The beavertail modified radial forearm free flap: Retrospective review of a versatile technique to increase flap bulk in the head and neck

OBJECTIVE

Utilization of free tissue transfers in head and neck reconstruction has greatly increased due to their dependability and reliability. Anterolateral thigh (ALT) and rectus abdominus (RA) free flaps may provide too much soft tissue bulk, especially in patients with a large body habitus. A radial forearm free flap (RFFF) may be modified with a "beaver tail" (BT), which provides a flap whose bulk may be tailored to a defect. The purpose of this paper is to describe the technique, how it can be used for a variety of defects and the outcomes of these reconstructions.

METHODS

A retrospective review of prospectively collected data was performed at single tertiary care center between 2012 and 2022. BT-RFFF was designed by leaving a fibroadipose tail vascularized to branches of the radial artery or separated from the vascular pedicle and left attached to the proximal portion of the skin paddle. Functional outcomes, tracheostomy dependence, and gastrostomy tube (G-tube) dependence as well as complications were determined.

RESULTS

Fifty-eight consecutive patients undergoing BTRFFF were included. Defects reconstructed included: oral tongue and/or floor of mouth 32 (55%), oropharynx 10 (17%), parotid 6 (10%), orbit 6 (10%), lateral temporal bone 3 (5%), and mentum 1 (2%). Indications for BTRFF were: need for bulk when the ALT and RA were too thick (53%) and need for a separate subcutaneous flap for contouring or deep defect lining (47%). Complications directly related to beavertail included a widened forearm scar (100%), wrist contracture (2%) partial flap loss (2%), and flap loss requiring a revision flap (3%). Ninety-three percent of patients with oral/oropharyngeal defects and 12-month follow-up tolerated oral intake without aspiration and 76% were tube-independent. Ninety-three percent were tracheostomy-free at last follow-up.

CONCLUSION

The BTRFF is a useful tool for reconstructing complex 3D defects requiring bulk where an ALT or rectus would otherwise provide too much bulk.

1012 Urologic Features Related to the First Uninterrupted Sleep Period (FUSP) in Nocturia

Introduction

In nocturia, longer FUSP (time to first void) correlates with better quality sleep (Bliwise et al, JCSM 2015;11:53-5) and, with treatment, longer FUSP is associated with decreased nightly voids (Epstein et al, Neurourol Urodyn 2018;37:186-91). We examined urologic correlates of FUSP in an outpatient nocturia population without comorbidities (CHF, OSA, ESRD, diuretics).

Methods

Participants (n=119; men) kept a home flow/volume diary, tracking clock time and quantity of each urination across a 24-hr period. FUSP was defined as time between going to bed and time of first void. We analyzed the urine volume at first nocturnal void (FNVV) (i.e., at end of FUSP). We also analyzed all nighttime volumes and divided by reported hours of sleep to impute nocturnal urine production (NUP) (in ml/hr, classified as high [>90 ml/hr] [n=49] vs low [<90 ml/hr] [n=60])—a measure correlated with number of nocturia episodes (van Doorn et al, J Urol 2014;191:1034-9). Nocturnal maximal voided volume (NMVV) at any single nocturnal void defined maximal functional nocturnal bladder capacity. Data were analyzed non-parametrically.

Results

For 53 of 119 patients, FNVV was identical to NMVV. This was more likely in patients with NUP >90 ml/hr vs <90 ml/hr (59% vs 40%, p=.046). High (vs low) NUP rates were also associated with higher FNVV (300 [225-420] vs 135 [100-200] ml, p<.001), as well as higher number of voids (3 vs. 2, p=.03).

Conclusion

For nearly half of these nocturia patients, the volume at first void occurred at their maximal nocturnal volume. In nocturia, higher FNVV also reflects greater overall nocturnal volume of urine produced, and excess urine volume (as opposed to insufficient bladder capacity) likely plays a central role in the pathogenesis of nocturia in these patients. The extent to which these higher initial volumes represent free-water vs solute-driven clearance is currently under investigation.

Support

N/A

0823 Age-Related Changes in Nocturnal Urine Composition

Introduction

In humans sleeping nocturnally, nocturnal polyuria (NP) refers to high rate of overnight urine production. NP is a heterogeneous condition that may reflect both free water and/or sodium diuresis, but the influence of age on differential fluid handling remains poorly understood. This study examined diuresis rate, sodium clearance, and free water clearance (FWC) by age, time of day (nighttime vs. daytime) and NP status (positive/negative) in subjects under entrained conditions sleeping nocturnally.

Methods

Convenience samples (age range 18-91; 82 men, 148 women) recruited from a urology ambulatory care unit (n=135) or continence clinic (n=95) collected 8 urine samples at 3-hour intervals over a single 24-hr period. Three separate mixed linear models were constructed for diuresis rate, sodium clearance, and FWC using four predictors: NP status (present [>90mL/h] vs. absent), time of day (night = 0100, 0400, 0700), age (as a continuous measure), and study source.

Results

Subjects with NP experienced both higher nighttime vs. daytime diuresis rate (1.89 vs. 1.44 mL/min, p<0.001), sodium clearance (0.91 vs. 0.74 mL/min, p<0.001), and FWC (-0.38 vs. -0.71 mL/min, p<0.001), whereas subjects without NP demonstrated lower nighttime vs. daytime diuresis rate (0.94 vs. 1.06, p=0.004) and no difference in sodium clearance (0.59 vs. 0.64, p=0.120) or FWC (-0.80 vs. -0.86, p=0.268). Regardless of NP status, FWC increased with age (p=0.039), and older age (>70) was accompanied by an increase in the ratio of nighttime/daytime diuresis rate and both nighttime and daytime sodium clearance.

Conclusion

Irrespective of NP, older adults experience proportionally greater nocturnal sodium clearance, as well as a complex surge in both daytime and nighttime FWC. The data imply that both nocturnal sodium clearance and FWC may reflect the relevant substrate underlying excess nocturnal urine production in elderly persons.

Support

N/A

0822 Frail Older Men With Nocturia are Disproportionately Affected by Excess Nocturnal Urine Production

Introduction

Nocturia is a risk factor for falls and hip fractures in older adults. We determined whether the Frailty Index (FI), incorporating comorbidities, functional performance, and physical signs, was associated with nocturia frequency and/or overnight urine production.

Methods

We examined nightly (24-hour) voiding diaries (men ≥65 years) in an outpatient urologic clinic demonstrating ≥2 nocturnal voids (n=158). FI calculations followed Rockwood (CMAJ 2005;173:489-95). A total of 39 conditions were assessed. Three FI groups were established: Low (≤0.077) (n=59), Intermediate (>0.077 and <0.179) (n=58), and High (≥0.179) (n=41). We compared number of nocturnal voids (NV), nocturnal urine volume (NUV) (in mL), and 24-hr total urine volume (24-hr TUV) (in mL) across groups.

Results

NV did not differ by group (p=0.333) (median for all groups=3). However, NUV (916 [671-1419] vs. 690 [505-942] vs. 630 [500-1050] mL) differentiated the High, Medium and Low FI groups (p<0.001 via Kruskal-Wallis with Bonferroni pairwise adjustments), respectively. Similarly, 24-hr TUV differentiated the 3 groups (2200 [1800-2550] vs. 1620 [1259-2119] vs. 1650 [1390-2517] mL, p=0.005). Differences in NUV remained significant (p=0.006) after eliminating Diabetes Mellitus cases (n=44). However, differences did not persist for 24-hr TUV (p=0.180).

Conclusion

Higher NUV, but not 24-hr TUV, was a robust correlate of frailty in these older men. Accounting for diabetes did not diminish the effect. Although undiagnosed sleep apnea remains a possible cause, recent chronobiologic data (Monaghan et al, Age Aging, 2020, in press) suggest that nocturia in the aged is characterized by excess free water clearance early in the sleep period. This argues against solute-driven urine production (as might be expected in sleep apnea) in accounting for the effect. Nocturia may represent a conspicuous and important change in circadian rhythm of urine production occurring in old age.

Support

N/A

fMRI evaluation of cochlear implant candidacy in diffuse cortical cytomegalovirus disease

Congenital cytomegalovirus infection is the most frequent nongenetic cause of pediatric hearing loss in the United States, affecting approximately 8,000 children each year. Due in part to variable cytomegalic involvement of the auditory cortex, cochlear implantation outcomes have varied widely. Functional magnetic resonance imaging (fMRI) has the potential to assist in determining candidacy for cochlear implantation through the detection of intact auditory pathways including the cortex. We report a case of a 21-month-old girl with cytomegalovirus-related deafness and diffuse white matter involvement in which fMRI was a determining factor for cochlear implantation and side selection.

Control of H- and J-aggregate formation via host-guest complexation using cucurbituril hosts

The binding interactions between two cyanine dyes, pseudoisocyanine (PIC) and pinacyanol (PIN), and the cucurbit[n]uril hosts, cucurbit[7]uril (CB7) and cucurbit[6]uril (CB6), were investigated by electronic absorption spectroscopy and DFT computational methods. The CB7 host forms more stable complexes with both dyes than CB6 and the computational studies suggest that the cavity of the smaller host CB6 is not threaded by the dyes. The equilibrium association constants (K) for complexation by CB7 were measured and found to be 2.05 x 10(4) and 3.84 x 10(5) M(-1) for PIC and PIN, respectively, in aqueous media at 23 degrees C. CB7 complexation was found to effectively disrupt the intermolecular forces responsible for the aggregation of both dyes. Thus, CB7 completely disrupts the J-aggregates formed by PIC and the H-aggregates (as well as lower concentrations of J-aggregates) formed by PIN. In both cases a competing guest, 1-aminoadamantane (AD), could be used to adjust the extent of aggregation of the cyanine dye. AD regulates aggregate formation because it forms an extremely stable complex with CB7 (K approximately = 10(12) M(-1)) and exerts a tight control on the CB7 concentration available to interact and bind with the dye.

Nocturia in men

Nocturia is a common source of sleep disturbance in men and can result from many different causes. A patient-generated frequency/volume chart, along with several simple mathematical formulas, is used to classify nocturia according to its principal aetiology. The categories are nocturnal polyuria (NP), reduced voided volumes, 24-h polyuria and a combination of the aforementioned factors. Identification of the precise type of nocturia can help direct treatment in the cause-specific manner. In particular, use of the antidiuretic desmopressin can be of benefit in those with NP and may also be useful as part of a combination treatment approach in nocturia of mixed aetiology.

Monomeric endotoxin:protein complexes are essential for TLR4-dependent cell activation

Potent TLR4-dependent cell activation by Gram-negative bacterial endotoxin depends on sequential endotoxin?protein and protein?protein interactions with LBP, CD14, MD-2 and TLR4. LBP and CD14 combine, in an albumin-dependent fashion, to extract single endotoxin molecules from purified endotoxin aggregates (E(agg)) or the bacterial outer membrane and form monomeric endotoxin:CD14 complexes that are the preferred presentation of endotoxin for transfer to MD-2. Endotoxin in endotoxin:CD14is readily transferred to MD-2, again in an albumin-dependent manner, to form monomeric endotoxin:MD-2 complex. This monomeric endotoxin:protein complex (endotoxin:MD-2) activates TLR4 at picomolar concentrations, independently of albumin, and is, therefore, the apparent ligand in endotoxin-dependent TLR4 activation. Tetra-, penta-, and hexa-acylated forms of meningococcal endotoxin (LOS) react similarly with LBP, CD14, and MD-2 to form endotoxin:MD-2 complexes. However, tetra- and penta-acylated LOS:MD-2 complexes are less potent TLR4 agonists than hexa-acylated LOS:MD-2. This is mirrored in the reduced activity of tetra-, penta- versus hexa-acylated LOS aggregates (LOS(agg)) + LBP toward cells containing mCD14, MD-2, and TLR4. Therefore, changes in agonist potency of under-acylated meninigococcal LOS are determined by differences in properties of monomeric endotoxin:MD-2.

Videourodynamic studies in men with lower urinary tract symptoms: a comparison of community based versus referral urological practices

PURPOSE

We compared the clinical and urodynamic characteristics of men referred for evaluation of lower urinary tract symptoms in community based versus referral urological practices and examined the various pathophysiological mechanisms of these symptoms.

MATERIALS AND METHODS

We reviewed a multicenter urodynamics database of 963 consecutive men referred for the evaluation of persistent lower urinary tract symptoms at 2 community based and 1 urological referral center. Of the 963 patients in the database 422 (44%) were excluded from study due to neurological disorder in 41%, previous urinary or pelvic surgery in 27% and the use of medications known to affect voiding in 24%. A total of 541 patients with a mean age plus or minus standard deviation of 64.4 +/- 13.8 years met study inclusion criteria and were analyzed further. We compared the clinical and urodynamic characteristics of patients at the community and referral centers.

RESULTS

Lower urinary tract symptoms were equally common in men presenting to community and referral centers. The most common symptom was difficult voiding, followed by frequency, urgency and nocturia in 58%, 54%, 43% and 40% of the study population, respectively. Urodynamic diagnoses were also similar in the 2 groups. Although bladder outlet obstruction was diagnosed in 69% of patients, it was the only urodynamic finding in a third of the patients with obstruction. The main concomitant urodynamic diagnoses were detrusor overactivity, bladder hyposensitivity, impaired detrusor contractility, low bladder compliance and bladder hypersensitivity in 47%, 10%, 10%, 9% and 3% of obstructed cases, respectively.

CONCLUSIONS

The pathophysiology of lower urinary tract symptoms in men is multifactorial, and similar at community practice and tertiary referral centers. The disparity in urodynamic findings and subjective symptoms emphasizes the need for a thorough and early clinical and urodynamic evaluation.

Outcome results of transurethral collagen injection for female stress incontinence: assessment by urinary incontinence score

PURPOSE

We assessed the results of collagen injection for female sphincteric incontinence using strict subjective and objective criteria.

MATERIALS AND METHODS

We evaluated 63 consecutive women with sphincteric incontinence who underwent a total of 131 transurethral collagen injections. Sphincteric incontinence was confirmed by urodynamics. All patients were treated with 1 to 5 transurethral collagen injections and treatment outcome was classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence documented by a 24-hour diary and pad test, and patient assessment that cure was achieved. Failure was defined as poor objective results and patient assessment that treatment failed. Cases that did not fulfill these cure and failure criteria were considered improved and further classified as a good, fair or poor response.

RESULTS

Mean patient age plus or minus standard deviation was 67.7 +/- 12.8 years. All women had a long history of severe stress urinary incontinence, 18 (29%) underwent previous anti-incontinence surgery, and 41% had combined stress and urge incontinence. Preoperatively diary and pad tests revealed a mean of 7.5 +/- 4.6 incontinence episodes and 152 +/- 172 gm. of urine lost per 24 hours. Overall 1 to 5 injections were given in 26, 17, 13, 3 and 4 patients, respectively. Mean interval between injections was 4.4 +/- 5.7 months, mean followup was 12 +/- 9.6 months, and mean interval between the final injection and outcome assessment was 6.4 +/- 4.9 months. There was a statistically significant decrease in the total number of incontinence episodes per 24-hour voiding diary after each injection session. Although there was a clear trend toward decreased urinary loss per 24-hour pad test, statistical significance was not established. Using the strict criteria of our outcome score overall 13% of procedures were classified as cure, 10%, 17% and 42% as good, fair and poor, respectively, and 18% as failure.

CONCLUSIONS

As defined by strict subjective and objective criteria, we noted a low short-term cure rate after collagen injection in women with severe sphincteric incontinence. It remains to be determined how patients with less severe incontinence would fare using our outcome assessment instruments.

Nocturia in adults: etiology and classification

Nocturia is one of the most bothersome of all urologic symptoms, yet even a rudimentary classification does not exist. We herein propose a classification system of nocturia based on a retrospective study. The records of 200 consecutive patients with nocturia were reviewed. Evaluation included history, micturition diary (including day, night, and 24-hr voided volume), postvoid residual urine (PVR), and videourodynamic study (VUDS). Functional bladder capacity (FBC) was determined to be the largest voided volume in a 24-hr period. The etiology of nocturia was thus classified into one of three groups: nocturnal polyuria ([NP] in which voided urine volume during the hours of sleep exceeds 35% of the 24-hr output), nocturnal detrusor overactivity ([NDO] defined as nocturia attributable to diminished bladder capacity during the hours of sleep), and mixed (NP+NDO); polyuria (24-hr urine output >2,500 cc) was classified separately. There were 129 women and 65 men ranging in age from 17 to 94 years (x=59). Overall 13 (7%) had NP, 111 (57%) NDO, and 70 (36%) had a mixed etiology of their nocturia (both NP and NDO). Forty-five (23%) also had polyuria. These data confirm that the etiology of nocturia is multifactorial and in many instances unrelated to the underlying urologic condition. Nocturnal overproduction of urine is a significant component of nocturia in 43% of patients, most of whom will also have NDO. We believe that treatment should be directed at both conditions.

The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study

PURPOSE

We examine various mechanisms of post-radical prostatectomy incontinence.

MATERIALS AND METHODS

A total of 83 consecutive men (mean age 68 +/- 6.6 years) referred for evaluation of persistent post-radical prostatectomy incontinence were enrolled in the study. All patients underwent clinical and urodynamic evaluation. Final diagnosis was based on clinical judgment considering patient history, pad test, voiding diary, free (unintubated) uroflow measurements, video urodynamics and linear passive urethral resistance relation curves. We compared free uroflow and pressure flow obtained with a 7Fr urethral catheter in place, and empirically defined low urethral compliance as at least 10 ml. per second difference between these measurements.

RESULTS

Sphincteric incontinence was the most common urodynamic finding, occurring in 73 patients (88%). Detrusor instability was identified in 28 patients (33.7%) and in 6 (7.2%) was the main cause of incontinence. In 2 other patients bladder outlet obstruction (1.2%) or impaired detrusor contractility (1.2%) was the only urodynamic finding. Impaired detrusor contractility was diagnosed by linear passive urethral resistance relation in 82% of cases but considered to be clinically relevant in only a third. In 25 cases (30.1%) low urethral compliance was noted, which we consider nearly synonymous with urethral scarring.

CONCLUSIONS

Sphincteric incontinence is the most common urodynamic finding in patients with post-radical prostatectomy incontinence, although other findings may coexist. The most accurate diagnosis is attained when all objective measures are put in perspective with the clinical setting.

Ordering an echocardiogram for evaluation of left ventricular function: level of expertise necessary for efficient use

This prospective study was performed to test the hypothesis that the yield of 2-dimensional echocardiography (2DE) would be higher when it is ordered by a cardiologist than by a noncardiologist. Patients referred for transthoracic 2DE for the evaluation of left ventricular systolic function for the 11-month period between July 10, 1995, and June 10, 1996, were included in the study. Demographic, historical, and clinical findings were recorded. Whether the patient was referred by a cardiologist versus a noncardiologist was used as the predictor variable in a binary logistic regression analysis. To address the possibility that the yield of 2DE may be higher for cardiologists because the prevalence of disease in patients referred to them may be higher (selection bias), the analysis was subjected to a propensity score adjustment. Of 2176 patients referred for 2DE during the study, 1033 were referred for the evaluation of left ventricular function. The test had a positive yield in 52% of patients for cardiologists versus 31% for noncardiologists (chi(2) = 45.5, P <.0001, odds ratio 2.4 [CI = 1. 9-3.1]). This difference remained highly significant even when propensity score risk adjustment was made (chi(2) = 54.2, P <.0001, odds ratio 2.0 [CI = 1.5-2.8]). We conclude that the yield of 2DE is higher for cardiologists compared with noncardiologists and that this result was not related to differences in patient populations examined by the two groups. Thus, more efficient use of 2DE may be achieved if patients are referred to cardiologists rather than directly sent for 2DE.

Nocturia

PURPOSE

We review the current state of knowledge of nocturia and present algorithms for diagnosis, classification and treatment.

MATERIALS AND METHODS

We reviewed the recent literature on nocturia, and state-of-the-art methods of diagnosis, classification and treatment.

RESULTS

Nocturia, which is among the most bothersome of all urological symptoms, has heretofore been poorly classified and understood. Multiple factors may result in nocturia, including pathological conditions, such as cardiovascular disease, diabetes mellitus, lower urinary tract obstruction, anxiety or primary sleep disorders, and behavioral and environmental factors. Nocturia may be attributed to nocturnal polyuria (nocturnal urine overproduction) and/or diminished nocturnal bladder capacity. Distinction between these conditions is made by a simple arithmetic analysis of a 24-hour voiding diary.

CONCLUSIONS

Nocturia has been poorly studied, and its etiology and pathogenesis have been classified only recently. We present a scheme for diagnosis and care of patients suffering from loss of sleep due to nocturnal voiding.

Results of pubovaginal sling for stress incontinence: a prospective comparison of 4 instruments for outcome analysis

PURPOSE

Presently to our knowledge there are no standardized techniques to assess outcomes after surgery for stress incontinence. We performed a prospective blinded study to assess the correlation among physician and patient assessments, and a validated 24-hour pad test and voiding diary.

MATERIALS AND METHODS

A total of 84 women were evaluated before and after pubovaginal sling for stress incontinence with a voiding diary, pad test and symptom questionnaire (patient assessment) administered by a blinded third party. The operating surgeon evaluated the patient using history, physical examination, pad test and voiding diary but was blinded to results of the outcome questionnaire. Preoperative focused neurourological examination and video urodynamics confirmed stress incontinence. Patients were assessed at least 1 year postoperatively. We compared patient assessment (cured, improved, failure) to the outcome of the pad test, voiding diary and physician assessment. The physician and questioner were blinded to each other. We considered patients with a pad test of 0 to 2 ml. as cured, 50% or more volume reduction as improved and less than 50% volume reduction as failure. Postoperative assessment did not differentiate between stress and urge incontinence. The kappa coefficient was used for statistical comparison.

RESULTS

Average patient age was 58 years and average followup for the entire group was 4 years. Agreement among the 4 instruments to assess outcome was excellent (k >0.9) with respect to cured/improved versus failure but only good for cured versus improved versus failure (k >0.5).

CONCLUSIONS

Outcomes following incontinence surgery may vary depending on how the analysis was performed, patient selection, definition of success and so forth. Our results indicate that a pad test and voiding diary are reliable and should be part of the normal followup after pubovaginal sling for sphincteric incontinence. When these tests are used in conjunction with defined parameters of success, there is excellent agreement with patient feelings in regard to success or failure of surgery. Nevertheless, these instruments and methods are imperfect at best.

Evaluation of the etiology of nocturia in men: the nocturia and nocturnal bladder capacity indices

To determine and quantify the cause of nocturia in men, we describe and evaluate the relative contribution of two complementary indices of nocturia: the nocturia index (Ni), a measure of nocturnal urine overproduction, and the nocturnal bladder capacity index (NBCi), reflective of nocturnal bladder capacity. The records of 100 consecutive men with lower urinary tract symptoms (LUTS), having undergone video-urodynamic studies (VUDS), were prospectively studied. Evaluation included American Urological Association symptom score (AUASS), micturition diary (day, night, and 24-hr voided volume), and VUDS. Voiding diary analysis was carried out as previously described by us, determining the Ni, NBCi, and nocturnal polyuria index (NPi) (nocturnal urine volume/24-hr urine volume). In the case of AUASS question #7 (degree of nocturia), the odds of having a severe AUA question #7 response was found to be 4.09 times higher for patients with NBCi > 2.0 compared with patients whose NBCi was </= 2.0 using logistic regression analysis. In comparing patients with severe nocturia and low NBCi with those having mild nocturia and low NBCi, Ni performed in a fashion superior to NPi in identifying relative nocturnal urine overproduction as the suspected explanation for their nocturia (Ni = 3.42 vs. 1.42, P = 0.0002 cf. Npi = 0.44 vs. 0.27, P = 0.018, Mann-Whitney test, respectively). We suggest a discriminating threshold of NBCi > 2 as highly significant in defining diminished NBC as a factor in the etiology of nocturia. In addition, we propose Ni of 1.5 as a threshold greater than which nocturia may be attributed to nocturnal urine overproduction in excess of maximum bladder capacity. Together, these indices describe in quantitative fashion the relative contributions of nocturnal urine overproduction and diminished NBC in identifying the etiology of nocturia in male patients. Neurourol. Urodynam. 18:559-565, 1999.

Fine needle aspiration cytology of gastric solitary fibrous tumor: a case report

BACKGROUND

Solitary fibrous tumors (SFT) occur mainly in the pleura and other serosal sites. However, they have been found in extraserosal sites and should be considered in the differential diagnosis (DDx) of any spindle cell lesion, including those in the gastrointestinal tract. In this report, we describe fine needle aspiration (FNA) cytologic evaluation of a gastric SFT, emphasizing the role of immunocytochemistry in the DDx.

CASE

Computerized tomography-guided FNA of a subserosal gastric mass in a 77-year-old female was performed. The moderately cellular smears showed neoplastic cells arranged in interlacing fascicles and in a "patternless" pattern. There was variable collagenous stroma. The cell block revealed a similar pattern, with a single mitotic figure. Nuclear atypia and necrosis were absent. The neoplastic cells were strongly reactive for vimentin and CD34, with weak focal reactivity for smooth muscle actin, suggestive of vessels in tangential section. They were nonreactive for muscle specific actin, desmin, S-100 and pancytokeratin. Other immunocytochemical markers were also studied.

CONCLUSION

SFT should be considered in the DDx of spindle cell lesion of the stomach. Cell block and immunocytochemical markers, especially CD34, were extremely useful in the diagnosis of SFT on FNA.

Neutrophils exposed to bacterial lipopolysaccharide upregulate NADPH oxidase assembly

Bacterial LPS is a pluripotent agonist for PMNs. Although it does not activate the NADPH-dependent oxidase directly, LPS renders PMNs more responsive to other stimuli, a phenomenon known as "priming." Since the mechanism of LPS-dependent priming is incompletely understood, we investigated its effects on assembly and activation of the NADPH oxidase. LPS pretreatment increased superoxide (O2-) generation nearly 10-fold in response to N-formyl methionyl leucyl phenylalanine (fMLP). In a broken-cell O2--generating system, activity was increased in plasma membrane-rich fractions and concomitantly decreased in specific granule-rich fractions from LPS-treated cells. Oxidation-reduction spectroscopy and flow cytometry indicated LPS increased plasma membrane association of flavocytochrome b558. Immunoblots of plasma membrane vesicles from LPS-treated PMNs demonstrated translocation of p47-phox but not of p67-phox or Rac2. However, PMNs treated sequentially with LPS and fMLP showed a three- to sixfold increase (compared with either agent alone) in plasma membrane-associated p47-phox, p67-phox, and Rac2, and translocation paralleled augmented O2- generation by intact PMNs. LPS treatment caused limited phosphorylation of p47-phox, and plasma membrane-enriched fractions from LPS- and/or fMLP-treated cells contained fewer acidic species of p47-phox than did those from cells treated with PMA. Taken together, these studies suggest that redistribution of NADPH oxidase components may underlie LPS priming of the respiratory burst.

Percutaneous drainage of recurrent pneumothoraces and pneumatoceles

Thoracic trauma victims commonly sustain visceral pleural injury with resultant pneumothorax. These injuries usually respond to standard tube thoracostomy decompression and drainage. However, a subset of these patients develop recurrent and/or loculated pneumothoraces or pneumatoceles that are not readily accessible by tube thoracostomy. Percutaneous catheter drainage of these collections provides a safe and reliable method of management in critically ill patients.

Percutaneous retrieval of a surgical laparotomy sponge from the peritoneal cavity

Percutaneous retrieval of an extravascular foreign body is an uncommon procedure. This report describes the successful retrieval of a 46 x 46-cm laparotomy sponge from the peritoneal cavity using a Nitinol Gooseneck Snare system. This technique can eliminate the need for exploratory surgery and may be particularly useful in poor operative candidates.

Primary treatment of radiation-induced hemorrhagic cystitis with hyperbaric oxygen: 10-year experience

Radiation-induced hemorrhagic cystitis continues to cause frustration for patients and urologists alike. Virtually all present modes of treatment tend to yield short-term benefits and entail potentially devastating risk by virtue of the tissue destructive nature. We report our 10-year experience in the treatment of hemorrhagic radiation cystitis with hyperbaric oxygen therapy, a tissue-reparative method, in followup of our prior reports. A total of 13 patients who previously underwent radiation therapy for various pelvic malignancies had endoscopically or biopsy proved hemorrhagic cystitis. All but 1 patient experienced durable cessation of hematuria with minimal side effects following hyperbaric oxygen therapy. These results suggest hyperbaric oxygen therapy to be a significant weapon in the armamentarium for treatment of hematuria secondary to radiation-induced injury to the bladder.

Double-blind study of a new nonionic contrast agent for digital subtraction arteriography

RATIONALE AND OBJECTIVES

Since the development of the first low-osmolality contrast agent in 1969, a new group of ionic and nonionic compounds have emerged. These new agents have dramatically improved diagnostic imaging by exhibiting significant improvements in safety and technical efficacy over that of high-osmolality agents. This study was designed to compare the safety, tolerance, and technical efficacy of iopromide, a new low-osmolality, nonionic contrast agent, with that of both ioversol and iopamidol for digital subtraction angiography (DSA).

METHODS

One hundred fifty patients with conditions requiring intraarterial digital subtraction angiography were randomly assigned to receive 150 mg I/mL iopromide or either 160 mg I/mL ioversol or 128 mg I/mL iopamidol. Cerebral, aortovisceral, and peripheral arteriography was performed.

RESULTS

No significant difference was found in safety, tolerance, and technical efficacy between iopromide and ioversol. Iopamidol had significantly less technical efficacy than iopromide, but there were no significant differences in safety or tolerance between these two agents.

CONCLUSIONS

All three contrast media (CM) are useful for cerebral DSA. Although these agents were diagnostically adequate for use during aortovisceral and peripheral DSA, none was able to optimally opacify vessels during these studies in the concentrations administered.

Percutaneous retrieval of foreign bodies: experience with the nitinol Goose Neck snare

PURPOSE

The authors present their experience with the nitinol Goose Neck snare system in the retrieval of retained foreign bodies in 20 patients.

PATIENTS AND METHODS

Foreign bodies were located in the vascular system in 13 patients, urinary tract in four, biliary system in one, gastrointestinal tract in one, and the peritoneal space in one. All retrievals were performed with use of standard angiographic/interventional techniques.

RESULTS

Success was achieved in all cases without attendant complications. Foreign bodies removed included catheter and guide-wire fragments, an embolization coil, broken or occluded double pigtail catheters, a Wallstent, and a surgical laparotomy sponge.

CONCLUSION

All procedures were performed quickly, safely, and without difficulty. Because of its excellent torque control, positive grasping capacity, excellent radiopacity, lack of traumatic effect, and availability in different sizes appropriate for use in a wide variety of difficult anatomic spaces, the authors recommend that this device be considered the first choice for all foreign body retrieval procedures.

Stent placement in a splenic vein stenosis after TIPS creation

A hemodynamically significant splenic vein stenosis was found during placement of a transjugular intrahepatic portosystemic shunt in a patient with gastric variceal bleeding. A second stent was placed across the splenic vein stenosis, which was obstructing normal hepatopetal flow, causing venous hypertension in the splenic and short gastric veins. This produced a successful hemodynamic and angiographic result and, clinically, controlled the patient's bleeding.

Traumatic rupture of the thoracic aorta

Because the diagnosis of a traumatic rupture of the aorta can be subtle, a high index of clinical suspicion must be maintained to arrive at a prompt and correct diagnosis. When chest radiography shows that the mediastinum is greater than 8 cm in width or that the arch or descending aorta are obscured, direct transfemoral arteriography remains the procedure of choice in hemodynamically stabilized patients. At the present time, computed tomography is not recommended as a definitive diagnostic modality.

Extrapulmonary tuberculosis in patients with human immunodeficiency virus infection

The annual number of cases of culture-proven extrapulmonary tuberculosis (TB) at our hospital increased from 47 cases in 1983 to 113 cases in 1988. At least 43% (199) of 464 consecutive patients with extrapulmonary TB during this 6-year period were infected with the human immunodeficiency virus (HIV); since HIV serologic testing was not performed routinely the true HIV prevalence is likely to be higher. Of the HIV-infected patients, 59% were intravenous drug users, 31% were Haitian, 3% were homosexual males, 1% were perinatally-infected infants, and 6% did not have a known risk factor for HIV infection. Ninety-eight percent of the HIV-infected patients were black (84%) or hispanic (14%). The HIV-infected patients were more likely than the control patients to have either disseminated, genitourinary, intra-abdominal, mediastinal, or concurrent pulmonary TB. Fever was nearly universal among the HIV-infected patients, but was absent in about one-third of the control patients. Among untreated HIV-infected patients, disease progression was rapid and nearly always fatal. Among HIV-infected patients who received treatment, the response to therapy, as judged by hospital survival and time to defervescence, was similar to that of the control patients. Despite the extensive tuberculous dissemination among the HIV-infected patients, the diagnosis of TB was difficult and often delayed. In addition to the decrease in tuberculin reactivity and the atypical chest radiograph patterns, there was a need to consider other HIV-related infections in the differential diagnosis. Although sputum specimens grew M. tuberculosis in greater than 90% of the HIV-infected patients in whom they were obtained, sputum AFB stains were positive in less than 50%. Blood and urine specimen cultures were positive in 56% and 77% of the HIV-infected patients in whom these specimens were obtained, but did not provide a means of early diagnosis. Cerebrospinal fluid and pleural fluid were abnormal in nearly all patients with involvement of these sites but were rarely AFB-positive and were, therefore, only suggestive of TB. Procedures such as biopsies and aspirates of peripheral lymph nodes, visceral lymph nodes, liver, and bone marrow provided the highest immediate diagnostic yields with rates between 50% and 90%. These procedures must be considered early in the course of illness in HIV-infected patients with suspected extrapulmonary TB due to the rapidly progressive nature of this often fatal but usually treatable infection.

Renal infarction secondary to fibrous dysplasia and aneurysm formation of renal artery

We report a case of a previously healthy forty-year-old man with bilateral renal artery stenosis secondary to bilateral medial fibrous dysplasia. He was additionally found to have a dissecting aneurysm of the left upper renal artery branch with resultant infarction of the upper and middle pole renal segments. We believe renal infarction secondary to medial fibrous dysplasia with occlusion of the renal artery associated with a dissecting aneurysm has not been reported, and we report the first such case. A multimodality treatment approach was utilized.

Hyperbaric oxygen: primary treatment of radiation-induced hemorrhagic cystitis

Of 8 patients with symptoms of advanced cystitis due to pelvic radiation treated with hyperbaric oxygen 7 are persistently improved during followup. All 6 patients treated for gross hematuria requiring hospitalization have been free of symptoms for an average of 24 months (range 6 to 43 months). One patient treated for stress incontinence currently is dry despite little change in bladder capacity, implying salutary effect from hyperbaric oxygen on the sphincter mechanism. One patient with radiation-induced prostatitis failed to respond. This experience suggests that hyperbaric oxygen should be considered the primary treatment for patients with symptomatic radiation-induced hemorrhagic cystitis.

Embryogenesis of ureteral anomalies: a unifying theory

Extensive gross, microscopic and clinical studies of various ureteral anomalies have enabled investigators to set forth theories regarding the aetiologies of these anomalies consistent with observed fact. Synthesis of these observations allows for a simplified classification of mega-ureter (primary obstructed, reflux and non-obstructed, non-reflux mega-ureters), ureterocele, duplex ureters and ectopic ureters based upon some combination of mesenchymal differentiation anomalies and location anomalies. A defect early in mesenchymal differentiation would be expected to result in panureteral disease. A defect later in development would result in a focal abnormality anywhere along the course of the ureter. Influence upon ureteral bud mesenchyme by local expansion factors in the bladder base may result in various types of ureterocele. Position of the ureteral orifice on the trigone or in Wolffian duct derivatives would occur in accordance with the Weigert-Meyer principle and would correlate with upper tract dysplasias. Thus, an attempt has been made to systematize and trace the origins of mega-ureter, ureterocele, duplex ureters and ectopic ureters to defects of differentiation of the basic mesoblastic cell in aberrant locations of the ureteral bud.

Recurrent penile condylomata acuminata in a 17-month-old boy

Penile condyloma acuminatum is a rare pediatric entity. We report on a 17-month-old boy with penile and urethral condyloma acuminatum. The presence of cervical dysplasia in a histological setting suggestive of condyloma in his mother supports congenital acquisition of the disease. Histological and histochemical evidence for a viral etiology of the disease in the mother and patient is presented.

Treatment of radiation-induced cystitis with hyperbaric oxygen

The effects of hyperbaric oxygen on radiation cystitis have been documented in 3 patients with radiation-induced hemorrhagic cystitis refractory to conventional therapy. Cessation of gross hematuria and reversal of cystoscopic bladder changes were seen in response to a series of hyperbaric oxygen treatments of 2 atmosphere absolute pressure for 2 hours. To our knowledge this is the first report of cystoscopically documented healing of radiation-induced bladder injury.

Preservation of periprostatic autonomic nerves during total perineal prostatectomy by intrafascial dissection

A modification of Young's total perineal prostatectomy technique is described to prevent damage to the apical branches of the cavernous nerves. Based on anatomic relationships between investing prostatic fascial layers and the neurovascular bundle, emphasis is placed on division of the apical prostatic urethra between the anterolateral endopelvic fascia and Denonvilliers fascia (intrafascial dissection) in avoidance of the apical nerves. Vertical incision in the fused distal portion of Denonvilliers fascia is necessary to make this dissection atraumatic regarding the adjacent paraprostatic neurovascular bundle. Clinical application of this completely intrafascial prostatic dissection is exemplified. It is concluded that careful modification of Young's technique of total perineal prostatectomy may result in increased postoperative potency rates.

Single unilateral vaginal ectopic ureter: is it really a rarity?

Although previously regarded as a rarity, 13 of the 20 published cases of single unilateral vaginal ectopic ureter have been reported within the last year. We have seen 4 cases of a single unilateral vaginal ectopic ureter within a 4-month interval. The relationship of vaginal ureteral ectopia to müllerian and mesonephric duct anomalies is discussed. If the ureteral bud originates laterally from the mesonephric duct then the ureter may retain its connection with the mesonephric duct while failing to connect to the bladder. This condition combined with persistence of the distal mesonephric (Gartner's) duct, which ruptures vaginally, accounts for vaginal ureteral ectopia and incontinence. The diagnostic studies for vaginal ureteral ectopia include excretory urography, radionuclide scanning, ultrasonography and administration of oral phenazopyridine in conjunction with careful vaginoscopic examination. The combination of lifelong wetting and solitary kidney on excretory urography should alert the urologist to this syndrome. The single unilateral vaginal ectopic ureter may be more common than has been suggested previously.

Sigmoidocystoplasty to augment bladder capacity

Sigmoidocystoplasty with subtotal cystectomy was carried out in 14 patients with severe, symptomatic contracture of the bladder, refractory to other modes of therapy. Eight patients had excellent results, four showed improvement, two showed no improvement and required supravesical diversion. Indications for the procedures, complications and over-all results are discussed, with emphasis on our surgical technique. The possible advantages of sigmoidocystoplasty over ileal and ileocecal cystoplasty are noted.

Renal hemangiopericytoma: surgical, radiological and pathological implications

The first case of renal hemangiopericytoma presenting radiologically as a hypovascular mass is described. Preoperative diagnostic evaluation included ultrasonography, retrograde pyeloureterography, computerized tomography and angiography. Electron microscopy is helpful to distinguish this lesion from histologically similar juxtaglomerular cell tumors. Although renal hemangiopericytoma may appear benign on pathological examination it should be treated as a low grade malignancy and followed carefully.

Regulation of growth hormone release: evidence against negative feedback in rat pituitary cells

To determine if the anterior pituitary gland is the site of negative feedback inhibition of GH release, we studied the effect of GH and multiplication-stimulating activity (MSA), a member of the somatomedin family, on isolated rat anterior pituitary cells in primary culture. The effect of GH was examined in two ways: 1) by adding to the cultures human GH (10 ng/ml to 20 microgram/ml) which was biologically active in the rat but not cross-reactive in the rat GH (rGH) RIA, and 2) by comparing rGH secretion in cultures of different cell densities. No suppression of either basal or prostaglandin E1-stimulated rGH release was found. An enhancement observed in serum-free conditions at high human GH concentrations was interpreted as a nonspecific response to protein, because bovine serum albumin produced the same effect. When added in the presence of serum, MSA (1--500 ng/ml) had no effect on rGH secretion. In the absence of serum, there were 71% and 30% increases in the basal and prostaglandin E1-stimulated rates of hormone release, respectively, possibly attributable to a trophic effect of MSA. Six other hormones having structural or functional similarity to either GH or somatomedin also failed to inhibit rGH secretion. Our results do not support the hypothesis that GH or somatomedin exerts a negative feedback effect on GH release directly on the anterior pituitary gland. Most likely, the hypothalamus or a higher brain center is the site for such regulation.

Effect of rat age on serum levels of growth hormone and somatomedins

The somatomedins are a family of hormones which appear to mediate many of the anabolic actions of growth hormone; these processes often exhibit an age-associated deterioration in intact animals. We have demonstrated the validity of a radioreceptor assay for the determination of somatomedin levels in rat serum. In this assay, we measure displacement of 125I-labeled Multiplication Stimulating Activity (MSA) from receptors prepared from human placental membranes. Results with this procedure confirm and extend a previous report from this laboratory indicating a significant decrease in somatomedin levels during the latter part of the lifespan. Data are presented to eliminate possible artifactual explanations for the observed age-related changes. Furthermore, we find that the decrease in somatomedin levels can not be a simple result of an age-related decrease in basal levels of growth hormone in serum. We conclude that the decrease with age in circulating levels of the somatomedins is most probably attributable to a decrease in the activity of responsiveness of the tissues (most probably liver) which secrete somatomedins in response to stimulation by growth hormone.

The effect of serum and multiplication stimulating activity on L6 myoblast growth: the lack of correlation with cyclic nucleotide changes

The role of cAMP and cGMP in triggering proliferation of rat myoblasts was evaluated by: (1) measuring effects of mitogens on intracellular cyclic nucleotide levels, and (2) observing effects of agents which altered cyclic nucleotide levels on cell proliferation. Multiplication stimulating activity (MSA, 1 microgram/ml), a member of the somatomedin family, stimulated cell proliferation after 48 hr. It had little effect on cellular cyclic nucleotide levels, measured by radioimmunoassay. Horse serum (HS) and fetal bovine serum (FBS) stimulated cell proliferation approximately equally. Neither affected cAMP levels; FBS reduced cGMP to 33% of control values, but HS had no effect. Thus, there was no simple correlation between mitogenic action and cyclic nucleotide levels at any time from 5 min to 24 hr after addition of a purified mitogen or serum. Furthermore, agents which caused substantial changes in cyclic nucleotide levels had no effect on cell proliferation. Prostaglandin E1 (5 microM) elevated cAMP 440% without affecting cGMP levels or cell growth. A potent phosphodiesterase inhibitor, 1-methyl-3-isobutylxanthine (MIX, 0.1 mM), when added alone or in the presence of MSA, HS, or FBS, elevated cAMP 200% and cGMP 167%, but it had little effect on their mitogenic action. Lastly, a purified mitogen such as MSA, unlike serum, must be present for extended periods of time in order to stimulate cell proliferation. This makes it unlikely that a trigger mechanism functions in initiating cell division. We conclude that neither cAMP nor cGMP appear to be second messengers for the mitogenic action of MSA or serum on muscle cells.

Dissociation of the intrinsic factor--vitamin B12 complex by bile: contributing factor to B12 malabsorption in pancreatic insufficiency

Human bile incubated with vitamin B12 bound to intrinsic factor in human gastric juice will effectively dissociate this complex, and the vitamin will transfer to non-intrinsic factor unsaturated binding protein(s) contained in bile. Preincubation of the bile with pancreatic enzymes, particularly trypsin, and pepsin, decreases this effect of bile on the intrinsic factor--vitamin B12 complex by digesting the unsaturated binder(s) in the bile. These studies help explain why there is malabsorption of tracer amounts of vitamin B12 in some patients with pancreatic insufficiency, and why this abnormality is correctable by the administration of pancreatic extract.

Formation of transcobalamin II--vitamin B12 complex by guinea-pig ileal mucosa in organ culture after in vivo incubation with intrinsic factor--vitamin B12

The in vivo incubation of intrinsic factor--[57Co]vitamin B12 in an ileal loop of a guinea-pig followed by in vitro culturing of segments of the ileum for 180 min has been used to study the transepithelial transport of vitamin B12. Analysis of the solubilized supernate of mucosa following the in vivo phase demonstrated that 44% of the [57Co]vitamin B12 was bound to intrinsic factor (IF), 26% was free, and 16% was bound to transcobalamin II (TCII). Following culture, similar analysis demonstrated that 18% of the vitamin was now bound to IF, 49% was free, and 35% ws bound to TCII. In the culture medium, 54% of the [57Co]vitamin B12 was free and 37% was bound to TCII. The formation of TCII-[57Co]vitamin B12 did not occur if homogenized mucosa was incubated with free[57Co]vitamin B12, but it did form in cultures of ileal segments from animals given an excess of unlabelled vitamin to saturate all circulating TCH, and in the medium containing puromycin. Indirect immunofluorescence using chicken anti-TCII demonstrated that TCII was associated with the mucosal cells of both the ileum and jejunum. These studies demonstrate that following transepithelial flux of vitamin B12 through the ileal mucosa, the vitamin becomes coupled to TCII. This coupling requires a structurally intact mucosa and the source of the TCII appears to be the ileal mucosal cell rather than unsaturated TCII circulating in the blood.