation and outcome after dual therapy immunosuppression with cyclosporine and steroids.

METHODS

Twenty-nine consecutive children with acute DCM underwent early endomyocardial biopsy. Children with "definite" myocarditis comprised group I (n = 9) and were treated with cyclosporine and prednisolone. Group II (n = 2) had "borderline" myocarditis, and group III (n = 18) nonspecific histologic findings. Outcome was assessed by echocardiographic measurement of left ventricular end-diastolic dimension and fractional shortening, with follow-up endomyocardial biopsy in group I subjects.

RESULTS

Myocardial inflammation with or without myocardial necrosis (groups I and II) was present in 38% of all cases. There were no initial clinical, electrocardiographic, or echocardiographic features to distinguish patients in group I from patients in group III. At presentation, the mean +/- SEM left ventricular end-diastolic dimension and fractional score-Z scores of group I patients were 4.6 +/- 1.7 and -5.1 +/- 0.8, respectively, compared with 0.8 +/- 0.3 and -0.9 +/- 0.4, respectively, at withdrawal of immunosuppression (p < 0.001 for both). Both of these parameters did not differ significantly from normal controls at least follow up. Two group I patients had a biopsy-proven relapse after withdrawal of therapy that responded to reinstitution of immunosuppression. At latest follow-up, all nine group I patients had regained normal left ventricular function compared with four of 18 group III patients (p < 0.001).

CONCLUSION

Lymphocytic myocarditis is frequent in children with dilated cardiomyopathy and cannot be predicted from noninvasive investigations. The use of cyclosporine and steroids is associated with a favorable outcome, and a controlled trial of dual therapy immunosuppression in children is therefore warranted.