Performance of bispectral index and auditory evoked potential monitors in detecting loss of consciousness during anaesthetic induction with propofol with and without fentanyl

BACKGROUND AND OBJECTIVE

To investigate and compare the performance of bispectral index (BIS) and auditory evoked response index (AAI) in detecting the transition from consciousness to unconsciousness during anaesthesia induction by propofol, alone and in combination with fentanyl.

METHODS

Anaesthesia was induced with either an intravenous infusion of 30 mg kg(-1)h(-1) of propofol plus 2 microg kg(-1) of fentanyl (Group PF, n = 20) or an intravenous infusion of 30 mg kg(-1) h(-1) of propofol plus normal saline (Group P, n = 20). BIS, AAI and the doses of propofol administered were recorded at the end-point of unresponsiveness to verbal commands. The propofol plasma concentration was also measured.

RESULTS

The propofol dose and plasma propofol concentration required to achieve loss of consciousness were significantly lower in patients pretreated with fentanyl (P < 0.001). The mean BIS value at loss of consciousness was significantly different between the two groups (74.10 in Group PF vs. 60.80 in Group P) (P < 0.001). However, no difference in the AAI was seen between the two groups at loss of consciousness (32.90 in Group PF vs. 31.80 in Group P) (P > 0.05). In both groups, the regression analysis values (r-values) between BIS and plasma propofol concentrations at the onset of unconsciousness were higher than those between AAI and propofol concentrations (0.553 vs. 0.180 in Group P; 0.432 vs. 0.308 in Group PF).

CONCLUSIONS

These results show that a fentanyl bolus is effective in augmenting the hypnotic effect of propofol during anaesthesia induction. AAI appears to be able to measure the transition from consciousness to unconsciousness at similar values, regardless of whether or not fentanyl pretreatment is used whereas the BIS values were not independent of fentanyl pretreatment. This suggests that AAI may be a better indicator of conscious status during propofol/fentanyl anaesthesia, where it appears to be independent of the anaesthesia regimen.

Adsorption of sevoflurane by soda-limes

Dry soda-lime adsorbs significant quantities of halothane, thus influencing on the speed of the induction of anaesthesia with the agent and also on the recovery from anesthesia. Sevoflurane is a new inhaled anesthetic. Although the chemical degradation of sevoflurane with soda-lime has been studied, no information is available about its adsorption by soda-lime. This issue can not be neglected clinically. Two different soda-limes were placed in saturated vapour of sevoflurane for 17 hours to weight adsorbed sevoflurane. Then soda-limes adsorbing sevoflurane was sealed in a test tube after air-drying for 1) 0 min, 2) 10 min, 3) 30 min and 4) 17 hours. The vapour phase of sevoflurane in the test tube at various temperatures were determined using gas chromatography. Sevoflurane vapour concentrations in the test tubes increased in a temperature-dependent manner. Those in the conventional soda-lime were higher than those in the new soda-lime under any experimental conditions. Sevoflurane was released from soda-limes even after air-drying for 17 hours. These results show that much amount of sevoflurane is adsorbed by soda-limes and is released easily in the air. Thus there is a possibility for our patients to inhale unexpected inhaled anesthetics, if we use our anesthetic machine repeatedly.

Production of l-2,3-butanediol by a new pathway constructed in Escherichia coli

AIMS

A metabolic pathway for L-2,3-butanediol (BD) as the main product has not yet been found. To rectify this situation, we attempted to produce L-BD from diacetyl (DA) by producing simultaneous expression of diacetyl reductase (DAR) and L-2,3-butanediol dehydrogenase (BDH) using transgenic bacteria, Escherichia coli JM109/pBUD-comb.

METHODS AND RESULTS

The meso-BDH of Klebsiella pneumoniae was used for its DAR activity to convert DA to L-acetoin (AC) and the L-BDH of Brevibacterium saccharolyticum was used to reduce L-AC to L-BD. The respective gene coding each enzyme was connected in tandem to the MCS of pFLAG-CTC (pBUD-comb). The divided addition of DA as a source, addition of 2% glucose, and the combination of static and shaking culture was effective for the production.

CONCLUSIONS

L-BD (2200 mg l(-1)) was generated from 3000 mg l(-1) added of DA, which corresponded to a 73% conversion rate. Meso-BD as a by-product was mixed by 2% at most.

SIGNIFICANCE AND IMPACT OF THE STUDY

An enzyme system for converting DA to L-BD was constructed with a view to using DA-producing bacteria in the future.

A novel splice site mutation of the thiazide- sensitive NaCl cotransporter gene in a Japanese patient with Gitelman syndrome

Gitelman syndrome (GS, MIM 263800) is an inherited disorder characterized by metabolic alkalosis with hypokalemia, hypomagnesemia, and hypocalciuria. The genetic abnormalities causing GS are known to lie in the thiazide-sensitive NaCl cotransporter (TSC), which is expressed in the distal tubule of the kidney. The TSC gene, located at chromosome 16, consists of 26 exons and encodes the protein containing 12 putative transmembrane domains with long intracellular amino and carboxy termini. Most of the abnormalities identified in GS were missense mutations, distributed throughout the TSC gene without a hot spot. A 42-year-old Japanese man was introduced for close examination of hypokalemia. In renal clearance studies using furosemide or thiazide, chloride clearance was increased after furosemide but not after thiazide administration. Furthermore, the distal fractional chloride reabsorption was dramatically decreased by furosemide but not thiazide administration, suggesting a defect in the distal tubule. We then analyzed the TSC gene to confirm the diagnosis of GS, and identified a novel G to T mutation at the acceptor splice site preceding exon 14, resulting in disruption of a conventional 3'AG consensus splice site. Abnormal splicing by this mutation is predicted to cause the formation of truncated TSC with a partial deletion of the transmembrane domain, which will loose the function of transporter. In conclusion, we have identified a unique novel splice site mutation of the TSC gene in GS. The predicted structure of this mutant TSC can conceivably cause an impairment of the transporter activity and thereby be responsible for the development of GS in our patient.

Small invasive colonic cancer occurring in a hyperplastic polyp

We report a case of advanced colon cancer which was supposed to have arisen from a hyperplastic polyp in a 68-year-old man. Colonoscopy revealed a depressed reddish area with a surrounding elevated lesion that was of a faded color compared with the normal mucosa. After the mucosal surface had been sprayed with crystal violet dye, magnifying colonoscopy showed an amorphous area in the central depression and the surrounding, slightly elevated lesion had an asteroid pattern. The depressed area was therefore considered to be a colonic cancer surrounded by a hyperplastic polyp. Endoscopic ultrasonography showed that the lesion was infiltrating further than the deep submucosal layer and it was therefore decided to treat the patient by laparoscopically assisted right hemicolectomy. The depressed lesion was found to be a well-differentiated adenocarcinoma invading the muscularis propria (diagnosed as IIc + IIa-like advanced adenocarcinoma). The surrounding flat elevated lesion was found to be hyperplastic mucosa. No adenomatous lesions were found. There have been few reported cases in which a preoperative diagnosis of carcinoma in a hyperplastic polyp has been made, but the possibility of carcinogenesis from hyperplastic polyps has come under consideration recently. This case was considered to be important because it raises the possibility that nonpolypoid cancer can develop from a hyperplastic polyp.

Night-time restricted feeding normalises clock genes and Pai-1 gene expression in the db/db mouse liver

AIMS/HYPOTHESIS

An increase in PAI-1 activity is thought to be a key factor underlying myocardial infarction. Mouse Pai-1 (mPai-1) activity shows a daily rhythm in vivo, and its transcription seems to be controlled not only by clock genes but also by humoral factors such as insulin and triglycerides. Thus, we investigated daily clock genes and mPai-1 mRNA expression in the liver of db/db mice exhibiting high levels of glucose, insulin and triglycerides.

METHODS

Locomotor activity was measured using an infrared detection system. RT-PCR or in situ hybridisation methods were applied to measure gene expression. Humoral factors were measured using measurement kits.

RESULTS

The db/ db mice showed attenuated locomotor activity rhythms. The rhythmic expression of mPer2 mRNA was severely diminished and the phase of mBmal1 oscillation was advanced in the db/db mouse liver, whereas mPai-1 mRNA was highly and constitutively expressed. Night-time restricted feeding led to a recovery not only from the diminished locomotor activity, but also from the diminished Per2 and advanced mBmal1 mRNA rhythms. Expression of mPai-1 mRNA in db/db mice was reduced to levels far below normal. Pioglitazone treatment slightly normalised glucose and insulin levels, with a slight reduction in mPai-1 gene expression.

CONCLUSIONS/INTERPRETATION

We demonstrated that Type 2 diabetes impairs the oscillation of the peripheral oscillator. Night-time restricted feeding rather than pioglitazone injection led to a recovery from the diminished locomotor activity, and altered oscillation of the peripheral clock and mPai-1 mRNA rhythm. Thus, we conclude that scheduled restricted food intake may be a useful form of treatment for diabetes.

Expression of myogenic regulating factors, Myogenin and MyoD, in two canine botryoid rhabdomyosarcomas

Myogenin and MyoD regulate the development of skeletal muscle, and their expressions are specific to the stages of myogenesis. Therefore, these myogenic regulatory proteins could be considered as sensitive and specific markers for rhabdomyosarcoma. In this report we investigated the immunohistochemical reactivities of myogenin and MyoD in two canine bladder botryoid rhabdomyosarcomas that were different in the degree of differentiation. MyoD was stained in the Ki-67 antigen-positive undifferentiated mesenchymal cells, which had proliferative activity similar to myoblasts differentiated from mesoblasts. In contrast, multinucleated neoplastic cells were positive for myogenin and alpha-sarcomeric actin but not for Ki-67 antigen, similar to the myotubes differentiated from myoblastic cells. The expressions of myogenin and MyoD were closely correlated to the histologic features of myogenic neoplastic cells.

Effects of h-PTH on cancellous bone mass, connectivity, and bone strength in ovariectomized rats with and without sciatic-neurectomy

The purpose of this study was to determine whether h-PTH (1-34) treatment would recover cancellous bone connectivity and bone strength in ovariectomized (OVX) or ovariectomized and sciatic-neurectomized (OVX+NX) rats. Seven-month-old female Wistar rats were treated with h-PTH or vehicle (6.0 microg/kg, six times a week, subcutaneously) for four weeks beginning 4, 8, or 12 weeks after OVX or OVX+NX. These were compared to age-matched baseline and sham-operated groups. Right tibiae were used for bone histomorphometry and node-strut analysis, and left tibiae were used for mechanical testing. The bone formation rates in the OVX and OVX+NX rats treated with h-PTH were significantly higher than those in their baseline controls. h-PTH treatment increased the node numbers and failure energies in the OVX rats, compared to their baseline controls, at all time points. However, in the OVX+NX rats, the effects of h-PTH treatment on the node number and failure energy were observed only at four weeks after surgery, but not at eight weeks or 12 weeks after surgery. These results suggest that the lowest limit, at which trabecular connectivity and bone strength are able to be restored by h-PTH, occurred between four and eight weeks in OVX+NX rats, but not in OVX rats. h-PTH cannot recover trabecular connectivity and bone strength in advanced osteopenia.

Clinical factors associated with fluconazole resistance and short-term survival in patients with Candida bloodstream infection

In a 1-year national surveillance program of Candida bloodstream infections in Japan, clinical factors predicting fluconazole resistance and survival of the patients were analyzed. Blood isolates and complete clinical histories were obtained from 326 patients. Fluconazole-resistant isolates were found in 15 (4.6%) of the cases. Univariate analysis of the demographic and clinical factors associated with fluconazole resistance revealed that age, hematologic malignancy, neutropenia, and immunosuppression were of statistical significance. A multiple logistic regression model showed that only hematologic malignancy as the underlying disease (odds ratio, 6.6; 95% confidence interval, 1.6-26.9; P=0.009) was independently associated with resistance. In 242 cases in which data regarding management and prognosis were available, the 30-day survival rate was 68.4%. In the univariate analysis of factors predicting survival, a significant association was found for Candida species, age of the patient, neutropenia, recent abdominal surgery, removal of the central venous catheter, and use of appropriate antifungal therapy. In the multivariate analysis, removal of the central venous catheter (odds ratio, 6.0; 95% confidence interval, 2.2-16.1; P<0.001) and the use of appropriate therapy (odds ratio, 2.1; 95% confidence interval, 1.1-4.1; P=0.03) were independent factors significantly associated with survival after the diagnosis of Candida bloodstream infection.

Urinary 8-hydroxydeoxyguanosine excretion in children before and after therapy for eradication of Helicobacter pylori infection

AIM

A number of reports have implicated oxygen free radicals in the pathogenesis of Helicobacter pylori (H. pylori)-associated disease. 8-hydroxydeoxyguanosine (8-OHdG) has recently been accepted as a sensitive marker for reflecting the oxidative DNA damage. However, there have been no previous studies comparing the changes in urinary 8-OHdG excretions before and after therapy for eradication of H. pylori infection, or to examine 8-OHdG excretions in children with H. pylori infection. The aim of this study was therefore to examine the DNA damage in gastric mucosal cells in children with H. pylori infection.

METHODS

Urinary 8-OHdG excretions were measured before and after therapy for eradication of H. pylori infection in 15 children diagnosed with the H. pylori infection and 13 parents who were also suffering from the same infection.

RESULTS

In both the children and their parents, no significant differences were found in urinary 8-OHdG excretions either before or after the eradication therapy. Furthermore, there was no significant difference in urinary 8-OHdG excretions between 8 children with peptic ulcers and 7 children without ulcers, either before or after the therapy.

CONCLUSION

These results suggest that measurement of urinary 8-OHdG levels is not useful for evaluation of the DNA damage in H. pylori-infected gastric mucosa in children.

Urinary 8-hydroxydeoxyguanosine excretion in children before and after therapy for eradication of Helicobacter pylori infection

AIM

A number of reports have implicated oxygen free radicals in the pathogenesis of Helicobacter pylori (H. pylori)-associated disease. 8-hydroxydeoxyguanosine (8-OHdG) has recently been accepted as a sensitive marker for reflecting the oxidative DNA damage. However, there have been no previous studies comparing the changes in urinary 8-OHdG excretions before and after therapy for eradication of H. pylori infection, or to examine 8-OHdG excretions in children with H. pylori infection. The aim of this study was therefore to examine the DNA damage in gastric mucosal cells in children with H. pylori infection.

METHODS

Urinary 8-OHdG excretions were measured before and after therapy for eradication of H. pylori infection in 15 children diagnosed with the H. pylori infection and 13 parents who were also suffering from the same infection.

RESULTS

In both the children and their parents, no significant differences were found in urinary 8-OHdG excretions either before or after the eradication therapy. Furthermore, there was no significant difference in urinary 8-OHdG excretions between 8 children with peptic ulcers and 7 children without ulcers, either before or after the therapy.

CONCLUSION

These results suggest that measurement of urinary 8-OHdG levels is not useful for evaluation of the DNA damage in H. pylori-infected gastric mucosa in children.

Obstructed Coarctation in a Right Aortic Arch in an Adult Female

Coarctation of a right aortic arch is rare congenital anomaly. We report a rare case of a 24-year-old female with coarctation of the right aortic arch with aberrant left subclavian artery between the right common carotid and right subclavian arteries. The coarctation progressed into complete obstruction as the interruption of the aorta in adulthood. To prevent cerebral complications and progression to heart failure, surgical procedure was selected. Extraanatomical bypass grafting between the ascending and descending aorta was successfully performed using cardiopulmonary bypass. Some patients diagnosed with interruption of the aortic arch in adulthood might be displaying progression of undiagnosed coarctation, as our in case. Three-dimensional computed tomography was useful to detect the obstructive lesion and to determine the surgical approach and methods.

Diaphragmatic hernia resulting from injury during microwave-assisted laparoscopic hepatectomy

A 31-year-old woman underwent microwave-assisted laparoscopic hepatectomy of the left lateral segment for focal nodular hyperplasia on January 14, 1998. On September 9, 1998, she felt continuous left abdominal pain and was admitted to our hospital for further examination. An upper gastrointestinal series showed converging folds of the greater curvature of the upper third of the stomach and craniad displacement of this portion. Thoracic magnetic resonance imaging showed herniation of the stomach into the pleural cavity. The patient was referred to our department, where she underwent surgery for a diaphragmatic hernia. The fundus of the stomach had escaped into the left pleural cavity through a defect in the diaphragm near where laparoscopic hepatectomy had been performed. The stomach was returned to the peritoneal cavity and the defect sutured. The patients postoperative course was uneventful. Although diaphragmatic hernia after laparoscopic surgery is a rare complication, with the performance of more advanced laparoscopic procedures and the use of higher-technology tissue-destruction/hemostatic devices such as the microwave coagulator, more caution should be observed to prevent injury to adjacent organs such as the diaphragm.

Differential effects of thiopental on methacholine- and serotonin-induced bronchoconstriction in dogs

BACKGROUND

Thiopental sometimes causes bronchospasm during induction of anaesthesia. In addition, we have reported previously that thiopental produced transient bronchospasm, which was blocked by atropine pretreatment, and worsened histamine-induced bronchoconstriction in dogs. Previous in vitro reports suggest that synthesis of contractile cyclooxygenase products, such as thromboxane A(2), may be involved in the mechanism of bronchospasm. However, the in vivo spastic effects have not been defined comprehensively.

METHODS

Twenty-seven mongrel dogs were anaesthetized with pentobarbital. Bronchoconstriction was elicited with methacholine (0.5 microg kg(-1)+5.0 microg kg(-1) min(-1); Mch group, n=7) or serotonin (10 microg kg(-1)+1 mg kg(-1) h(-1); 5HT group, n=20), and assessed as percentage changes in bronchial cross-sectional area (BCA, basal=100%) using a bronchoscope. In the 5HT group, dogs were subdivided into four groups of five each: S-5HT, I-5HT, 5HT-S and 5HT-A. In the S-5HT and I-5HT groups, 30 min before serotonin infusion dogs were given saline and indomethacin respectively at 5 mg kg(-1) i.v. In all groups, 30 min after bronchoconstrictor infusion started, dogs were given thiopental at doses between 0 (saline) and 20 mg kg(-1). In the 5HT-S and 5HT-A groups, dogs were given saline or atropine 0.2 mg kg(-1) i.v. 5 min after thiopental 20 mg kg(-1).

RESULTS

Methacholine and serotonin reduced BCA by about 50 and 40% respectively. Thiopental 20 mg kg(-1) increased and decreased BCA by about 20 and 10% in the Mch and 5HT groups respectively. Indomethacin and atropine did not attenuate the potentiation of serotonin bronchoconstriction produced by thiopental.

CONCLUSION

The present study indicates that thiopental may attenuate or worsen bronchoconstriction induced by muscarinic or serotonin receptor stimulation, respectively. The synthesis of contractile cyclooxygenase products and cholinergic stimulation may not be involved in the contractile effect of thiopental on serotonin bronchoconstriction.

Comparison of the BDProbeTec ET system with the Cobas Amplicor PCR for direct detection of Mycobacterium tuberculosis in respiratory samples

In the study presented here, the performance of the BDProbeTec ET system (Becton Dickinson, USA) was compared with the Roche Cobas Amplicor-PCR (Roche, Switzerland) to detect Mycobacterium tuberculosis complex (MTB) in clinical respiratory samples. The Bactec MGIT 960 liquid culture system (Becton Dickinson) was used as a reference method. A total of 411 samples were tested. Of the 93 culture-positive samples, both the BDProbeTec ET system and the Cobas Amplicor-PCR detected 87 (sensitivity, 93.5%). When only smear-negative samples were considered, the BDProbeTec ET exhibited a sensitivity of 50% and the Cobas Amplicor-PCR 60%. Specificity was 99.7% for the BDProbeTec ET system and 100% for the Cobas Amplicor-PCR. Percent agreement between the two nucleic amplification methods was 98.7%. Inhibition occurred in three (0.7%) samples in the BDProbeTec ET system. The high sensitivity and specificity of the BDProbeTec ET system suggest it is a useful method for the rapid and direct detection of MTB in smear-positive respiratory samples.

Induced HMGA1a expression causes aberrant splicing of Presenilin-2 pre-mRNA in sporadic Alzheimer's disease

The aberrant splicing isoform (PS2V), generated by exon 5 skipping of the Presenilin-2 (PS2) gene transcript, is a diagnostic feature of sporadic Alzheimer's disease (AD). We found PS2V is hypoxia-inducible in human neuroblastoma SK-N-SH cells. We purified a responsible trans-acting factor based on its binding to an exon 5 fragment. The factor was identified as the high mobility group A1a protein (HMGA1a; formerly HMG-I). HMGA1a bound to a specific sequence on exon 5, located upstream of the 5' splice site. HMGA1a expression was induced by hypoxia and the protein was accumulated in the nuclear speckles with the endogenous splicing factor SC35. Overexpression of HMGA1a generated PS2V, but PS2V was repressed by cotransfection with the U1 snRNP 70K protein that has a strong affinity to HMGA1a. HMGA1a could interfere with U1 snRNP binding to the 5' splice site and caused exon 5 skipping. HMGA1a levels were significantly increased in the brain tissue from sporadic AD patients. We propose a novel mechanism of sporadic AD that involves HMGA1a-induced aberrant splicing of PS2 pre-mRNA in the absence of any mutations.

Isolation and cDNA cloning of novel hydrogen peroxide-dependent phenol oxidase from the basidiomycete Termitomyces albuminosus

A novel hydrogen peroxide-dependent phenol oxidase (TAP) was isolated from the basidiomycete Termitomyces albuminosus. TAP is an extracellular monomeric enzyme with an estimated molecular weight of 67 kDa. The purified enzyme can oxidize various phenolic compounds in the presence of hydrogen peroxide, but cannot oxidize 3,4-dimethoxybenzyl (veratryl) alcohol. Mn(II) was not required for catalysis by TAP. The optimum pH for TAP activity was 2.3, which is the lowest known optimum pH for a fungal phenol oxidase. The cDNA encoding TAP was cloned with reverse transcription-polymerase chain reaction (RT-PCR) using degenerate primers based on the N-terminal amino acid sequence of TAP and 5' rapid amplification of cDNA ends (RACE)-PCR. The cDNA encodes a mature protein of 449 amino acids with a 55-amino-acid signal peptide. The deduced amino acid sequence of TAP showed 56% identity with dye-decolorizing heme peroxidase (DYP) from the ascomycete Geotrichum candidum Dec 1, but no homology with other known peroxidases from fungi.

Effects of stool dilution on the faecal Helicobacter pylori antigen test

OBJECTIVE

To examine the effects of stool dilution on the results of the faecal Helicobacter pylori antigen test.

METHODS

Stool samples from nine children with H. pylori infection were diluted with normal saline at dilutions of 1, 5, 10, 50, 100 and 500 times, and optical density (OD) was measured.

RESULTS

The faecal H. pylori antigen test yielded positive results for all samples at dilutions of 1:10 and less, although the sample from the case whose original stool showed the lowest OD value changed from positive to negative at a dilution of 1:50.

CONCLUSION

Our results suggest that stools at dilutions of less than 1:10 usually do not yield false-negative results in the faecal H. pylori antigen test, even in patients with low faecal antigen levels.

Doppler ultrasound monitoring for detection of microembolic signals in peripheral arteries

OBJECTIVE

to use Doppler ultrasound to detect peripheral microemboluation.

METHODS

standard Transcranial Doppler equipment was used to peripheral detect peripheral embolic high intensity transient signals (HITSs) in a pig model following injection of microparticles and atheroma, and in 23 patients who underwent open repair of an abdominal aortic aneurysm (AAA), six patients with blue toe syndrome and 10 age matched healthy subjects.

RESULTS

the pig study showed increasing signal intensity with particle size. Particles of 100 (n=24), 200 (n=17), and 400 microm (n=31) elicited 14, 25, 33 dB signals, respectively (p<0.05). During AAA surgery, the intensity (median) of HITSs before clamping (n=226) and after declamping (n=1216) were 14, and 20dB, respectively (p<0.001). Quite a few HITSs were detected after surgery. In patients with blue toe syndrome, a total of 63 HITSs could be detected, and the frequency of HITSs (median: 5.72/30min) was significantly higher than that in patients with AAA before surgery (0.065/30min) (p<0.001).

CONCLUSIONS

Doppler ultrasound technique may be a clinically useful test to guide the treatment of patients at risk of distal atheroembolic events.

Rhabdomyosarcoma (botryoid sarcoma) of the urinary bladder in a Maltese

A urinary bladder tumour was diagnosed in a two-year-old female Maltese with haematuria and pollakiuria on the basis of ultrasonography and pneumocystography findings. The mass was resected, and the bladder was preserved at surgery. Histological and immunohistochemical examination confirmed the tumour to be a rhabdomyosarcoma, which has rarely been reported in small breeds of dog. There was no recurrence of the tumour at the original site in the urinary bladder two months later, when the dog died due to metastasis to the liver. This is believed to be the first report of bladder rhabdomyosarcoma in a Maltese.