Breast cancer patient-reported outcomes on level 1 and level 2 oncoplastic procedures using BREAST-Q®

PURPOSE

In breast cancer management not only mortality and surgical morbidity measurements are important but also patient satisfaction indexes. The authors evaluated the satisfaction and health-related quality of life (HRQOL) using the breast-conserving therapy (BCT) and breast reduction (BR) modules of BREAST-Q^®.

METHODS

This is a cross-sectional study that analyzed breast cancer patients consecutively submitted to breast surgery between January 2011 and April 2018 using two modules of BREAST-Q^®. 968 patients were contacted and 232 answers were gathered: 171 patients submitted to oncoplastic level 1 surgery answered the BCT module and 61 submitted to oncoplastic level 2 surgery answered the BR module. Clinical data were retrieved from patients' medical records.

RESULTS

Among the 232 questionnaires received, the median scores for psychosocial well-being, sexual well-being and (postoperative) satisfaction with breasts for BCT and BR modules were, respectively, 77.0 and 73.5 (p = 0.17); 62.0 and 53.0 (p = 0.14); 72.0 and 66.0 (p = 0.66). The median of adverse effects of radiation in the BCT module was 87.0. The median satisfaction with outcome in the BR module was 86.0. Both groups of patients revealed high scores of satisfaction with care. For the BCT patients, satisfaction with breasts strongly correlated with sexual well-being and was moderately correlated with psychosocial and physical well-being. For the BR patients, the satisfaction with outcome strongly correlated with satisfaction with medical team and moderately correlated with the remaining scales.

CONCLUSION

Both oncoplastic surgery levels yielded similar satisfaction outcomes when assessed using BCT and BR modules of BREAST-Q^®.

Cardiac autonomic modulation in children with severe liver disease, before and after liver transplantation

BACKGROUND

The cardiovascular system is directly influenced by the autonomic nervous system (ANS); its changes affect heart rate variability (HRV) and are sensitive indicators of physiological changes. Autonomic dysfunction (AD) is manifested in up to 60% of patients with cirrhosis. Therefore, we aim to analyze the indexes of HRV pre- and post-surgery of children submitted for liver transplantation (LT).

METHODS

HRV, in children of both genders from 6 months of age to 10 years, that attended at the pediatric surgery clinic in the queue for LT at the Children's Institute were analyzed. To access HRV we analyzed indexes such as standard deviation of the RR intervals (SDNN), root-mean-square of the successive normal sinus RR interval difference (RMSSD), low frequency (LF), high frequency (HF), and LF/HF.

RESULTS

The analysis of the behavior of cardiac autonomic modulation, in the period prior to LT and after surgery, showed an increase in HRV linear parameters SDNN, TINN (triangular interpolation of NN interval histogram), HFms². In the time domain, there was also an increase in the HFms² index.

CONCLUSIONS

The analysis of the period preceding LT and two months after surgery showed an increase in the HRV linear parameters representing a global HRV improvement. In the time domain, there was also an increase in the HFms² index, parasympathetic tone of the HRV.

Initial experience with targeted axillary dissection after neoadjuvant therapy in breast cancer patients

Background

Targeted axillary dissection (TAD) combines sentinel node biopsy (SNB) with the removal of the previously marked metastatic node. TAD is a promising concept for axillary restaging in node-positive breast cancer patients with pathological complete response (pCR) to neoadjuvant therapy (NAT). We aimed to evaluate TAD feasibility in this context.

Methods

A prospective observational study was conducted in biopsy-confirmed cN1 patients. The removal of the clipped node (CN) was guided by intraoperative ultrasound. SNB used indocyanine green and patent blue V dye. If the CN or sentinel lymph nodes (SLN) had any metastatic foci, or the TAD procedure was unsuccessful, the patient underwent axillary lymph node dissection (ALND).

Results

Thirty-seven patients were included. TAD and SNB identification rates were 97.3%. Every retrieved CN was also a SLN. At the individual level, SNB identification rate was 89.2% with indocyanine green and 85.5% with patent blue V dye. The CN identification rate was 81.1%, being higher when the CN was localized on the intraoperative ultrasound (84.4% vs 60.0%). Nodal pCR was achieved by 54.1% of our patients and was more frequent in HER2-positive and triple-negative tumors (p = 0.039). Nineteen patients were spared from ALND.

Conclusion

TAD with intraoperative ultrasound-guided excision of the CN and SNB with indocyanine green and patent blue V dye is a feasible concept to identify patients without axillary residual disease after NAT, that can be spared from ALND, although the need for marking the biopsied node should be further investigated.

Electrical ammeter based on spin-valve sensor

The present work shows an electrical ammeter for laboratory purpose based on a magnetoresistive (MR) spin-valve (SV) sensor. The proposed ammeter measures a 10 A maximum current and offers a maximum frequency response between 150 and 800 kHz depending on the electronics whole gain. These features are due to the use of a new generation MR-SV current sensor and a conditioning electronics that compensates in frequency and temperature the sensor response. With little adjustments in the electronics and changing the position of the sensor with respect to current carrying conductor, the designed instrument is able to measure higher current levels. The work shows the proposed ammeter with its different subsystems and describes the procedure used to test the instrument. Also a discussion of the obtained experimental results is included.

Spintronic platforms for biomedical applications

Since the fundamental discovery of the giant magnetoresistance many spintronic devices have been developed and implemented in our daily life (e.g. information storage and automotive industry). Lately, advances in the sensors technology (higher sensitivity, smaller size) have potentiated other applications, namely in the biological area, leading to the emergence of novel biomedical platforms. In particular the investigation of spintronics and its application to the development of magnetoresistive (MR) biomolecular and biomedical platforms are giving rise to a new class of biomedical diagnostic devices, suitable for bench top bioassays as well as point-of-care and point-of-use devices. Herein, integrated spintronic biochip platforms for diagnostic and cytometric applications, hybrid systems incorporating magnetoresistive sensors applied to neuroelectronic studies and biomedical imaging, namely magneto-encephalography and magneto-cardiography, are reviewed. Also lab-on-a-chip MR-based platforms to perform biological studies at the single molecule level are discussed. Overall the potential and main characteristics of such MR-based biomedical devices, comparing to the existing technologies while giving particular examples of targeted applications, are addressed.

Surface studies on acrylic bone cement

Poly(methyl methacrylate) (PMMA) is used to fill the gap between the prosthesis and the surrounding bone in cemented arthroplasties. Biocompatibility problems related to bone cement application limit the clinical success of these cemented arthroplasties. Being the cement surface in close connection with the living bone, it is reasonable to assume that surface properties such as, surface composition and surface energy, will play a role in the biomaterial performance. X-ray photoelectron spectroscopy (XPS) analysis and surface energy studies were carried out during 4 months, in order to assess a possible correlation between aging time and surface changes. The aging of PMMA, in a biological model fluid, strongly influences the composition and wettability of the cement surface. These changes may be explained through the hydrolysis of PMMA ester groups and the subsequent hydrogen bonding. Although our study does not exactly reproduce the in vivo environment surrounding a prosthesis, it suggests that the changes in the composition and wettability of the surface may modulate the host response towards the implant, thus contributing to its loosening.

Study on the scale-up of human IgG3 purification using protein A affinity chromatography

The purification of human IgG3 subclass out of IgG (Immunoglobulin-G) was studied using protein A-Sepharose affinity chromatography. The effect of operational parameters such as flow rate, ionic strength, pH and size of sample was investigated, and the process was scaled-up 10-fold. The use of 0.5 m NaCl in the loading buffer had a dramatic effect in the purity of IgG3 recovered in the flowthrough fraction (values in the order of 97% were consistently obtained). This was attributed to a more effective binding of IgG subclasses 1, 2 and 4 to protein A (well known classical mechanism based in Fc fragment) and in some extent to a decrease in the binding of subclass 3 to protein A by the alternative mechanism based in the Fab fragment. The increase in residence time also increased in a relevant way the purity of IgG3. This is attributed to an increased effectiveness of the mechanisms mentioned above. The recovery yields in the IgG3 rich fraction were in the range 21-32% and are possibly a consequence of binding to protein A by the alternative mechanism and also due to deactivation during processing.

The effect of ethanol on acrylic bone cement

Prosthesis loosening is a major problem associated with the use of poly(methyl methacrylate) (PMMA) bone cement that may be related to a peri-implant vacuolisation commonly observed at bone-cement interface. Methyl methacrylate (MMA) monomer may be one of the cement components partly responsible for the mentioned vacuolisation due to a cytotoxic effect associated to this compound. Alcoholism has been related to bone necrosis in predisposed individuals. Furthermore, ethanol has been shown to clean material with adherent cement debris during cleaning procedure in laboratory. Consequently, we have decided to study whether ethanol will also be related to an increased liberation of MMA from the polymer matrix. 'In vitro' release studies using PMMA plates were conducted to access the role of ethanol on the liberation of the monomer. Contact angle measurements and surface tension estimation were also carried out in order to find a possible effect of ethanol on surface cement properties. Results suggest that ethanol, even in small quantities, enhances the leaching of the monomer from the polymer matrix, but does not considerably change the wettability properties of the cement surface.

Chronic oesophagitis in the cat

BACKGROUND

Our understanding of the pathophysiology of gastro-oesophageal reflux disease (GERD) in man is limited. The aim of the present study was to establish a long-term (>1 year) animal model for reflux oesophagitis which would allow us to study various aspects of the development of chronic reflux oesophagitis.

METHODS

Myotomy was carried out in the gastro-oesophageal junction in eight cats; seven other cats were sham-operated. Before the operation, and every 2 months thereafter, oesophagoscopy was carried out, biopsies were taken for histology, and manometry was performed to determine the lower oesophageal sphincter pressure (LESP). The cats were killed 1 year after the operation.

RESULTS

The myotomy operation resulted in a significantly decreased LESP. In oesophageal biopsies from these cats, there was a varying degree of oesophagitis starting already 2 months after surgery. In six of the eight myotomized cats there was hyperplasia of the stratum basale, and cardiac type metaplasia was observed in two cats. The control cats showed no significant changes in LESP or in the histology of the oesophagus.

CONCLUSIONS

In cats followed for more than a year, myotomy in the gastro-oesophageal junction results in reflux oesophagitis similar to that seen in patients with chronic gastro-oesophageal reflux.

Importance of ICOS-B7RP-1 costimulation in acute and chronic allograft rejection

Primary T cell activation requires B7-CD28 and CD40-CD154 costimulation, but effector T cell functions are considered to be largely independent of these costimulatory pathways. Although blockade of costimulation with cytolytic T lymphocyte-associated antigen 4-immunoglobulin (CTLA-4-Ig) or monoclonal antibody (mAb) to CD154 prolongs allograft survival, chronic rejection follows, which suggests that additional key costimulatory pathways are active in vivo. We found that both antibody to inducible costimulator (anti-ICOS) and an ICOS-Ig fusion protein suppressed intragraft T cell activation and cytokine expression and prolonged allograft survival in a manner similar to that in ICOS-/- allograft recipients. The combination of anti-ICOS therapy and cyclosporin A led to permanent engraftment. In addition, ICOS-B7RP-1 costimulation was required for the development of chronic rejection after CD40-CD154 blockade. These data demonstrate a key role for the ICOS-B7RP-1 pathway in acute and chronic rejection and highlight the benefits of targeting this pathway in combination with the use of conventional immunosuppressive agent.

The influence of vacuum mixing on methylmethacrylate liberation from acrylic cement powder

Polymethylmethacrylate (PMMA) bone cement is a biomaterial used to anchor prostheses during joint replacement surgery. Residual methylmethacrylate monomer (MMA) may be related with the cytotoxic effect of PMMA. The aim of the present paper was to investigate the effect of two different cement mixing methods: hand stirring at atmospheric pressure and under partial vacuum (0.330 and 0.154 bar) on residual monomer liberation in phosphate buffer saline solution from acrylic cement powder. Residual MMA content was determined by high-performance liquid chromatography. Mathematical models were applied to experimental dissolution data revealing that monomer release was significantly reduced in bone cement powder obtained at 0.154 bar vacuum pressure compared to the other mixing conditions. The kinetic models applied are consistent with a simple diffusion mechanism of the monomer from the polymer matrix.

Gallbladder muscle dysfunction in patients with chronic acalculous disease

BACKGROUND & AIMS

The mechanisms responsible for the abnormalities of gallbladder emptying in patients with chronic acalculous gallbladder disease (AGD) have not been elucidated. This study was designed to determine whether a muscle defect could explain this gallbladder dysfunction.

METHODS

Gallbladder contraction induced by a continuous intravenous cholecystokinin octapeptide (CCK-8) infusion was determined by ultrasonography in control subjects, patients with AGD, pigment stones, and cholesterol stones. Muscle cells were obtained by enzymatic digestion. (125)I-CCK-8 binding and [(35)S]guanosine triphosphate gamma S (GTP gamma S) binding studies were performed.

RESULTS

In vivo gallbladder contraction induced by CCK-8 was significantly lower in AGD (29.4%) and cholesterol stones (28.8%) than in pigment stones (59.8%) and normal controls (57.8%; P < 0.01). In vitro muscle cell contraction induced by CCK-8 was also lower in AGD than in pigment stones. It remained impaired in AGD after stimulation with the G-protein activators GTP gamma S and AlF(4) and with the second messenger 1,2-dioctanoyl-sn-glycerol. However, GTP gamma S binding induced by CCK-8 and vasoactive intestinal polypeptide and the binding capacity of CCK receptors were not different between AGD and pigment stones.

CONCLUSIONS

These findings suggest that there is a good correlation between in vivo and in vitro gallbladder response to CCK-8 in patients with AGD. Unlike those found in cholesterol stones, the muscle defects in AGD appear to reside in the contractile apparatus.

Natural occurrence of entomopathogenic nematodes (rhabditida: steinernema, heterorhabditis) in the azores

A soil survey for entomopathogenic nematodes was conducted throughout the nine islands of the Azorean archipelago. Forty-six out of 1,180 samples (3.9%) were positive, with Heterorhabditis spp. isolated from 30 sites on six islands and Steinernema spp. isolated from 16 sites on three islands. São Miguel and Terceira Islands were positive for both genera, and Pico Island was positive only for Steinernema. Entomopathogenic nematodes were found from sea level up to 750 m. Seventy percent of the samples positive for Heterorhabditis were collected below 150 m, whereas 62.5% of the samples positive for Steinernema were collected above 300 m. Heterorhabditis was not isolated above 450 m. Steinernema was collected mostly in loamy-sand and sandy-loam soils with a pH below 6, whereas Heterorhabditis was mostly collected in sandy and loamy-sand soils with pH higher than 6. Steinernema and Heterorhabditis were found in cropland, orchards, and pastures, while Heterorhabditis was found also in woodland and native vegetation.

In vitro release studies of methylmethacrylate liberation from acrylic cement powder

Bone cement or polymethylmethacrylate (PMMA) is commonly used for anchoring cemented prosthesis to the bone. Cytotoxic effect of culture media exposed to PMMA powder may be related with long term problems associated with acrylic cement application, being the monomer (methylmethacrylate) one of the cement's component partly responsible for the cytotoxic effect. The present work reports the studies of monomer release from acrylic bone cement powder under different experimental conditions: setting time of PMMA (in solution and air) and different culture media composition. High-performance liquid chromatography was used for the determination of residual monomer. Mathematical models were applied to experimental dissolution data revealing that monomer release is lightly affected by the studied variables. The monomer release seems to be a surface phenomena, suggesting that the possible actions of monomer will mainly be due to the initial loss of non polymerized monomer rather than to further depolymerization of the already polymerized cement.

Defect of receptor-G protein coupling in human gallbladder with cholesterol stones

Human gallbladders with cholesterol stones (ChS) exhibit an impaired muscle contraction and relaxation and a lower CCK receptor-binding capacity compared with those with pigment stones (PS). This study was designed to determine whether there is an abnormal receptor-G protein coupling in human gallbladders with ChS using (35)S-labeled guanosine 5'-O-(3-thiotriphosphate) ([(35)S]GTPgammaS) binding, (125)I-labeled CCK-8 autoradiography, immunoblotting, and G protein quantitation. CCK and vasoactive intestinal peptide caused significant increases in [(35)S]GTPgammaS binding to Galpha(i-3) and G(s)alpha, respectively. The binding was lower in ChS than in PS (P < 0.01). The reduced [(35)S]GTPgammaS binding in ChS was normalized after the muscles were treated with cholesterol-free liposomes (P < 0.01). Autoradiography and immunoblots showed a decreased optical density (OD) for CCK receptors, an even lower OD value for receptor-G protein coupling, and a higher OD for uncoupled receptors or Galpha(i-3) protein in ChS compared with PS (P < 0.001). G protein quantitation also showed that there were no significant differences in the Galpha(i-3) and G(s)alpha content in ChS and PS. We conclude that, in addition to an impaired CCK receptor-binding capacity, there is a defect in receptor-G protein coupling in muscle cells from gallbladder with ChS. These changes may be normalized after removal of excess cholesterol from the plasma membrane.

CCK receptor dysfunction in muscle membranes from human gallbladders with cholesterol stones

Human gallbladders with cholesterol stones exhibit impaired muscle contraction induced by agonists that act on transmembrane receptors, increased membrane cholesterol content, and abnormal cholesterol-to-phospholipid ratio compared with those with pigment stones. The present study was designed to investigate the functions of the CCK receptor of gallbladder muscle membranes by radioreceptor assay and cross-linking. 125I-labeled CCK-8 binding was time-dependent, competitive, and specific. Scatchard analysis showed that the maximum specific binding (Bmax) was significantly decreased in cholesterol compared with pigment stone gallbladders (0.18 +/- 0. 07 vs. 0.38 +/- 0.05 pmol/mg protein, P < 0.05). In contrast, the affinity for CCK was higher in cholesterol than pigment stone gallbladders (0.18 +/- 0.06 vs. 1.2 +/- 0.23 nM). Similar results were observed in binding studies with the CCK-A receptor antagonist [3H]L-364,718. Cross-linking and saturation binding studies also showed significantly less CCK binding in gallbladders with cholesterol stones. These abnormalities were reversible after incubation with cholesterol-free liposomes. The Bmax increased (P < 0.01) and the dissociation constant decreased (P < 0.001) after incubation with cholesterol-free liposomes. In conclusion, human gallbladders with cholesterol stones have impaired CCK receptor binding compared with those with pigment stones. These changes are reversed by removal of the excess membrane cholesterol. These receptor alterations may contribute to the defective contractility of the gallbladder muscle in patients with cholesterol stones.

Excess membrane cholesterol alters human gallbladder muscle contractility and membrane fluidity

BACKGROUND & AIMS

The relationship between muscle contractility, plasma membrane cholesterol, and fluidity was investigated in human gallbladders with gallstones.

METHODS

Isolated gallbladder muscle cells were used to measure contraction. Plasma membranes of gallbladder muscle were purified in a sucrose gradient and measured for cholesterol content and cholesterol/phospholipid mole ratio. Membrane fluidity was determined by using fluorescence polarization and was expressed as the reciprocal of anisotropy.

RESULTS

The maximal contraction induced by cholecystokinin octapeptide was significantly less in gallbladders with cholesterol stones than in those with pigment stones. The membrane cholesterol content and cholesterol/phospholipid mole ratio were significantly higher in gallbladders with cholesterol stones than in those with pigment stones. Membrane anisotropy was also higher than in gallbladders with pigment stones, reflecting lower membrane fluidity in gallbladders with cholesterol stones. After muscle cells from cholesterol stone gallbladders were incubated with cholesterol-free liposomes for 4 hours, cholecystokinin octapeptide-induced contraction, membrane cholesterol content and cholesterol/phospholipid ratio, and membrane fluidity returned to normal levels.

CONCLUSIONS

Gallbladder muscle from patients with cholesterol stones has increased membrane cholesterol/phospholipid mole ratio and decreased membrane fluidity resulting in impaired muscle contractility. These abnormalities are corrected by removing the excess cholesterol from the plasma membranes.

Intracellular RNA cleavage by the hairpin ribozyme

Studies involving ribozyme-directed inactivation of targeted RNA molecules have met with mixed success, making clear the importance of methods to measure and optimize ribozyme activity within cells. The interpretation of biochemical assays for determining ribozyme activity in the cellular environment have been complicated by recent results indicating that hammerhead and hairpin ribozymes can cleave RNA following cellular lysis. Here, we report the results of experiments in which the catalytic activity of hairpin ribozymes is monitored following expression in mammalian cells, and in which post-lysis cleavage is rigorously excluded through a series of biochemical and genetic controls. Following transient transfection, self-processing transcripts containing active and inactive hairpin ribozymes together with cleavable and non-cleavable substrates were generated within the cytoplasm of mouse OST7-1 cells using T7 RNA polymerase. Unprocessed RNA and products ofintracellular cleavage were detected and analyzed using a primer-extension assay. Ribozyme-containing transcripts accumulated to a level of 4 x 10(4) copies per cell, and self-processing proceeded to an extent of >75% within cells. Cellular RNA processing was blocked by mutations within the ribozyme (G8A, G21U) or substrate (DeltaA-1) that, in vitro , eliminate cleavage without affecting substrate binding. In addition to self-processing activity, trans -cleavage reactions were supported by the ribozyme-containing product of the self-processing reaction, and by the ribozyme linked to the non-cleavable substrate analog. Ribozyme activity was present in extracts of cells expressing constructs with active ribozyme domains. These results provide direct biochemical evidence for the catalytic activity of the hairpin ribozyme in a cellular environment, and indicate that self-processing ribozyme transcripts may be well suited for cellular RNA-inactivation experiments.

Gallbladder relaxation in patients with pigment and cholesterol stones

BACKGROUND & AIMS

Gallbladders with cholesterol stones show a defective contraction in response to agonists. The aim of this study was to investigate the muscle relaxation of human gallbladders with cholesterol or black pigment gallstones.

METHODS

Gallbladder relaxation was measured in vitro using muscle strips and single muscle cells. Relaxation was expressed as percent inhibition of either basal active tension in strips or maximal cell contraction induced by diacylglycerol. The production of cyclic nucleotides was determined using a 125I-labeled radioimmunoassay kit.

RESULTS

Frequency-dependent relaxation evoked by electrical field stimulation was significantly lower in gallbladders with cholesterol stones than in gallbladders with pigment stones. Relaxation and adenosine 3',5'-cyclic monophosphate (cAMP) production induced by isoproterenol, vasoactive intestinal peptide, and forskolin were also significantly decreased in gallbladders with cholesterol stones. However, the relaxation in response to 8-bromo-cAMP, nitric oxide (NO), and the NO donor S-nitroso-N-acetylpenicillamine (SNAP), which circumvent plasma membrane receptors and directly activate intracellular mechanisms, was similar in gallbladders with cholesterol and pigment stones. Guanosine 3',5'-cyclic monophosphate production induced by NO and SNAP was also similar.

CONCLUSIONS

Human gallbladder muscle from specimens with cholesterol stones show an impaired relaxation and lower cAMP production compared with specimens with pigment stones. The muscle defect(s) responsible for this impairment seem to be in the plasma membranes.

Different pathways mediate cholecystokinin actions in cholelithiasis

Smooth muscle from gallbladders with cholesterol stones exhibits impaired response to cholecystokinin (CCK). This study investigated whether the impaired response is mediated by different signal-transduction pathways responsible for CCK-induced contraction in prairie dog and human gallbladders with cholesterol stones. Gallbladder muscle cells were isolated enzymatically to study contraction. Protein kinase C (PKC) activity was measured by examining the phosphorylation of a specific substrate peptide from myelin basic protein Ac-MBP-(4-14). Gallbladder muscle cells from high-cholesterol-fed prairie dogs contracted less in response to CCK octapeptide (CCK-8) than those from the control group. However, inositol-1,4,5-trisphosphate (IP3), diacylglycerol, and guanosine 5'-O-(3-thiotriphosphate) induced the same magnitudes of contraction in these two groups. In control prairie dog and human gallbladders, the maximal contraction caused by 10(-8) M CCK-8 was blocked by the calmodulin antagonist CGS9343B but not by the PKC inhibitor H-7. Conversely, in gallbladders with cholesterol stones from prairie dogs or human patients, the maximal contraction induced by 10(-8) M CCK-8 was blocked by H-7 and chelerythrine but not by CGS9343B. In these gallbladders CCK-8 caused a significant PKC translocation from the cytosol to the membrane. High CCK concentrations may activate the calmodulin-dependent pathway in functionally normal gallbladder muscle and the PKC-dependent pathway in muscle from gallbladders with cholesterol stones. The defect of gallbladder muscle after cholesterol feeding and stones might reside in the steps before G protein activation.

Direct G protein activation reverses impaired CCK signaling in human gallbladders with cholesterol stones

Human gallbladders were used to investigate the mechanisms of the impaired contraction induced by cholecystokinin (CCK) associated with cholesterol stones. Single muscle cells were isolated enzymatically with collagenase. Inositol 1,4,5-trisphosphate was measured by high-performance liquid chromatography. Diacylglycerol was assayed by thin-layer chromatography. CCK stimulation showed decreased muscle contraction and production of inositol 1,4,5-trisphosphate and diacylglycerol in gallbladders with cholesterol stones compared with those with pigment stones. Exogenous calmodulin induced maximal contraction of 22.4 +/- 0.5 and 21.0 +/- 0.6% in gallbladders with cholesterol and pigment stones, respectively. Similar findings were observed with a synthetic diacylglycerol analogue. Two G protein activators, aluminum fluoride and guanosine 5'-O-(3-thiotriphosphate), evoked similar responses in these two types of gallbladders, with maximal contractions of 21.3 +/- 0.4 and 23.3 +/- 0.5%, respectively, in those with cholesterol stones and 20.9 +/- 0.8 and 22.6 +/- 0.4%, respectively, in those with pigment stones. These results suggest that receptor-dependent ligands like CCK cannot fully activate the intracellular pathways, which, however, can be fully stimulated by circumventing receptors with G protein activators or second messengers. After G protein activation, the pathways appear to be functionally intact. The defect might then reside in the receptor or in the interaction between receptors and G proteins.

Percutaneous anterior discectomy under ultrasound guidance

The object of this experiment was to demonstrate that, by using a peritoneal fluid infusion coupled with ultrasound guidance, a safe anterior entry into the L5-S1 disc of the pig could be made. The goal was to develop a procedure with the advantages of a laparoscopic approach to the disc which has been published to allow removal of extruded herniations, that a neurosurgeon could perform without a general surgeon in attendance. The procedure was carried out under general anesthesia and fluoroscopic control. One liter of normal saline was then infused into the abdomen of a pig. Under ultrasound guidance and laparoscopic confirmation, a Nucleotome was placed into the L5-S1 disc and the disc was aspirated. The results showed that the disc was safely entered in all 5 pigs. The disc was successfully removed in 4 of 5 pigs. In all animals the bowel floated out of the pelvis, obviating the need for bowel manipulation. Laparoscopic ultrasound was needed for visualization in 3 pigs, while external ultrasound was used in two. Our conclusion is that peritoneal fluid infusion and ultrasound guidance, when applied to laparoscopic anterior discectomy, eliminates the need for retroperitoneal dissection and bowel manipulation, significantly simplifying the laparoscopic discectomy procedure.

Laparoscopic unroofing of a renal cyst via a mesocolonic window: a different approach

We report a case of an elective laparoscopic transperitoneal removal of a large renal cyst by dividing the colonic mesentery without mobilizing the colon to gain access to the kidney. This appears to be a safe and potentially less costly approach compared to the standard flank approach of these simple renal cysts.

Cholecystokinin-coupled intracellular signaling in human gallbladder muscle

BACKGROUND/AIMS

It has been shown that cholecystokinin (CCK) contracts the gallbladder muscle by utilizing intracellular calcium, but the intracellular pathways have not been elucidated. The present study was designed to characterize the signal transduction pathways that mediate CCK-induced contraction of human gallbladder muscle.

METHODS

Single muscle cells were isolated from human gallbladders by enzymatic digestion with collagenase. Permeable cells were obtained by incubation with saponin. Protein kinase C (PKC) activity was determined by measuring the phosphorylation of a specific substrate peptide from myelin basic protein, Ac-MBP(4-14).

RESULTS

The inositol-1,4,5-trisphosphate (IP3) antagonist heparin blocked the contractions induced by CCK. The PKC inhibitor H-7 blocked the contractions caused by low, but not high, concentrations of CCK and IP3. In contrast, the calmodulin inhibitor CGS9343B blocked the contractions induced by high, but not low, doses of CCK and IP3. Furthermore, exogenously activated calmodulin blocked the PKC-mediated contraction induced by diacylglycerol. Direct measurements of PKC activity showed that low, but not high, CCK concentrations caused PKC translocation.

CONCLUSIONS

CCK contracts the gallbladder muscle via IP3-mediated calcium release. CCK activates the PKC pathway at low concentrations, whereas it activates the calmodulin pathway at high concentrations, which in turn inhibits the activation of PKC.

Improvement in survival from typhoid ileal perforation. Results of 221 operative cases

Typhoid ileal perforation remains a frequently fatal illness in the developing world. The purpose of a retrospective review of 195 cases was to ascertain prognostic indices and therapeutic options influencing outcome. The overall mortality rate of 31% was worsened by extremes of age (p less than 0.025), generalized peritonitis (p less than 0.025), lower white blood cell count (p less than 0.05), increased number of perforations (p less than 0.005), and postoperative enterocutaneous fistula (p less than 0.005). Double-layer closure of the perforation lowered the mortality rate compared with single-layer closure (p less than 0.01). Broader-spectrum antibiotics, in the form of chloramphenicol with gentamycin, metronidazole, or both, reduced the mortality rate compared with chloramphenicol alone (p less than 0.05). Based on these findings, a prospective series was initiated in which all patients were treated with two-layer closure and chloramphenicol, gentamycin, and metronidazole. The mortality rate of 8% for the 26 patients treated in this manner confirmed the improved survival with these treatment modalities. Improved survival from typhoid perforation is possible with simple, low-cost measures.

Value of random endoscopic biopsy in the diagnosis of bladder carcinoma in situ

The data obtained from 2,272 random biopsies performed on cystocopically normal mucosa in 457 cases of primary bladder tumors, that did not undergo any previous treatment, are present. Dysplasia was found in 119 cases (26.04%) and carcinoma in situ in 100 cases (21.88%). The relationship between cancer in situ and tumoral grade was: G1, 4 of 76 (5.26%); G2, 33 of 225 (14.66%), and G3, 58 of 152 (38.16%). The relationship between cancer in situ and tumoral stage for superficial tumors (pTa-pT1) was 52 of 314 (16.56%), and for deep tumors (pT2, pT3, pT4), 42 of 109 (38.53%). In this least group of 109 cases, 53 cystectomies were performed and the diagnosis obtained by random biopsy and mapping of the surgical sample were correlated. A coincidence in both techniques was found in 77.36% of the cases.