Application of a protocol for magnetic resonance spectroscopy of adrenal glands: an experiment with over 100 cases

Objective

To evaluate a protocol for two-dimensional (2D) hydrogen proton (1H) magnetic resonance spectroscopy (MRS) (Siemens Medical Systems; Erlangen, Germany) in the detection of adrenal nodules and differentiation between benign and malignant masses (adenomas, pheochromocytomas, carcinomas and metastases).

Materials and Methods

A total of 118 patients (36 men; 82 women) (mean age: 57.3 ± 13.3 years) presenting with 138 adrenal nodules/masses were prospectively assessed. A multivoxel system was utilized with a 2D point-resolved spectroscopy/chemical shift imaging sequence. The following ratios were calculated: choline (Cho)/creatine (Cr), 4.0–4.3/Cr, lipid (Lip)/Cr, Cho/Lip and lactate (Lac)/Cr.

Results

2D-1H-MRS was successful in 123 (89.13%) lesions. Sensitivity and specificity values observed for the ratios and cutoff points were the following: Cho/Cr ≥ 1.2, 100% sensitivity, 98.2% specificity (differences between adenomas/pheochromocytomas and carcinomas/ metastases); 4.0–4.3 ppm/Cr ≥ 1.5, 92.3% sensitivity, 96.9% specificity (differences between carcinomas/pheochromocytomas and adenomas/metastases); Lac/Cr ≤ –7.449, 90.9% sensitivity and 77.8% specificity (differences between pheochromocytomas and carcinomas/adenomas).

Conclusion

Information provided by 2D-1H-MRS were effective and allowed for the differentiation between adrenal masses and nodules in most cases of lesions with > 1.0 cm in diameter.

Validation of the Brazilian version of the Expanded Prostate Cancer Index Composite (EPIC) for patients submitted to radical prostatectomy

OBJECTIVES

Validation of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire translated to Portuguese. This is an evaluation tool of the effects of treatment on quality of life of patients with prostate cancer.

MATERIALS AND METHODS

In order to translate and validate, several recommended methodological techniques in the literature were included: initial translation, synthesis of translation, board committee review and back translation. Sample included 40 patients with localized prostate cancer submitted to surgical retropubic radical prostatectomy from 2008 to 2010.

RESULTS

The internal consistency analysis of the scales of the questionnaire resulted in alpha Cronbach coefficients "very good" (> 0.9) and "good" (> 0.8) to 8 of 14 domains. The higher coefficients (0.94) were assigned to sexual score, subscales incontinence and sexual function. Post-operatory follow-up ranged from 3 to 35 months, median 18.7 months.

CONCLUSIONS

The Brazilian version of EPIC is reliable and valid, and is a useful tool to evaluate the impact of retropubic radical prostatectomy on quality of life of Brazilian patients with localized prostate cancer, in national and internationals studies.

Adherence and genotypic drug resistance mutations in HIV-1-infected patients failing current antiretroviral therapy

The aim of this study was to assess the correlation between the estimated adherence of HIV-1 infected patients with antiretroviral (ARV) therapy failure and drug-resistant mutations. We studied 40 patients with virological and immunological ARV-therapy failure. In order to assess the adherence of patients we used the SERAD questionnaire. Genomic sequencing of the HIV-1 pol gene was performed. 100% adherence was reported by 27 patients (67.5%) (adherent patients). Multivariate analysis showed that only baseline and nadir CD4+ counts maintained a significant correlation with the adherence. For PR and NNRTI mutations, we did not find any difference between the two groups of patients. Baseline NRTI mutations were higher in adherent patients than in non-adherent patients (p<0.05). No differences were found between plasma mutations and PBMC mutations. The authors conclude that genotypic resistance mutations were found in the majority of patients with ARV-therapy failure despite a good self-reported adherence to therapy. Adequate adherence to therapy is not the only key factor in viral suppression.

Children with Cushing's syndrome: Primary Pigmented Nodular Adrenocortical Disease should always be suspected

Primary Pigmented Nodular Adrenocortical Disease (PPNAD) is a rare form of bilateral adrenocortical hyperplasia that is inherited in an autosomal dominant manner and leads to ACTH-independent Cushing's syndrome (CS). PPNAD may be isolated or associated with Carney Complex (CNC). For the diagnosis of PPNAD and CNC, in addition to the hormonal and imaging tests, searching for PRKAR1A mutations may be recommended. The aims of the present study are to discuss the clinical and molecular findings of two Brazilian patients with ACTH-independent CS due to PPNAD and to show the diagnostic challenge CS represents in childhood. Description of two patients with CS and the many sequential steps for the diagnosis of PPNAD is provided. Sequencing analysis of all coding exons of PRKAR1A in the blood, frozen adrenal nodules (patients 1 and 2) and testicular tumor (patient 1) is performed. After several clinical and laboratory drawbacks that misled the diagnostic investigation in both patients, the diagnosis of PPNAD was finally established and confirmed through pathology and molecular studies. In patient 1, sequencing of PRKAR1A gene revealed a novel heterozygous 10-bp deletion in exon 3, present in his blood, adrenal gland and testicular tumor. The etiologic diagnosis of endogenous CS in children is a challenge that requires expertise and a multidisciplinary collaboration for its prompt and correct management. Although rare, PPNAD should always be considered among the possible etiologies of CS, due to the high prevalence of this disease in this age group.

Prognostic factors of long-term CD4+count-guided interruption of antiretroviral treatment

Aim of the study was to determine predictors of the duration of antiretroviral treatment interruption in patients infected with HIV. This pilot prospective, open-label, multicenter trial comprised 62 HIV-seropositive subjects who decided voluntarily to interrupt therapy after two or more years of successful HAART. The primary end-point was the time to patients being free of therapy before reaching a CD4+ cell count < or =350/microl. Fifteen of 62 patients remained in treatment interruption for more than 180 days. Patients restarting therapy had higher HIV-DNA levels (P = 0.05), were treated more frequently with NNRTI-drugs (P = 0.02), had a shorter period of HAART (P = 0.046), and lower CD4+ cell counts after day 14 of interruption of treatment (P = 0.04). Multivariate regression analysis showed that less than 323 baseline proviral HIV-DNA cp/10(6) PBMCs and more than 564 CD4 cells/microl at day 14 after interruption were associated independently with a reduced risk of restarting treatment (P = 0.041 and P = 0.012, respectively). A score based on CD4+ cell counts at nadir, at baseline, at week 2 of treatment interruption, and on baseline HIV-DNA values can identify patients with a prolonged period free safely of treatment.

O valor da fase sem contraste na tomografia computadorizada do abdome

OBJETIVO: Determinar o valor agregado da fase sem meio de contraste da tomografia computadorizada do abdome em pacientes sem diagnóstico determinado ou em estadiamento tumoral. MATERIAIS E MÉTODOS: Estudo prospectivo e transversal em 100 pacientes consecutivos submetidos a tomografia computadorizada abdominal sem e com meio de contraste intravenoso. Dois examinadores avaliaram todos os exames, procurando estabelecer, através da fase com meio de contraste intravenoso (primeira análise) e posteriormente através da fase sem contraste (segunda análise), o diagnóstico principal e os secundários em função da indicação clínica do exame. Mediu-se a freqüência de mudança diagnóstica decorrente da análise combinada das fases pré- e pós-contraste intravenoso. Casos que tiveram mudança diagnóstica foram avaliados por especialistas clínicos para determinar se implicaria mudanças de conduta. RESULTADOS: Diagnósticos principal e secundário foram modificados em 1 e 18 casos, respectivamente (p = 1,000; p = 0,143). Os diagnósticos modificados foram: esteatose, definição de nódulo em adrenal, nefrolitíase, classificação de cistos renais e calcificação hepática. Nos casos em que a fase sem contraste modificou o diagnóstico, os especialistas mudaram sua conduta em 14/19 (73%) dos pacientes (p = 0,038). CONCLUSÃO: A fase sem contraste não modificou significativamente o diagnóstico principal ou secundário. Porém, as mudanças nos diagnósticos secundários influenciaram na conduta adotada pelos especialistas.

Adrenal masses: characterization with in vivo proton MR spectroscopy--initial experience

PURPOSE

To prospectively determine the accuracy of in vivo proton ((1)H) magnetic resonance (MR) spectroscopy in distinguishing adrenal adenomas, pheochromocytomas, adrenocortical carcinomas, and metastases, with histologic or computed tomographic findings and follow-up data as the reference standards.

MATERIALS AND METHODS

This study was approved by the institutional ethics committee, and informed consent was obtained. Sixty consecutive patients (24 male and 36 female patients; mean age, 53 years) harboring adrenal tumors larger than 2 cm in diameter (mean diameter, 4.6 cm +/- 3.4 [standard deviation]) entered the study and were examined with a 1.5-T MR imaging system and point-resolved multivoxel (1)H MR spectroscopy. Thirty-eight patients had adenomas; 10, pheochromocytomas; five, carcinomas; and seven, metastases. Amplitude values for choline, creatine, lipid, and a metabolite peak at precession frequency of 4.0-4.3 ppm were measured. Metabolite ratios (choline-creatine, choline-lipid, lipid-creatine, and 4.0-4.3 ppm/creatine) and cutoff values (obtained by using receiver operating characteristic analyses) were obtained and compared for each type of adrenal mass, which was identified previously on the basis of clinical, hormonal, and pathologic evidence. Results were evaluated with chi(2) and Student t tests. Significance was inferred at P < .05.

RESULTS

Cutoff values of 1.20 for the choline-creatine ratio (92% sensitivity, 96% specificity; P < .01), 0.38 for the choline-lipid ratio (92% sensitivity, 90% specificity; P < .01), and 2.10 for the lipid-creatine ratio (45% sensitivity, 100% specificity) enabled adenomas and pheochromocytomas to be distinguished from carcinomas and metastases. A 4.0-4.3 ppm/creatine ratio greater than 1.50 enabled distinction of pheochromocytomas and carcinomas from adenomas and metastases (87% sensitivity, 98% specificity; P < .01). The best distinction was obtained by comparing choline-creatine and 4.0-4.3 ppm/creatine ratios.

CONCLUSION

(1)H MR spectroscopy can be used to characterize adrenal masses on the basis of spectral findings for benign adenomas, carcinomas, pheochromocytomas, and metastases.

In-vitro renal shrinkage after hypertonic saline perfusion for organ removal during laparoscopic nephrectomy

BACKGROUND AND PURPOSE

To evaluate the possibility of shrinking the kidney by perfusion with hypertonic solution to facilitate organ removal in laparoscopic surgery.

MATERIALS AND METHODS

After 18 open nephrectomies (ONs) in 9 pigs, one of four saline solutions (5%, 7.5%, 10%, and 15%) was infused through a catheter into the renal artery for 5 minutes in four kidneys each. The volumes and weights of the kidneys were measured before and after renal perfusion; the kidneys were then sent for histologic evaluation. Eight ONs were performed, and the kidneys were removed from the abdominal cavity in a plastic bag in order to mimic organ entrapment during laparoscopy. The kidneys were perfused with hypertonic solution and were again put in a plastic bag and removed from the same animal's abdomen through another incision. The incisions were measured with calipers before and after extraction of the unperfused and perfused organs.

RESULTS

The kidneys that underwent perfusion with 5% saline had the greatest decrease in both weight and volume, an average of 16% and 17.8%, respectively. The average incision needed for extraction of unperfused kidneys was 44.9 mm (range 40-58 mm), whereas the mean size of the incision needed to remove perfused kidneys was 26.6 mm (range 20-30 mm) (P < 0.001). The relative reduction in the necessary incision size therefore was 44.3% (range 33.3%-55%).

CONCLUSION

Perfusion with 5% saline is able to shrink the kidney volume slightly with mild histologic changes. In the pig, it is possible to decrease the renal incision necessary for kidney removal by 44% using this method.

Renoduodenal Fistula After Renal Tumor Ablation With Radiofrequency

PURPOSE

To report a renoduodenal fistula after renal tumor ablation with radiofrequency (RFA).

METHODS

A 1-inch right anterior renal cell carcinoma was subjected to percutaneous RFA under sedation. We used a 14-gauge probe guided by ultrasonographic images in real time.

RESULTS

On the fifth day the computerized tomography with double contrasts showed a fistula between the pelvis and the duodenum.

CONCLUSIONS

A major concern regarding this approach relates to the anterior renal tumor and the guided images during the procedure. To our knowledge, there has never been any report of renoduodenal fistula after RFA.

Opinions and self-reported health status of Italians seeking homeopathic treatment

The use of homeopathy is increasing worldwide. This multi-centre cross-sectional study aims to describe the opinions and self-reported health status of a sample of Italian people seeking homeopathic care. A self-administered questionnaire including socio-demographic characteristics, knowledge and opinions about homeopathy, personal experience with homeopathy, and, self-reported health status (SF-12), was administered to a sample of people who had sought homeopathy. Of a possible 1229 individuals invited to participate, 1223 did so. The majority of the participants were female, young (mean age 42 years), well educated (mean 13 years of education). The reason for seeking care was for either physical or emotional conditions. Most participants had fair to good knowledge of homeopathy, and the self-experienced effect (subjective judgment on efficacy) was good regardless of the type of health condition reported. The Physical Component Summary (PCS-12) scores were similar to the general Italian population, but the Mental Component Summary (MCS-12) scores were lower in all relevant strata examined. This study provides information on the characteristics of people seeking homeopathic care, in particular the results of the SF-12 self-reported health status evaluation.

Porcine reproductive and respiratory syndrome (PRRS) virus-specific interferon-gamma(+) T-cell responses after PRRS virus infection or vaccination with an inactivated PRRS vaccine

Although field studies have found porcine reproductive and respiratory syndrome (PRRSV) inactivated vaccines to be beneficial in reducing losses linked to PRRSV infection, immune mechanisms induced by these vaccines need better understanding. In the study reported here, we examined the interferon-gamma(+) (IFNgamma(+)) PRRS-specific T cell responses induced after infection and vaccination with an inactivated PRRS vaccine. Autologous monocyte-derived dendritic cells loaded with the PRRSV P120 strain were used to re-stimulate ex vivo T cells that had been primed in vivo by either the virus or the vaccine, or both. Virus-specific IFNgamma(+) T cells were quantified by using a porcine IFNgamma- ELISpot assay. A specific but low live virus-induced response was observed between days 35 and 70 for most of the pigs tested, while a significant inactivated vaccine-induced PRRSV-specific IFNgamma(+) T-cell response was measured soon after vaccination. Moreover, we observed that vaccination of pre-challenged pigs clearly favoured the PRRSV-specific cell-mediated immunity primed by the live virus. To characterize further the nature of the PRRSV-specific T cells, the different T-cell subsets involved in PRRSV immunity were analyzed by flow cytometry. We showed that the inactivated vaccine was able to prime both CD4(+)CD8(int+) and CD8(high) virus-specific T cells and that CD4(+)CD8(int+) were preferentially recalled by the live virus.

Toward a detailed characterization of feline immunodeficiency virus-specific T cell immune responses and mediated immune disorders

Infection of domestic cats with feline immunodeficiency virus (FIV) is associated with the development of an acquired immunodeficiency syndrome (AIDS). The pathogenesis of FIV is not fully understood but it has been reported that the immune system is progressively impaired during disease progression. As a result, anti-FIV specific immune response will usually not clear the virus and the acute stage is followed by a chronic asymptomatic phase. The overall objective of this study was to characterized FIV-induced immune cellular responses and -mediated immune disorder following the first weeks post-infection. Using both cytokine ELISpot and intracellular staining assays, FIV-specific T cells were monitored at 6, 9 and 12 weeks post-infection. We demonstrated that both IFNgamma(+) and, CD4 and CD8 TNFalpha(+) T cells specifically respond to FIV antigens. These responses were found to reach a peak at 9 weeks post-infection. It was further shown that the TNFalpha(+)CD8(+) responding T cells were contained within a CD8beta(low)CD62L(-) T cell subpopulation, expanded in FIV-infected cats. This T cell subpopulation which present features of activated CD8 T cells was further shown to be susceptible to spontaneous apoptosis following a short-term in vitro culture. Moreover, it was observed that cell death by apoptosis of this T cell subset was increased following FIV antigen-recognition. Therefore, FIV might alter immune homeostasis in inducing chronic activation of TNFalpha(+)CD8(+) T cells which eventually will die following antigen contact while deleting CD4(+) T cells. Interestingly, this study confirmed the strong similarity between FIV and HIV pathogenesis.

Rupture of vesicourethral anastomosis following radical retropubic prostatectomy

OBJECTIVE

Rupture of vesicourethral anastomosis following radical retropubic prostatectomy is a complication that requires immediate management. We evaluated the morbidity of this rare complication.

MATERIALS AND METHODS

We analyzed retrospectively 5 cases of disruption of vesicourethral anastomosis during post-operative period in a consecutive series of 1,600 radical retropubic prostatectomies, performed by a single surgeon.

RESULTS

It occurred in a ratio of 1:320 prostatectomies (0,3%). Management was conservative in all the cases with an average catheter permanence time of 28 days, being its removal preceded by cystography. Two cases were secondary to bleeding, 1 followed the change of vesical catheter and 2 by unknown causes after removing the Foley catheter. Only one patient evolved with urethral stenosis, in the period ranging from 6 to 120 months.

CONCLUSION

Rupture of vesicourethral anastomosis is not related to the surgeon's experience, and conservative treatment has shown to be effective.

Quantification of tumor extension in prostate biopsies - importance in the identification of confined tumors

OBJECTIVE

To assess the importance of quantifying the adenocarcinoma in prostate biopsies when determining the tumor's final stage in patients who undergo radical prostatectomy. To identify the best methodology for obtaining such data.

PATIENTS AND METHODS

Prostate biopsies from 132 patients were examined, with determination of Gleason histological grade and tumor volume in number of involved fragments, tumor extent of the fragment mostly affected by the tumor and the total percentage of tumor in the specimen. Theses parameters were statistically correlated with the neoplasia's final stage following the evaluation of radical prostatectomy specimens.

RESULTS

An average of 12 and a median of 14 biopsy fragments were evaluated per patient. In the univariate analysis the Gleason histological grade, the largest tumor extent in one fragment and the total percentage of tumor in the specimen were correlated with tumor stage of the surgical specimen. In the multivariate analysis, the Gleason histological grade and the total percentage of tumor were strongly correlated with the neoplasia's final stage. The risk of the tumor not being confined was 3 for Gleason 7 tumors and 10.6 for Gleason 8 tumors or above. In cases where the tumor involved more than 60% of the specimen, the risk of non-confined disease was 4.4 times. Among 19 patients with unfavorable histological parameters, Gleason > 7 and extension greater than 60% the tumor final stage was pT3 in 95%.

CONCLUSION

When associated to the Gleason histological grade, tumor quantification in prostate biopsies is an important factor for determining organ-confined disease, and among the methods, total percentage of tumor is the most informative one. Such data should be included in the pathological report and must be incorporated in future nomograms.

Telerobotic-assisted laparoscopic operation performed at a remote site: initial experience

Robotic surgery is an option to laparoscopy that may offer some benefits including the possibility of performing surgery when the surgeon is geographically away from the patient and faster tireless repetitive movements with greater precision. At present, robot-assisted surgery has been done routinely in several institutions around the world, however, to the best of our knowledge, it is the first time such procedure is performed in our academic environment and herein is reported the first telerobotic-assisted laparoscopic cystectomy performed in a domestic pig at our institution using the Zeus®robotic system (Computer Motion, EUA). The procedure was performed using two different operating rooms geographically apart from each other. The assistant was in an operating room that was set with the operating table and the pig as well as with the Zeus® robotic arms. In the other operating room, the surgeon was seated in the control console with a three-dimensional imaging five meters away from the operating table connected with electric cables. The assistant surgeon established the pneumoperitoneum and five trocars were placed in a fan configuration. The surgeon started performing the surgery using three out of the five ports taking control of the laparoscope (voice control) and manual control of laparoscopic instruments connected to the robotic arms using the joysticks. The other two ports were used by the assistant for traction and clips placement that was also necessary for exchanging the many laparoscopic instruments connected to the robot. The laparoscopic total cystectomy was successfully performed in 25 minutes with no complications. The truly benefits as well as the cost-effectiveness of the robotic surgery in our environment is yet to be determined after experience acquisition with telerobotic before start performing such procedures routinely in humans. The present report shows the technical feasibility of telerobotic surgery in a developing country.

Acucise™ endopyelotomy in a porcine model: procedure standardization and analysis of safety and immediate efficacy

PURPOSE

The study here presented was done to test the technical reliability and immediate efficacy of the Acucise device using a standardized technique.

MATERIALS AND METHODS

56 Acucise procedures were performed in pigs by a single surgeon who used a standardized technique: insert 5F angiographic catheter bilaterally up to the midureter, perform retrograde pyelogram, Amplatz super-stiff guidewire is advanced up to the level of the renal pelvis, angiographic catheters are removed, Acucise catheter balloon is advanced to the ureteropelvic junction (UPJ) level, the super-stiff guide-wire is removed and the contrast medium in the renal pelvis is aspirated and replaced with distilled water, activate Acucise at 75 watts of pure cutting current, keep the balloon fully inflated for 10 minutes, perform retrograde ureteropyelogram to document extravasation, remove Acucise catheter and pass an ureteral stent and remove guide-wire.

RESULTS

In no case did the Acucise device present malfunction. The electrocautery activation time was 2.2 seconds (ranging from 2 to 4 seconds). The extravasation of contrast medium, visible by fluoroscopy, occurred in 53 of the 56 cases (94.6%). In no case there was any evidence of intraoperative hemorrhage.

CONCLUSIONS

This study revealed that performing Acucise endopyelotomy routinely in a standardized manner could largely preclude intraoperative device malfunction and eliminate complications while achieving a successful incision in the UPJ. With the guidelines that were used in this study, we believe that Acucise endopyelotomy can be completed successfully and safely in the majority of selected patients with UPJ obstruction.

A Simple Way to Take Pictures During Endoscopic Procedures

PURPOSE

We describe a new method of taking pictures from endoscopic images using a digital photo camera coupled to the endoscopic lens without an adapter.

MATERIALS AND METHODS

We used a digital camera with 3.3 megapixel resolution and 6 x optical zoom. The camera was coupled to the endoscopic lens with no special adapter. The image was accompanied through the LCD (liquid crystal display) visor, and the picture was taken with the flash button on and with no macro resource. The image was then enlarged by optical and digital zoom before being easily stored in photo files at the personal computer.

RESULTS

The quality of the photos obtained by this method was at least similar to that of traditional photos, and the data were promptly stored.

CONCLUSIONS

We describe a simple method of taking pictures from endoscopic images with the additional advantage of a facility to edit and store the photographs.

Quantitative analysis of the antigen-specific IFNgamma+ T cell-mediated immune response in conventional outbred pigs: kinetics and duration of the DNA-induced IFNgamma+ CD8+ T cell response

It is now well established that antigen-specific CD8(+) T cells play a major role in vaccine-induced immunity against intracellular pathogens and tumor cells. The detection of these immune cells in outbred animals has been hampered mainly by the need to generate individual autologous antigen-presenting cells (APCs) due to the high degree of polymorphism of the major histocompatibility complex (MHC) Class I loci. We used individually derived immature porcine dendritic cells infected with a pox-based recombinant viral vector to ex vivo stimulate PBMCs from vaccinated conventional pigs. The frequencies of antigen-specific T cells was determined by the number of IFNgamma-secreting cells in a quantitative enzyme-linked immune spot (ELISPOT) assay. Using this approach we were able to rank different pseudorabies virus (PRV) vaccines strategies for their ability to prime viral-specific IFNgamma(+) T cells. Plasmid DNA has recently emerged as a promising tool with multiple applications in the field of infectious diseases, allergy and cancer. We showed for the first time in this study that DNA immunization induced a long-lived antigen-specific IFNgamma(+) T cells response in conventional pigs. Additional studies allowed us to show that these virus-specific IFNgamma(+) responding cells detected in this ELISPOT assay were MHC-restricted and comprised in the CD8alpha(bright) pig T cell subset. These new data confirm the usefulness of DNA vaccines to control diseases requiring cellular immunity in pigs.

Assessment of optimal balloon size for rupture of the ureteropelvic junction and mid-ureter in a porcine model

PURPOSE

Balloon dilation potentially represents a safer and simpler technique for the treatment of ureteropelvic junction (UPJ) obstruction and ureteral strictures. Using a porcine model, we sought to establish the optimal balloon size for endoballoon rupture of the UPJ and ureter.

MATERIALS AND METHODS

The efficacy of endoballoon rupture of the proximal and middle ureter with 24F, 30F, and 36F balloon catheters was compared in 19 female minipigs. At the proximal ureter, the effect of the rate of dilation also was evaluated for each balloon size. Extravasation of methylene blue-stained contrast material was assessed with retrograde pyelograms and direct laparoscopic vision. After acute sacrifice, the dilated segments were evaluated histologically with hematoxylin and eosin and Masson's trichrome staining.

RESULTS

At the proximal ureter, free extravasation of contrast was observed in 61% of the rapid inflation and 72% of the slow inflation trials; contained extravasation was noted in 28% of the rapid inflation and 17% of the slow inflation trials. Except for two of the 24F slow inflation trials, all of the proximal ureteral trials produced at least one full-thickness tear into the periureteral fat. Grossly, the tears appeared linear with various lengths and no consistent orientation. Rapid inflation and increasing balloon size tended to produce a ureterotomy with less damage to the ureter surrounding the tear. At the mid-ureter, none of the balloon sizes consistently produced a transmural tear.

CONCLUSIONS

Rapid dilation and use of a 36F balloon capable of maintaining a low profile after inflation may result in a cleaner proximal ureterotomy with less distortion of the untorn neighboring proximal ureter. Both 36F and 30F balloons consistently produced a full-thickness proximal ureterotomy in normal porcine tissue. For mid-ureteral strictures, balloon dilation to even 36F may fail to create a suitable ureterotomy. However, it must be noted that dysplastic or scarred tissue may respond differently to dilation than the more elastic normal porcine tissues used in this study.

Comparison of renal ablation with cryotherapy, dry radiofrequency, and saline augmented radiofrequency in a porcine model

BACKGROUND

Needle ablative therapy has recently generated a lot of interest in the urologic community. We compare renal lesions produced in a porcine model using three forms of needle ablative energy: cryoablation (CR), dry radiofrequency (RF), and saline augmented radiofrequency (SARF).

STUDY DESIGN

In 10 farm pigs, under ultrasonographic guidance, 40 laparoscopic renal lesions were produced: 825-mm CR lesions were produced with 2.4-mm cryoprobes (Endocare Inc, Irvine, CA), after 1-mL preinfusions of 14.6% saline, 12 SARF lesions were created with 22-gauge needles (2 mL/minute 14.6% saline, 50 W 510 kHz RF for 60 seconds), 12 RF lesions were created with a 2-cm array LeVeen electrode and an RF2000 generator using impedance limited 30 to 60 W double activations (Radiotherapeutics Corp, Mountain View, CA), and 8 RF lesions were produced using 22-gauge needles and double 10 W activations with the RF2000 generator. Eight animals were sacrificed after 1 week for acute pathology. An additional two animals were sacrificed at 8 weeks to provide chronic pathology results for the LeVeen dry RF and SARF modalities.

RESULTS

CR produced a regular 18- to 22-mm zone of complete necrosis bordered by a 1.5- to 2.5-mm zone of partial necrosis. Acutely, LeVeen RF and single-needle RF produced lesions 25 to 45 mm and 6 to 10 mm wide, respectively. Acutely, SARF produced irregular cone-shaped lesions 15 to 31 mm wide. Only one of eight acute LeVeen RF lesions showed complete necrosis; none of the four 8-week LeVeen RF lesions displayed complete necrosis. Two of the four 8-week SARF lesions displayed complete necrosis. The remainder of the LeVeen RF, single-needle RF, and SARF lesions showed early, indeterminate tubular damage with relative glomerular sparing and bands of complete necrosis (0.5 to 1.5 mm) and inflammation (0.5 to 2 mm) at the periphery. Only CR could be consistently monitored with laparoscopic ultrasonography.

CONCLUSIONS

Renal cryoablation produces well-defined, completely necrotic lesions that can be monitored reliably with ultrasonography. Longer followup may be required to characterize the full extent of renal necrosis produced by RF, but in the short run, none of the RF modalities reliably produced 100% necrosis in all cases.

Laparoscopic bilateral hand assisted nephrectomy for autosomal dominant polycystic kidney disease: initial experience

PURPOSE

The laparoscopic technique for bilateral nephrectomy in patients with autosomal dominant polycystic kidney disease is technically difficult. The procedure may be more acceptable if alterations to the technique made it safer and easier to perform. We describe our initial experience with, and the feasibility and potential benefits of hand assisted laparoscopic nephrectomy for approaching these large kidneys in patients with autosomal dominant polycystic kidney disease.

MATERIALS AND METHODS

This approach was successfully applied in 3 patients with end stage renal disease due to autosomal dominant polycystic kidney disease. After obtaining transumbilical pneumoperitoneum ports were placed in the umbilicus (12 mm.), sub-xiphoid in the midline (12 mm.) and subcostal in the midclavicular line on each side (12 mm.). The table was tilted 40 degrees away from the planned side of initial nephrectomy with the patient in the half lateral position. A 7 cm. midline incision was made that incorporated the umbilical port and a commercially available hand assistance device was positioned. One surgeon hand was inserted into the abdomen to serve as a retractor/blunt dissector, while the other operated the electrosurgical instruments. The right hand was inserted for left nephrectomy and the left hand was inserted for right nephrectomy. The laparoscope was passed via the sub-xiphoid port and the instruments were placed through the ipsilateral subcostal laparoscopic port. Nephrectomy was completed and the specimen was removed through the hand port incision by draining the cysts as they were exposed to view via the midline incision. When dissection was difficult, an additional port was placed in the anterior axillary line at the umbilical level. Some cysts were ruptured or aspirated to decrease overall kidney size and make extraction possible via the 6 to 7 cm. midline incision.

RESULTS

All procedures were successfully completed. Mean operative time for bilateral hand assisted laparoscopic nephrectomy was 5.5 hours (range 4.5 to 6.6). Estimated blood loss was 200 cc or less. Patients resumed oral intake on postoperative day 1. The mean amount of parenteral analgesics required postoperatively was decreased. Mean hospital stay was 4.3 days but it was 3 days when considering nephrectomy only. Patients returned to normal activity after an average of 2 weeks. There was sustained resolution of preoperative discomfort based on pain analog scales. At 1 month or less all patients recorded absent pain. They uniformly noticed improved preoperative pulmonary and gastrointestinal symptoms

CONCLUSIONS

Hand assisted laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease makes bilateral nephrectomy a reasonable option. The bilateral procedure may be performed as rapidly as laparoscopic only, unilateral nephrectomy in these cases. The advantages of the hand assisted approach include using tactile sensation to facilitate dissection, rapid blunt finger dissection, hand retraction and the application of immediate tamponade when needed. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay and rapid convalescence in this group of patients at high risk.

Flexible ureteroscopic lithotripsy: first-line therapy for proximal ureteral and renal calculi in the morbidly obese and superobese patient

BACKGROUND AND PURPOSE

The surgical treatment of kidney and proximal ureteral stones in morbidly obese patients (>14 kg/m2) remains difficult because shockwave lithotripsy is precluded by weight limitations and percutaneous nephrolithotomy is associated with difficult access and a high (9%) rate of transfusion. We review our experience with retrograde ureteroscopic lithotripsy in morbidly obese patients with renal and proximal ureteral stones.

PATIENTS AND METHODS

Between December 1992 and April 2000, five women and three men with a mean age of 46.5 years (range 33-68 years) and a mean body mass index of 54 (range 45-65.2) underwent 10 independent ureteroscopic procedures for urolithiasis. The average stone size was 11.1 mm (range 5-25 mm). Lithotripsy was performed with the holmium laser in eight patients (60%) the electrohydraulic lithotripter in four (30%), and the tunable-dye laser in the remaining patient. Stone-free status was defined as no stones visible on a plain film with nephrotomograms or CT scan at 3 months.

RESULTS

The mean operation time was 101 minutes (range 45-160 minutes), and 60% of the procedures were done on an outpatient basis. After the initial procedure, the stone-free rate was 70%. Two patients had fragments <4 mm, and no further therapy was undertaken. There was one complication: transient renal insufficiency (serum creatinine concentration 3.7 mg/dL) secondary to aminoglycoside toxicity. No transfusions were needed.

CONCLUSION

In the morbidly obese patient with symptomatic stones <1.5 cm, ureteroscopic lithotripsy is safe, successful, and efficient.

Functional and phenotypic characterization of distinct porcine dendritic cells derived from peripheral blood monocytes

Dendritic cells (DCs) are bone marrow-derived antigen-presenting cells that have an exquisite capacity to interact with T cells and modulate their responses. Little is known about porcine DCs despite the fact that they represent an important target in strategies that are aimed at modulating resistance to infection in pigs and may be of major importance in transplantation biology. We generated immature monocyte-derived porcine dendritic cells (MoDCs) directly from adherent peripheral blood cells treated with porcine granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-4 (IL-4). The cells were observed via electron microscopy and their phenotype was characterized using monoclonal antibodies. The functionality of the porcine MoDCs was demonstrated showing that the cells were capable of different specialized functions relevant to antigen capture and were potent stimulators in a primary allo-mixed leucocyte reaction. Treatment of the MoDCs with porcine cell line-derived necrotic factors resulted in the phenotypic and functional maturation of MoDCs. We confirmed also that monocyte-derived DCs were differentially regulated by cytokines, showing that transforming growth factor-beta1 (TGF-beta1) is able to redirect monocytic precursors into the differentiation pathway of Langerhans' cells presenting typical Birbeck granules. Interestingly, and in contrast to the human and murine model, we showed that the monocyte-derived porcine Langerhans'-type cells (MoLCs) were much more potent activators of allogeneic T cells than MoDCs obtained without TGF-beta1.

Laparoscopic renal ablation: an in vitro comparison of currently available electrical tissue morcellators

OBJECTIVES

Morcellation with the Cook high-speed electrical laparoscopic (HSEL) morcellator in an impermeable nylon/plastic sack (LapSac) has remained unchanged since its inception nearly one decade ago. Sack deployment and specimen entrapment remain relatively difficult, and morcellation with this device is expensive and relatively slow. As such, in an effort to facilitate specimen entrapment and morcellation, we adapted two currently available electrical morcellators (the Steiner gynecologic morcellator and the electrical prostate morcellator [EPM]) for renal morcellation and compared them with the HSEL morcellator.

METHODS

All morcellation was performed through a simulated abdominal wall under direct laparoscopic vision. Ten porcine kidneys were ablated with each of the following techniques: HSEL morcellation in a LapSac; HSEL morcellation in a fluid-filled LapSac; Steiner morcellation in an insufflated Endocatch sack; and EPM morcellation in a fluid-filled Endocatch sack. A modified laparoscopic trocar was constructed and used for the Steiner and EPM morcellation. The time to complete morcellation, morcellation product size, and entrapment sack integrity were evaluated for each technique. Cost data for each morcellator are also presented.

RESULTS

The mean morcellation time for the Steiner, HSEL dry, HSEL wet, and EPM morcellation was 6.0, 15.9, 14.7, and 26.0 minutes, respectively. The mean fragment size for these morcellators was 2.97, 0.65, 0.62, and 0.013 g, respectively. A single entrapment sack perforation was documented in a LapSac during routine HSEL morcellation.

CONCLUSIONS

Renal morcellation with all three morcellators is feasible. The Steiner morcellator combined with an Endocatch resulted in more rapid morcellation and larger morcellation products.

Evaluating the clinical performance of the Osseotite implant: defining prosthetic predictability

A 5-year prospective, multicenter study is in progress at four private dental practices to determine the cumulative implant survival rate and prosthetic outcome when using the Osseotite dental implant in posterior maxillary and mandibular areas. An interim evaluation after 34.4 months of study progress is presented. A total of 219 Osseotite implants were placed in 74 patients (34 women and 40 men with a mean age of 57.8 +/- 15.2 years) using a conventional two-stage surgical protocol and 3- to 6-month healing time. Subsequently, patients were restored with fixed or removable restorations. Nineteen of the 74 patients reported smoking an average of 13.2 cigarettes per day. Restorative treatments included 40 single-unit restorations; 53 splinted 2-, 3-, 4-, and 5-unit implant-supported maxillary and mandibular prostheses; 4 full-arch fixed maxillary prostheses; 1 mandibular fixed/detachable hybrid prosthesis; and 1 mandibular overdenture. The mean time from implant placement to second stage surgery was 6.2 +/- 2.0 months; from restoration and implant loading to the most recent follow-up evaluation was 20.9 +/- 6.8 months. Of the 219 implants placed, three posterior maxillary implants developed infections and were removed prior to second stage surgery. No implant failures occurred at second stage surgery or after implant loading. Using the Kaplan-Meier method, the cumulative implant survival rate was 100% for anterior implants and 98.4% for posterior implants at 28.5 +/- 5.7 months. The cumulative postloading implant survival rate was 100% for both anterior and posterior implants. The results of this study indicate that the Osseotite dental implant achieved a high rate of integration that remained stable during nearly 2 years of implant function. In addition, because no postloading implant failures have occurred, the Osseotite implant has provided a high level of prosthetic predictability.

The serum albumin-binding region of streptococcal protein G (BB) potentiates the immunogenicity of the G130-230 RSV-A protein

BBG2Na is a protein comprising residues 130-230 of the respiratory syncytial virus subgroup A (RSV-A) G protein (G2Na) fused to the albumin-binding domain of streptococcal G protein (BB). BBG2Na was cloned, expressed in Escherichia coli and renaturated. In rodent models, this subunit RSV vaccine adjuvanted in Alhydrogel induced specific antibodies and conferred protection to RSV infection. Comparison of the antibody production in a BALB/c mouse model revealed that BBG2Na induced a stronger and earlier G2Na antibody response than G2Na alone, without altering the IgG subclass distribution. To address the role of the BB part, we explored its carrier properties and showed that it is a Th dependent antigen, generating a more potent G2Na-specific B cell memory response and able to generate Th cells that provide help for G2Na antibody production.

The recombinant Klebsiella pneumoniae outer membrane protein OmpA has carrier properties for conjugated antigenic peptides

Klebsiella pneumoniae OmpA, the 40-kDa major protein of the outer membrane, was cloned and expressed in Escherichia coli. The recombinant protein was produced intracellularly in E. coli as inclusion bodies. Fusion of a short peptide to the N-terminus of native P40 facilitated high-level expression of the recombinant protein. Purified recombinant P40 was analyzed to verify purity and structural integrity. The molecular mass of purified recombinant P40 determined by electrospray mass spectrometry was 37,061 Da, in agreement with the theoretical mass deduced from the DNA sequence. Specific proliferation of recombinant-P40-primed murine lymph node cells in response to recombinant P40 stimulation in vitro indicated the presence of a T-cell epitope on recombinant P40. The induction of high serum antibody titers to a synthetic peptide derived from the attachment protein G of the respiratory syncytial virus when chemically coupled to recombinant P40 indicated that the protein had potent carrier properties.

Avidin-binding to peripheral blood B lymphocytes and monocytes

Avidin-coated magnetic beads bind peripheral blood B lymphocytes and monocytes. This unwanted reactivity is not due to the membrane expression of avidin target molecules since beads coated with a biotin-binding analogue are non-reactive and binding occurs even when cellular carbohydrate-binding sites are not active, in the absence of Mg2+ and Ca2+ cations, or when they are blocked by a alpha-D-glucose or alpha-D-mannose in presence of Ca2+ and Mg2+. The non-polar residues of avidin appear not to be engaged in a hydrophobic bond with the membrane molecule since suroptimal quantities of serum albumin do not prevent the avidin binding. It is suggested that ionic interactions explain the binding of avidin-coated beads to B lymphocytes and monocytes and that these can be inhibited with high molecular weight serum molecules or with 0.4 M NaCl.

Modification of human long-term bone marrow cultures: establishment of a functional stromal microenvironment devoid of myeloid progenitors

Differences in the plastic adhesive properties of bone marrow (BM) cells were used to initiate modified stromal layers (MSL) from long-term cultures by removing non-adherent cells shortly (4 to 18 hours) after initial seeding. Following this early modification, adherent cells generated a confluent layer after 21 days of culture. Cellular characteristics of volume and spontaneous fluorescence determined by flow cytometry showed that the MSL included 82% fibroblastic stromal cells, 8% macrophages and 10% myelomonocytic cells. Furthermore, clonogenic assays revealed that the MSL were devoid of hematopoietic progenitor cells. MSL were found to sustain long-term myelopoiesis for at least 7 weeks from exogenously added hematopoietic progenitors isolated from bone marrow (CD34+ cells), thereby demonstrating their functionality. The present experimental model appears of interest for the study of interactions between defined populations of hematopoietic cells and cells of the adherent layer. Of importance, our present modifications of human long-term bone marrow culture are technically simple and do not involve manipulation of the stromal cells.

Phenotypic analysis of a large number of normal human bone marrow sample by flow cytometry

Bone marrow aspirates from 48 healthy donors (34 adults, 14 children) were analyzed by flow cytometry (FACS Analyzer) after purification of low-density bone marrow cells (Ld BMC) on a density gradient (d = 1,077) and labelling with 23 anti-hematopoietic cell monoclonal antibodies. Based on physical properties, these Ld BMC could be divided into four different populations called E, My, Mo and L, which comprised 14% +/- 9%, 31% +/- 16%, 10% +/- 5% and 45% +/- 14% of these cells, respectively. The phenotypic analysis of these different populations enabled the identification in E, of erythrocytes (Glycophorin A+, Rhesus D+, but negative for early erythroid differentiation markers such as the transferrin receptor (Tf. R) and the FA6-152 antigen); in My of cells of the myeloid lineage (VIM2+, HLA DR-); in Mo of cells of the monocytic lineage (VIM2+, CD14+) plus some myeloblasts (VIM2+, CD14-, HLADR+) and finally in L of a heterogeneous population including: 1. T lymphocytes labelled to the same extent by CD2, CD3, CD5 and CD6 (28% +/- 10%), B lymphocytes assessed by CD19 and CD20 (12% +/- 8%), Pre-B cells (CD10+ = 8% +/- 7%), less than 5% of "natural killer" cells (CD16+ or Leu7+) and finally, less than 6% of myelomonocytes (CD14+ and/or VIM2+). 2. The erythroid lineage (rhesus D+ = 42% +/- 20%, Tf.R+ and FA6-152+ = 32% +/- 12%). 3. Undifferentiated cells or progenitor cells (CD34+ = 7% +/- 5%). 4. Cells unlabelled by any antibodies (approximately 6%). We observed no difference between bone marrow samples from adults or children, with respect to physical properties, and with all but four immunological markers. A significantly higher proportion of B cells (CD19+ and CD10+) (P less than 0.001) and undifferentiated cells (CD34+ and HLADR+) (P less than 0.02) was observed in children. These data, obtained from a large number of bone marrow samples, could be used to quantify the imbalance of some bone marrow disorders.

Long-term culture of human bone marrow. I. characterization of adherent cells in flow cytometry

Using long-term culture techniques, we were able to characterize the different adherent cell elements of the in vitro bone marrow microenvironment by flow cytometry. After 2 weeks of culture, four adherent cell subsets, L, MM, F, and M, were distinguished according to their intrinsic cellular characteristics of volume and spontaneous fluorescence. Using four immunological markers, we identified each population as a hematopoietic lymphocytic group (L), CD45+, VIM2-, CD14-; a hematopoietic myelomonocytic group (MM), CD45+, VIM2+, CD14-; a hematopoietic macrophage group (M), brightly autofluorescent, CD45+, VIM2-, CD14+; and a group of fibroblastoid cells (F) with a very high volume, CD45-, VIM2-, CD14-, and collagen III+. Isolation of the different hematopoietic and nonhematopoietic components of long-term bone marrow culture is thus possible using flow cytometry analysis according to the cell characteristic of volume and spontaneous fluorescence alone.

Spontaneous expression of a low affinity Fc receptor for IgA (Fc alpha R) on human B cell lines

Expression of receptors for IgA (Fc alpha Rs) was investigated on a panel of 35 human B cell lines by labelling with human secretory IgA (0.5 mg/ml) and flow cytometry analysis after staining with fluoresceinated goat anti-human secretory component and/or anti-alpha chain F(ab')2 fragments. Receptors for IgA could be demonstrated on one out of nine Burkitt's lymphoma cell lines, three out of five myeloma cell lines and five out of 21 lymphoblastoid cell lines. The percentage of Fc alpha R-positive cells within the same B cell line varied upon repeated examination. Human dimeric IgA1 lambda myeloma protein revealed the same number of IgA receptor positive cells as did secretory IgA, whereas monomeric IgA did not bind to Fc alpha R. Detection of Fc alpha R was not inhibited when the tests were carried out in the presence of human dimeric IgG, IgM, asialo-orosomucoid, and secretory component but it was abrogated by pre-treatment of the cells with trypsin. The binding characteristics of Fc alpha Rs were studied on the myeloma cell line Esteve, using 125I-labelled human dimeric IgA and secretory IgA. The binding was dose-dependent with rapid kinetics and specific inhibition by unlabelled secretory IgA. Scatchard plot analysis resulted in an equilibrium constant K ranging from 3.2 to 4.7 x 10(6) M/l. No correlation was observed between Fc alpha R expression and differentiation stage, monoclonality, polyclonality of the cell lines, or Ig class produced by the B cells.

Quantitative analysis of cultured thymic reticulo-epithelial cells labelled by different antibodies: a flow cytometric study

Quantitative measurements of cultured human and murine thymic, and human thymoma reticuloepithelial cells (REC), immunolabeled by different antibodies (Ab) (TE3, TE4, anti-HTLV p19(p19), lu5, K11 and Aks) and by thymic hormones (thymulin and thymosin alpha 1 (Ta1)) within these cells, were performed using a flow cytometric technique. The anti-keratin polyclonal Ab labeled nearly the whole human or murine population. The p19 monoclonal Ab (MoAb), specific for the subcortical/medullary thymic regions, labelled 37-77% of the human REC. The TE3 MoAb, specific for the cortical region, labelled 54-83% of the REC. These percentages suggest that the cultured thymic REC (TREC) had markers of both regions together and therefore that these markers are not absolutely specific to determine their subcortical/medullary or cortical thymic origin. For the three populations there were more cells containing Ta1 than thymulin. The overlap of the percentage of labelled cells suggests that the same cell could synthesize the two hormones and that these hormones could be localized within the TE3 positive cells.