Anatomical Position of Four Different Transobturator Mesh Implants for Female Anterior Prolapse Repair

Purpose: Polypropylene mesh implants are frequently used for pelvic floor reconstruction in women. Yet they vary in size and fixation. The purpose of this study is to compare four mesh products with regard to their anatomical positioning and functionality within the pelvic floor, to determine whether each mesh fits equally well in a female cadaver. Methods: One female pelvis was dissected, opening the retropubic space exposing the endopelvic fascia and demonstrating the arcus tendineus fasciae pelvis (ATFP). Anatomical parameters were measured before and after implanting four meshes via the transobturator approach. Results: The anterior fixation of the ATFP was found to be 5 mm lateral to the symphysis in this cadaver. The endopelvic fascia covered 54.6 cm². The obturator nerve was located 35 mm from the white line. The distance of the proximal and lateral points of mesh fixation from the ischial spine or ATFP varied from 0 to 25 mm. The meshes varied in size and anatomical positioning. Conclusion: These observations demonstrate the necessity of developing optimally sized meshes and appropriate introducer techniques that can provide sufficient vaginal support. Surgeons, furthermore, need profound knowledge of anatomy, the patient's pelvic floor defect and the meshes available on the market.

[End of life care in intensive care units]

In intensive care units, death occurs after a medical decision of treatment limitation in a great majority of patients. In this context, taking care of the patient and his relatives is ethically, practically and emotionally complex. End of life is a well known factor of conflict, burnout and stress among medical and nursing teams in the ICU. The recommendations described in the following article are expected to clarify the roles and practices of the professionals involved in end of life procedures in the ICU.

Recombinant hirudin for cardiopulmonary bypass anticoagulation: a randomized, prospective, and heparin-controlled pilot study

BACKGROUND

Lepirudin, a recombinant hirudin, is a direct acting thrombin inhibitor that has been used as a heparin alternative in patients with heparin-induced thrombocytopenia requiring on-pump cardiac surgery. To evaluate the efficacy, safety, and clinical utility of lepirudin as a cardiopulmonary bypass (CPB) anticoagulant, we compared lepirudin with heparin in a routine CPB setting.

METHODS

Twenty patients were randomly assigned to receive lepirudin (0.25 mg/kg b. w. bolus and 0.2 mg/kg b. w. added to the CPB priming) or heparin (400 U/kg b. w. bolus) with protamine reversal. Lepirudin and heparin anticoagulation during CPB was monitored using the ecarin clotting time or ACT, respectively and additional lepirudin (5 mg) or heparin (5000 U) boluses were administered.

RESULTS

The CPB circuit was performed in both groups without thromboembolic complications. Median blood loss during the first 36 hours was statistically higher ( P = 0.007) in the lepirudin group (1.226 +/- 316 ml) compared to the heparin group (869 +/- 189 ml). One patient of the lepirudin group developed pulmonary embolism 24 hours after surgery. This patient was tested homozygous for the FV-Leiden mutation.

CONCLUSION

Lepirudin provides effective CPB anticoagulation but induces a higher postoperative blood loss than heparin. Lepirudin should be restricted to patients undergoing CPB who cannot be exposed to heparin.

[Secondary splenic rupture after thrombolysis for acute myocardial infarction]

Secondary splenic rupture after thrombolysis for acute myocardial infarction. HISTORY AND ADMISSION FINDINGS: A 67-year-old male patient was admitted with acute chest pain and signs of an acute anterior myocardial infarction in the ECG. The usual contraindications were excluded and after a systemic lysis with rt-PA the ECG-alterations as well as the symptoms of angina resolved completely. 2 hours later the patient developed an acute abdomen with a severe circulatory shock. INVESTIGATIONS: On ultrasound and CT a massive intraabdominal bleeding was found. TREATMENT AND COURSE: Emergency laparotomy revealed a splenic rupture. Retrospectively, 6 weeks before admission, the patient had fallen from a ladder to his left side. This is a rare case of a secondary splenic rupture during thrombolysis for acute myocardial infarction. 2 weeks later the patient developed rein-farction with angiographically shown two vessel disease. After angioplasty of the ramus interventricularis anterior (RIVA) he was stable. CONCLUSIONS: Intravenous thrombolysis in case of acute myocardial infarction is the method of choice. In the past a great number of patients were excluded from thrombolysis because of an extensive interpretation of contraindications. The aim to reach an alteration in this use may not risk health of patients by insufficient history.

Body mass index, abdominal adiposity and blood pressure: consistency of their association across developing and developed countries

BACKGROUND

Obesity is increasing worldwide because developing countries are adopting Western high-fat foods and sedentary lifestyles. In parallel, in many of them, hypertension is rising more rapidly, particularly with age, than in Western countries.

OBJECTIVE

To assess the relationship between adiposity and blood pressure (BP) in a developing country with high average BP (The Seychelles, Indian Ocean, population mainly of African origin) in comparison to a developed country with low average BP (Switzerland, population mainly of Caucasian origin).

DESIGN

Cross-sectional health examination surveys based on population random samples.

SETTING

The main Seychelles island (Mahé) and two Swiss regions (Vaud-Fribourg and Ticino).

SUBJECTS

Three thousand one hundred and sixteen adults (age range 35-64) untreated for hypertension.

MEASUREMENTS

Body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), systolic and diastolic blood pressure (SBP and DBP, mean of two measures).

METHODS

Scatterplot smoothing techniques and gender-specific linear regression models.

RESULTS

On average, SBP and DBP were found to increase linearly over the whole variation range of BMI, WHR and WC. A modest, but statistically significant linear association was found between each indicator of adiposity and BP levels in separate regression models controlling for age. The regression coefficients were not significantly different between the Seychelles and the two Swiss regions, but were generally higher in women than in men. For the latter, a gain of 1.7 kg/m(2) in BMI, of 4.5 cm in WC or of 3.4% in WHR corresponded to an elevation of 1 mmHg in SBP. For women, corresponding figures were 1.25 kg/m(2), 2.5 cm and 1.8% respectively. Regression coefficients for age reflected a higher effect of this variable on both SBP and DBP in the Seychelles than in Switzerland.

CONCLUSION

These findings suggest a stable linear relation of adiposity with BP, independent of age and body fat distribution, across developed and developing countries. The more rapid increase of BP with age observed in the latter countries are likely to reflect higher genetic susceptibility and/or higher cumulative exposure to another risk factor than adiposity.

Neodymium:YAG laser coagulation prostatectomy: 3 years of experience with 227 patients

PURPOSE

For 3 years we prospectively followed a cumulative cohort of men who underwent neodymium:YAG laser coagulation prostatectomy to relieve bladder outlet obstruction to determine the safety, efficacy and durability of this procedure.

MATERIALS AND METHODS

A total of 227 men with symptomatic bladder outlet obstruction was treated with the Urolase side-firing laser fiber between October 15, 1991 and October 15, 1994. Voiding outcomes, including peak urinary flow rates, residual urine volumes and American Urological Association symptom scores, were measured with time, and immediate and long-term complications were assessed.

RESULTS

Median patient followup was 26 months (maximum 42). Significant improvement occurred in all measured voiding parameters, including 133% in peak flow rates and 61% in symptom scores 1 year postoperatively. Overall 87% of patients noticed improved quality of life as a result of surgery. Minimum postoperative followup was 6 months in all cases. Complications included prostatitis in 2.6% of patients, urethral stricture in 1.8%, bladder neck contracture in 4.4% and reoperation for residual prostate tissue in 5.3%.

CONCLUSIONS

Neodymium:YAG laser coagulation of the prostate represents an efficacious surgical intervention for symptomatic bladder outlet obstruction with minimal associated morbidity. Voiding outcomes are durable through 3 years.

Induction of the POU domain transcription factor Oct-2 during T-cell activation by cognate antigen

Oct-2 is a transcription factor that binds specifically to octamer DNA motifs in the promoters of immunoglobulin and interleukin-2 genes. All tumor cell lines from the B-cell lineage and a few from the T-cell lineage express Oct-2. To address the role of Oct-2 in the T-cell lineage, we studied the expression of Oct-2 mRNA and protein in nontransformed human and mouse T cells. Oct-2 was found in CD4+ and CD8+ T cells prepared from human peripheral blood and in mouse lymph node T cells. In a T-cell clone specific for pigeon cytochrome c in the context of I-Ek, Oct-2 was induced by antigen stimulation, with the increase in Oct-2 protein seen first at 3 h after activation and continuing for at least 24 h. Oct-2 mRNA induction during antigen-driven T-cell activation was blocked by cyclosporin A, as well as by protein synthesis inhibitors. These results suggest that Oct-2 participates in transcriptional regulation during T-cell activation. The relatively delayed kinetics of Oct-2 induction suggests that Oct-2 mediates the changes in gene expression which occur many hours or days following antigen stimulation of T lymphocytes.

Selection criteria for waste management processes in manned space missions

Management of waste produced during manned space exploration missions will be an important function of advanced life support systems. Waste materials can be thrown away or recovered for reuse. The first approach relies totally on external supplies to replace depleted resources while the second approach regenerates resources internally. The selection of appropriate waste management processes will be based upon criteria which include mission and hardware characteristics as well as overall system considerations. Mission characteristics discussed include destination, duration, crew size, operating environment, and transportation costs. Hardware characteristics include power, mass and volume requirements as well as suitability for a given task. Overall system considerations are essential to assure optimization for the entire mission rather than for an individual system. For example, a waste management system designed for a short trip to the moon will probably not be the best one for an extended mission to Mars. The purpose of this paper is to develop a methodology to identify and compare viable waste management options for selection of an appropriate waste management system.

Differentiation of PC12 cells with K-ras: comparison with nerve growth factor

The cell line PC12, derived from a rat pheochromocytoma, has served as a model for studies on the mechanism of action of nerve growth factor, as well as for the exploration of neuronal differentiation in general. When treated with nanomolar concentrations of nerve growth factor, these neoplastic chromaffin-like cells stop dividing and acquire, for all intents and purposes, the phenotype of mature sympathetic neurons. This phenotype is characterized by the extensive outgrowth of electrically excitable neurites, the ability to form functional synapses, and the acquisition of a number of biochemical markers. Treatment of PC12 cells with retroviral vectors encoding the K-ras, the N-ras, or the v-src oncogenes also produces a marked morphological differentiation very similar to that seen upon treatment with nerve growth factor. Treated cells stop dividing and develop an extensive network of neurites. It has recently been shown that PC12 cells differentiated with v-src, while resembling, morphologically, those treated with nerve growth factor, differ substantially in the biochemical characteristics normally associated with nerve growth factor-induced differentiation. Cells infected with K-ras also develop a neurite network similar to that seen after treatment with nerve growth factor. In addition, such cells develop tetanus toxin-binding sites and saxitoxin-binding sites, as do cells treated with nerve growth factor. Decreases in the binding of epidermal growth factor and in the activity of calpain also occur and these, as well, are characteristic of nerve growth factor-treated cells. But the adhesive properties of cells infected with K-ras are different than those of nerve growth factor-treated cells, and the former do not show an increase in the NILE glycoprotein. Finally, K-252a, an inhibitor of the actions of nerve growth factor on PC12 cells, has no effect on the neurite outgrowth produced by infection with K-ras. Thus, many of the key markers of nerve growth factor-induced differentiation of PC12 cells also appear upon differentiation with K-ras, but there are, nevertheless, some crucial differences in the properties of these two sets of cells.

Differentiation of PC12 cells with v-src: comparison with nerve growth factor

The PC12 rat pheochromocytoma cell line is used extensively as a model to study neuronal differentiation. These cells resemble adrenal chromaffin cells, differentiating both morphologically and biochemically when cultured in the presence of dexamethasone, but develop a sympathetic neuron-like phenotype when cultured in the presence of nerve growth factor. Expression of the protein product of the v-src oncogene in PC12 cells also induces neurite outgrowth similar to that resulting from nerve growth factor treatment (Alema et al: Nature 316:557-559, 1985). It is thus possible that c-src or a src-like tyrosine kinase participates in the signal transduction pathway by which nerve growth factor acts on PC12 cells. In this study a temperature-sensitive v-src gene has been introduced into PC12 cells. When cultures of these src-transformed cells are switched from the nonpermissive (40 degrees C) to the permissive (37 degrees C) temperature they elaborate neurites. The differentiation induced by src has been compared with that induced by nerve growth factor by determining whether src-transformed PC12 cells at 37 degrees C exhibit the same biochemical alterations as those induced in PC12 cells treated with nerve growth factor. Neurite extension at 37 degrees C in v-src-transformed cells, like NGF-induced differentiation, is accompanied by an increase in the nerve growth factor-inducible large external (NILE) protein. However, neurite extension in v-src-transformed cells is not blocked by the protein kinase inhibitor K-252a, which completely blocks NGF-induced neurite extension. Likewise, EGF receptor down-regulation and the development of saxitoxin and tetanus toxin binding sites are either much reduced or completely absent in src-differentiated compared with NGF-differentiated PC12 cells.

Determination of the membrane potential of vacuoles isolated from red-beet storage tissue : Evidence for an electrogenic ATPase

The membrane potential of isolated vacuoles of red beet (Beta vulgaris L.) was estimated using several methods. The quenching of the fluorescence of the cyanine dyes 3,3'-diethylthiodicarbocyanine iodide (DiS-C2-(5)) and 3,3'-dipropylthiodicarbocyanine iodide (DiS-C3-(5)) in vacuoles indicated a transmembrane potential difference, negative inside at low external potassium concentrations. The Δψ was found to be-55 mV with two other methods, the distribution of (204)T1(+) in the presence of valinomycin and the distribution of the lipophilic cation triphenylmethylphosphonium. Uncouplers reduced this value to-35 mV. High external potassium concentrations, comparable to cytosolic values, abolished the membrane potential almost completely. The addition of 1 mM Tris-Mg(2+)-ATP markedly hyperpolarized the membrane to-75 mV. This effect was prevented by inhibitors of the ATPase activity located in isolated vacuole membranes.

Characteristics of the sucrose uptake system of vacuoles isolated from red beet tissue. Kinetics and specifity of the sucrose uptake system

The uptake of sucrose against a concentration gradient into the dextran-impermeable [(3)H]H2O space of red beet (Beta vulgaris L.) vacuoles has been studied using silicone-layer-filtering centrifugation on both fluorometric and (14)C-measurement of sucrose. Sucrose transport into vacuoles proceeds partly by an active transport system and partly by passive permeation. The K M(20°C) for active sucrose uptake was found to be about 22 mM and the V Max(20°C) was about 174 nmol sucrose x (unit betacyanin)(-1) x h(-1). The temperature dependency of sucrose transport appears to have an activation energy of 35,0 KJ×mol(-1). Among various mono-, di-, and trisaccharides tested, raffinose acts as a competitive inhibitor of sucrose uptake.

Accumulation of sucrose in vacuoles isolated from red beet tissue

Vacuoles were isolated from red beets (Beta vulgaris L.) by slicing the tissue and separated using a discontinuous dextran gradient centrifugation. The uptake of sucrose against a concentration gradient into the dextran-impermeable [(3)H]-H2O space of these organelles was studied using silicone layer filtering centrifugation on both fluorometric and (14)C-measurement of sucrose. The rate is 24 nmol sucrose (unit betacyanin)(-1) h(-1) and appears to be stimulated by ATP to an uptake rate of 34 nmol. Control experiments with slices cut from red beet tissue and incubated with [(14)C]sucrose gave comparable results. An ATPase activity dependent on both Mg(2+) and K(+) seems to be localized at the inner surface of the tonoplast. This activity is strongly inhibited by EDAC and tartrate and there is no effect of oligomycin, whereas a slight stimulation was caused by DCCD.