Screening of antiviral activities in medicinal plants extracts against dengue virus using dengue NS2B-NS3 protease assay

Dengue virus infects millions of people worldwide and there is no vaccine or anti-dengue therapeutic available. Screening large numbers of medicinal plants for anti-dengue activities is an alternative strategy in order to find the potent therapeutic compounds. Therefore, this study was designed to identify anti-dengue activities in nineteen medicinal plant extracts that are used in traditional medicine. Local medicinal plants Vernonia cinerea, Hemigraphis reptans, Hedyotis auricularia, Laurentia longiflora, Tridax procumbers and Senna angustifolia were used in this study. The highest inhibitory activates against dengue NS2B-NS3pro was observed in ethanolic extract of S. angustifolia leaves, methanolic extract of V. cinerea leaves and ethanol extract of T. procumbens stems. These findings were further verified by in vitro viral inhibition assay. Methanolic extract of V. cinerea leaves, ethanol extract of T. procumbens stems and at less extent ethanolic extract of S. angustifolia leaves were able to maintain the normal morphology of DENV2-infected Vero cells without causing much cytopathic effects (CPE). The percentage of viral inhibition of V. cinerea and T. procumbens extracts were significantly higher than S. angustifolia extract as measured by plaque formation assay and RT-qPCR. In conclusion, The outcome of this study showed that the methanolic extract of V. cinerea leaves and ethanol extract of T. procumbens stems possessed high inhibitory activates against dengue virus that worth more investigation.

Potential use of cholecalciferol polyethylene glycol succinate as a novel pharmaceutical additive

D-alpha-tocopheryl polyethylene glycol succinate (TPGS) has been utilized in numerous drug delivery formulations in recent years. Because of its amphiphilic structure, it can be used as emulsifier and vehicle for lipid-based drug delivery formulations. It is also an effective P-glycoprotein (P-gp) inhibitor. However, TPGS represents only one of the surfactants in the class of "Vitamin-PEG" conjugated surfactants. To design a new adjuvant or additive, a conjugate made of vitamin D (cholecalciferol) and PEG-cholecalciferol polyethylene glycol succinate (CPGS) was synthesized via a two-step reaction. We hypothesized that CPGS may exhibit similar characteristics to TPGS, and thus the physicochemical properties as well as the anticancer properties of CPGS were studied. The results demonstrated that CPGS reduced the particle size and increased the encapsulation efficiency of the PLGA nanoparticles, indicating that CPGS may also have the emulsifier function similar to TPGS. The drug release profiles showed that the nanoparticles with CPGS additive had a lower initial burst and more sustained release pattern. In vitro testing with Caco-2 cells showed that CPGS could increase the cytotoxicity of DOX-loaded PLGA nanoparticles. Based on the rhodamine accumulation study, the increased cytotoxicity is possibly due to the P-gp inhibition by CPGS. From current results, the use of CPGS as an adjuvant is promising and may enhance the efficacy of the overall drug delivery system.

Susceptibility to neuroleptic-induced tardive dyskinesia and the T102C polymorphism in the serotonin type 2A receptor

BACKGROUND

Genetic factors have been implicated in the pathophysiology of the movement disorder tardive dyskinesia, which may involve dopamine-serotonin interaction. Case-control association studies have identified the T102C polymorphism of the 5-HT2A receptor gene as being associated with schizophrenia and responsiveness to clozapine. In this study, we examine the association of this polymorphism in the 5-HT2A receptor gene as a risk factor for developing schizophrenia and tardive dyskinesia from prolonged treatment with neuroleptics.

METHODS

Ninety-seven healthy control subjects with no history of mental illness and 221 schizophrenic patients (87 with tardive dyskinesia, 134 without) were genotyped by PCR-RFLP.

RESULTS

Comparison between cases and control subjects revealed no significant association between the C allele and schizophrenia. There was significant difference in allele frequency (p = .044, OR = 1.54 95% CI = 1.02-2.33) between patients who developed tardive dyskinesia and those who did not. Significant difference remains even after adjusting for age and neuroleptic dosage (p = .041) with the odds ratio at 1.64 (95% CI = 1.02-2.62).

CONCLUSIONS

A genetic variant of the 5-HT2A receptor may be associated with neuroleptic-induced tardive dyskinesia in schizophrenia. Further studies are needed to replicate the finding. The role of 5-HT2A receptor in the etiology of tardive dyskinesia or treatment-resistant schizophrenia should be further investigated.

Attempted suicide and polymorphism of the serotonin transporter gene in Chinese patients with schizophrenia

Abnormalities of serotonin synthesis and metabolism may be associated with suicidality. The serotonin transporter gene (5-HTT) is one of the important genes involved in the regulation of serotonin neurotransmission. We examined the association of suicidal behavior in Chinese schizophrenic patients with a functional polymorphism of the promoter region of the 5-HTT gene (5-HTTLPR). The 5-HTTLPR genotype was determined by polymerase chain reaction for 76 suicidal and 262 non-suicidal patients with a diagnosis of schizophrenia (DSM-IV criteria). All subjects were unrelated to each other, and all were Chinese. There was no significant genotypic or allelic association of the 5-HTTLPR polymorphism with history of attempted suicide. From our results, this 5-HTTLPR polymorphism is unlikely to have a major effect on suicidal behavior in Chinese patients with schizophrenia.

Tardive dyskinesia is not associated with the serotonin gene polymorphism (5-HTTLPR) in Chinese

Neuroleptics are the mainstay of treatment for schizophrenia, but one of the complications is the development of tardive dyskinesia (TD). The pathophysiology of TD may involve dopamine-serotonin interaction. The serotonin transporter participates in the reuptake and termination of serotonin neurotransmission, and the gene that codes for this protein is thus a candidate gene for the development of TD. There is a functional polymorphism in the transcriptional control region of the serotonin transporter gene, and we investigated the association between this polymorphism and TD in Chinese schizophrenic patients. The patients who did not differ in age and sex distribution did not show variation on the rates of TD and Abnormal Involuntary Movements Scale (AIMS) scores with genotypes. Our findings suggest that 5-HTTLPR polymorphism is not a risk factor for TD in Chinese. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:712-715, 2000.

Identification of genes for schizophrenia susceptibility

INTRODUCTION

Advances in genotyping, mapping and genome analysis methods over the last few years offer great promise towards the discovery of genes involved in the pathogenesis of schizophrenia, a mental disorder with a high degree of heritability.

METHODS

This article draws on published reports in major international journals in the field of schizophrenia and human genetics.

RESULTS

We summarise the major findings from family linkage studies, genome scan with microsatellite markers and association studies with polymorphisms in candidate genes. However, although recent developments in the technology for genotyping and gene identification have provided new leads to genetic abnormalities underlying schizophrenia, they have yet to result in the identification of any disease gene. There are both positive and negative data for reported linkages to specific chromosomal regions and candidate gene polymorphisms.

CONCLUSIONS

Conflicting data and nonreplication of association and linkage studies are problems that need to be addressed. One solution might be clearer and narrower definition of subphenotypes and use of only a specific phenotypic marker in linkage and association studies. When successful, identification of susceptibility genes will lead to better understanding of cognitive functions and socio-emotional behaviour and also help in the formulation of preventive strategies for those found to be at high risk.

[Delayed (tension) pneumothorax after placement of a central venous catheter]

Laborious attempts at introducing a central venous catheter for parenteral nutrition in two women, aged 36 and 62 years, were followed by shortness of breath after 32 and 10 hours, respectively. This symptom was due to a (tension) pneumothorax not visible on earlier roentgenograms. Thoracic drainage led to recovery. In all patients with a central venous catheter an undetected delayed pneumothorax can be present. Urgent chest X-ray examination should be performed in all patients with acute respiratory symptoms. Patients undergoing elective intubation with positive pressure breathing should be examined carefully, since they are at risk of developing a late (tension) pneumothorax.

Ethnic differences in genetic susceptibility to atopy and asthma

The genetics of asthma and atopy is complex, but can be approached by studies of both candidate genes and mapping of susceptibility loci. Genetic factors conferring susceptibility to disease may vary among ethnic groups. We present our experience with some candidate gene studies for asthma and atopy and susceptibility locus mapping for linkage to chromosome 5q.

A comparison of free radical-induced vascular and skeletal muscle damage in immunocompetent and neutropenic rats

BACKGROUND

Intraarterial infusion of the free radical donor tert. -butyl-hydroperoxide (tert.-BuOOH) into one extremity of the rat induces vascular permeability and considerable skeletal muscle damage. However, it remains unclear what the role of polymorphonuclear neutrophils (PMNs) is in oxidative stress-related processes. Therefore, we investigated possible differences between neutropenic and normal animals in this model.

METHODS

Neutropenia was induced in male rats by intraperitoneal administration of cyclophosphamide. tert.-BuOOH was continuously infused intraarterially into one hindlimb of normal or neutropenic nonanesthetized rats for 24 h. The control neutropenic rats were infused with the same volume of saline. After the infusion, 99mTc-IgG was administered intravenously followed by scintigraphic imaging analysis of the left/right uptake ratio of the hindlimbs and by gamma counting of the tissue samples of the gastrocnemius and gluteus maximus muscles. Samples of these muscles were analyzed by light microscopy.

RESULTS

The uptake ratios were significantly increased in the normal and neutropenic tert.-BuOOH-infused animals as compared with the saline-infused neutropenic rats (P < 0.05). The uptake ratios were significantly higher in normal than in neutropenic tert.-BuOOH-infused rats (P < 0.05). Histological analysis of the saline infused skeletal muscles showed unaffected skeletal muscles with intact arterioles and arteries. In the gastrocnemius and gluteus maximus muscles of the normal tert. -BuOOH-infused and neutropenic rats, similar morphological damage was observed.

CONCLUSIONS

PMNs can increase, to some extent, the vascular permeability of the free radical damaged small arteries and arterioles of a tert.-BuOOH-infused hindlimb. However, in the present animal model, tert.-BuOOH alone can induce oxidative stress-related abnormalities with skeletal muscle tissue damage that is mainly independent of the presence of PMNs.

Soft tissue repair capacity after oxygen-derived free radical-induced damage in one hindlimb of the rat

Oxygen-derived free radicals are suspected to play an important role in the pathogenesis of inflammation and ischemia/reperfusion of an extremity. In this study we investigated the repair capacity of a free radical-damaged hindlimb of the rat and the effect of the anti-oxidant N-acetyl-L-cysteine (NAC). In nonanesthetized rats (n = 39), the left hindlimb was continuously infused intra-arterially (1 ml/hr) for 24 hr with the free radical donor tert-butylhydroperoxide (tert-BuOOH, 25 mM). Subsequently the infusion system was disconnected and the repair of soft tissue damage was observed with special attention to various pain tests, vascular permeability ((99m)Tc-IgG scintigraphy), and histology for a maximum period of 6 weeks. In 12 of these tert-BuOOH-infused rats the antioxidant NAC was injected intraperitoneally. Six of the NAC-treated rats were killed after 24 hr of infusion, while the remaining 6 rats were disconnected, reinjected with NAC, and observed for 1 week. Tert-BuOOH infusion for 24 hr led to significantly increased pain sensations, vascular permeability, and histological damage. Treatment with NAC significantly reduced pain sensations and vascular permeability, though not to control levels. One week after disconnection, tissue damage was almost completely repaired in the NAC-treated rats. In the untreated rats, repair took longer but histology and vascular permeability were completely normalized within the observation period. Soft tissue damage, induced by 24-hr infusion of the free radical donor tert-BuOOH, showed spontaneous repair within 6 weeks. The antioxidant NAC significantly reduced the soft tissue damage and shortened the repair period.

Posterior fossa cystic lesions--magnetic resonance imaging manifestations

Cystic lesions of the posterior fossa remain a controversial subject as to clinical classification and diagnosis, especially for those in combination with other intracranial abnormalities. During the period of November 1985 to June 1991, 16 patients with cystic lesions of the posterior fossa were retrospectively reviewed on neuroradiological evaluation with MR images. The patients were 9 males and 7 females aged from 5 days to 15 years old (medium 1 year old). They were classified into three groups as Dandy-Walker cyst (group A, 5 patients), mega cisterna magna (group B, 4) and retrocerebellar pouch or cyst (group C, 7). Nine patients had associated intracranial anomalies, holoprosencephaly in 3 (group A, 3), dysgenesis of the corpus callosum in 4 (group A, 2; group C, 2), and occipital meningoceles in 2 (group C, 2). Hydrocephalus or ventricular enlargement was found in 10 patients (group A, 5; group B, 2; group C, 3). Surgical treatment (cyst-peritoneal shunt or cystectomy) was performed for 10 patients with clinical symptoms due to cyst. Postoperatively, clinical symptoms due to increased intracranial pressure or hydrocephalus improved in 7 patients. For long-term results, the cyst was reduced in 1 of 5 patients of group A and 2 of 5 of group C. Most of our patients have a poor prognosis because of the associated intracranial anomalies or atrophy of the cerebellum. Multiplanar MR images may provide sufficient evidence for the diagnosis of posterior fossa cysts, especially in the case of rotation or upward displacement of the cerebellar vermis. However, the cyst membrane, and the communication of fluid between the cyst and the cistern, cannot be demonstrated on MR images. Further investigation on these subjects and indications for surgical intervention is highly necessary.

Determination of heparan sulphate in kidney tissues of patients with calcium nephrolithiasis

While the pathogenic mechanisms responsible for calcium nephrolithiasis remain unknown, the influence of heparan sulphate proteoglycan (HSPG) on disease progression of other diseases, such as polycystic kidneys and diabetic glomerulosclerosis, makes it an important candidate for the study of stone formation. Using the indirect immunofluorescence assay and image analysis, we were able to quantify and visualize the loss of HSPG localized in the basement membrane of the glomerulus and the mucosa of ureter or renal pelvis in patients with recurrent calcium nephrolithiasis as compared to normal subjects. However, no significant change in HSPG was observed in the basement membrane of the tubular epithelium. The decreased HSPG in the glomerulus may reflect the potentially disrupted anion/neutral barrier for glomerular filtration, which would encourage the accumulation of stone solutes. The drop in HSPG staining intensity in the basement membrane of the mucosa of ureter/renal pelvis may suggest the tendency of adhesion of crystal to urothelial surfaces. Based on these immunological data, it appears that HSPG plays a modulatory role in the pathogenesis of this disease.

Bacillus Calmette-Guerin (BCG) in the treatment of superficial bladder cancer

We evaluated the efficacy of immune and scarification Bacillus Calmette-Guerin (BCG) in the treatment of carcinoma in situ and prophylaxis against recurrence in patients with superficial transitional carcinoma of the bladder. A single-blind, randomised, comparative trial involving 43 patients with a median follow-up of 39 months was analysed. The end points were progression to muscle invasive disease or recurrence. The overall response rate was 93% after one to two courses. There was no difference between the two preparations and no statistically significant difference between the response or progression rates of the carcinoma in-situ or prophylactic groups. However, the response to BCG was found to be a significant prognostic indicator in a multivariate analysis.

Pharmacotherapy in benign prostatic hyperplasia

Symptomatic bladder outlet obstruction due to benign prostatic hyperplasia (BPH) has been conventionally treated by transurethral resection. In recent years, a better understanding of the natural history and pathophysiology of BPH coupled with significant morbidity of prostate surgery has led to renewed interest in the medical therapy of BPH. Both alpha 1 blockers and 5 alpha-reductase inhibitors have been shown to be effective in recent clinical trials in the treatment of BPH. Both these drugs are safe and their side effects reversible. Medical therapy has a bigger role to play now especially for those high risk patients with moderate to severe symptoms of BPH. Further development of more effective alpha blockers and anti-androgens with less side effects would make pharmacotherapy an even more attractive alternative than the more invasive procedures.

Extracorporeal shock wave lithotripsy monotherapy for selected staghorn stones

OBJECTIVE

To define a subgroup of staghorn stones that is amenable to extracorporeal shockwave lithotripsy (ESWL) monotherapy and review the need for prophylactic ureteric stents.

METHODS

Fifty-eight renal units with staghorn calculi in 56 patients (30 males and 26 females) were treated by ESWL monotherapy on the EDAP LT-01 lithotripter. The stones were grouped as complete staghorn (11, 19%), partial staghorn (34, 59%) and borderline staghorn (13, 22%). Results of treatment were analysed in relation to subgroup and calyceal dilatation. Post-treatment complications were studied and the influence of prophylactic ureteric stents examined.

RESULTS

The average number of ESWL sessions was 3.1 (range: 1 to 8). The mean follow-up period was 13 months. Stone-free rate at 10 months was 52%. When clinically insignificant residual fragments less than 4mm were included, the overall clearance rate was 75%. Favourable factors influencing treatment outcome included smaller stone burden, peripheral distribution of stone mass and absence of pelvicalyceal dilatation. The overall complication rate was 39% with urosepsis being the commonest. Complications were related to stone burden. More than half of the renal units with complete staghorn stones developed one or more complications. Auxiliary procedures were required in 18% of the renal units. Twenty of 39 renal units with a stone burden (sum of length and width) greater than 50mm had pretreatment ureteric stenting using the double-J (DJ) siliastic stent. A urosepsis rate of 50% was noted in those with ureteric stents compared to 26% in those not stented. The stents did not offer any advantage in preventing post-treatment obstruction by fragments. Six of 7 renal units with post-treatment obstruction had in-situ stents.

CONCLUSIONS

ESWL monotherapy is suitable for selected staghorn stones. Prophylactic ureteric stents do not offer any advantage and may predispose to urosepsis.

The human active breakpoint cluster region-related gene encodes a brain protein with homology to guanine nucleotide exchange proteins and GTPase-activating proteins

GTPase-activating proteins (GAPs) modulate the activity of the ras superfamily of proteins by converting active GTP-bound to inactive GDP-bound p21s. Employing a novel GAP overlay assay (Manser, E., Leung, T., Monfries, C., Teo, M., Hall, C., and Lim, L. (1992) J. Biol. Chem. 267, 16025-16028), we demonstrated a diversity of proteins with GAP activities in different tissues. Using a polymerase chain reaction strategy exploiting conserved residues in the GAP domains of n-chimaerin and the product of the breakpoint cluster region gene (BCR), we isolated a human brain 5.3-kilobase cDNA containing a 486-base pair region with complete identity to a previously reported active BCR-related (ABR) gene sequence on human chromosome 17. The brain cDNA encoded a 98-kDa protein (ABR) resembling BCR (68% identity), containing both the oncogene dbl-related domain at the N terminus and the GAP domain at the C terminus; however, it lacks the N-terminal BCR protein kinase domain. The ABR GAP domain expressed as an Escherichia coli fusion protein was active against Rac1 and Cdc42 of the rho subfamily. The ABR mRNA is highly enriched in the brain. ABR probably corresponds to the brain-enriched 100-kDa GAP for Rac and Cdc42Hs previously detected. The relationship of ABR to Miller-Dieker syndrome, a neurological disorder co-mapping to 17p13.3, is discussed.

Characteristics of histamine receptors in human cerebral arteries

Histamine and 2,2-pyridylethylamine, an H1-receptor agonist, (both 10(-8)-10(-3) M) caused contraction of human cerebral artery preparations in the absence of active tension, while dimaprit, an H2-receptor agonist, caused vasorelaxation. The histamine-induced vasoconstriction was blocked non-competitively by tripelennamine, an H1-receptor antagonist. In the presence of cimetidine, an H2-receptor antagonist, histamine-induced contraction was enhanced. The histamine-induced contraction was not affected by phentolamine or propranolol, but abolished by nifedipine. In prostaglandin F2 alpha-precontracted arteries, histamine and dimaprit caused relaxation, while 2,2-pyridylethylamine had no apparent effect. Histamine-induced relaxation was much greater in the presence than in the absence of an H1-antagonist. The vasorelaxation induced by histamine in the presence of an H1-antagonist was also inhibited by an H2-antagonist. Histamine caused no apparent relaxation in precontracted preparations without endothelium. The present results provide further evidence that histamine causes either vasocontraction or vasodilation in human cerebral arteries, and suggest that vasocontraction and vasorelaxation are due to the activation of H1- and H2-receptors, respectively. The relaxation induced by histamine may also be related to the endothelium-derived relaxing factors released from endothelial cells.

[Regional phacomatosis with cerebral AVMs and cavernous hemangioma of the skull--report of a case]

We report the coexistence of multiple arteriovenous malformations (AVMs) and hemangioma of the skull in a 38-year-old man with associated varicose veins in his scalp. The patient also had hypotrophy of all right limb tissues with skin pigmentation and syndactyly of both feet. CT scans revealed intraventricular hemorrhage and a hemangioma of the skull at the posterior fossa. Because of the location of the arteriovenous malformations, surgical evacuation and resection were not attempted. The hemangioma was totally removed to decompress the posterior fossa. A few cases of regional phacomatosis with intracranial AVMs have been reported, but we could not find a report of the coexistence of intracranial multiple AVMs and hemangioma of the skull with associated varicose veins of the scalp and skeletal hypotrophy. We discuss on the etiology of the coexistence of regional phacomatosis and hemangioma and on the difference between our case and typical regional phacomatosis.

Acute obstructive hydrocephalus caused by a migrating intraventricular calculus. Case report

A 10-year-old boy presented with acute obstructive hydrocephalus caused by the impaction of a calculus on the cerebral aqueduct. The calculus migrated from the third ventricle to the fourth ventricle after ventricular drainage and right ventriculoperitoneal shunt placement had been performed. The nature and origin of the calculus could not be determined, although its release from the choroid plexus in the lateral ventricle is highly possible.

Congenital inclusion cysts over the anterior fontanel in Japanese children: a study of five cases

Congenital inclusion cysts over the anterior fontanel are rare in children in Asia and Europe. However, recent evidence of an increase in cases in both areas has been presented. In the period from 1980 to 1989, four patients with a dermoid cyst and one with an epidermoid cyst have undergone total excision in our department. Including the previously reported Japanese cases, the number of recorded Japanese cases is now 15, the number of Asian cases thus corresponding to the number in Europe. Although these lesions are unlikely to have intracranial extensions, noninvasive neuroimaging methods such as computed tomography and magnetic resonance imaging are recommended for preoperative investigations.

Re-evaluation of indications for percutaneous nephrostomy and interventional uroradiological procedures in pelvic malignancy

Twenty-two patients with advanced cancer involving the pelvis were treated by percutaneous uroradiological techniques. Percutaneous nephrostomy was performed for renal failure or urosepsis or before chemotherapy. In 8 patients, ureteric stents were also placed by the antegrade route, across malignant ureteric strictures, following nephrostomy. In another 8 patients, the ureteric obstruction could not be crossed and permanent nephrostomies were required. Fifteen patients were able to achieve a useful life but in the other 7 patients there was no improvement in their quality of life and they all died 1 month after intervention. Percutaneous nephrostomy also contributed to the death of 1 patient. Not all obstructed kidneys require drainage and in patients with disseminated or advanced disease involving the pelvis, the indications for intervention need to be individually assessed. An improvement in laboratory criteria of renal function following intervention does not necessarily result in improvement in quality of life. This retrospective study highlights the difficulty in selection of patients with advanced disease for intervention and previously suggested guidelines for intervention are reviewed.

Novel brain-specific bovine cDNA for a developmentally regulated mRNA encoding a putative new member of the leucine-rich glycoprotein (LRG) family

We have isolated a bovine cDNA which hybridized to a 2 kb mRNA specifically expressed in the rat and human brain. The mRNA was abundantly expressed in adult but not 21-week old human brain. In the rat brain, there was very little of the transcript in 15-day old fetus but it increased in abundance with development, being most abundant in the adult and expressed in all brain regions. Genomic analysis showed that the sequence is single copy and conserved in all vertebrates examined, including chicken. The 702 bp partial cDNA encoded an amino acid sequence for a putative member of the leucine-rich glycoprotein (LRG) family known to be involved in cell adhesion/recognition. The predicted polypeptide displayed sequence identity with that recently reported for the human oligodendrocyte-myelin glycoprotein. This cDNA should prove useful in further investigations on brain-specific cell-cell interactions.

Does Transurethral Laser Ureterolithotripsy Justify its Cost?

A prospective consecutive series of 64 patients who underwent transurethral laser ureterolithotripsy using a 7.2F semirigid ureteroscope was compared to the immediately preceding consecutive series of 98 patients who had undergone ultrasound lithotripsy using rigid 9.5F or 12.5F ureteroscopes. The distribution of the calculi by size and composition in both series was similar. There was a higher proportion of upper ureteral calculi in the laser lithotripsy series. The success rate for a first attempt at laser lithotripsy was 92.2% versus 71.4% for the ultrasound series (p less than 0.01). When the stone could be reached ultrasound and laser lithotripsy had a fragmentation rate of 97%. The principal reason for the difference in results was the poorer ability to reach calculi when using the larger rigid ureteroscopes. One patient who had failed ultrasound lithotripsy was successfully treated with laser lithotripsy a year later. The overall morbidity was less for laser lithotripsy. The 3-year cost-benefit analysis revealed a smaller difference in cost than expected and the 5-year analysis was advantageous for laser lithotripsy because of its higher success rate. Savings were also realized in the laser series because of the higher proportion of subjects treated as outpatients, and a lower mean duration of hospitalization and time missed from work. For our center with an annual work load of approximately 100 cases laser lithotripsy achieved a superior cost-benefit ratio.

Intravesical chemotherapy for superficial carcinoma of the bladder

Intravesical chemotherapy has been shown to be of value in the treatment of superficial transitional cell carcinoma of the bladder, not only in the prevention of recurrence but possibly progression of the disease to higher stage as well. At the Department of Surgery, National University of Singapore from 1980 to 1986 we had used intravesical chemotherapy for multiple or recurrent superficial carcinoma of bladder in 45 patients. Of these, 21 patients had associated carcinoma in situ. Initially, thiotepa was used as the main intravesical chemotherapeutic agent. Since 1984, mitomycin C was introduced. The schedule used is 30 mg in 30 mg of water, and left in the bladder for 2 hours weekly for 4 weeks. Intermittent courses were given when deemed necessary on follow-up cystoscopy at 3 to 6 months. Patients were deemed to have good response if there was no evidence of tumour on cytology and biopsy at follow-up cystoscopy. Eleven patients had thiotepa only, of these 4 had good response, 4 were stable and 3 had progression of disease to higher stage. Thirty-four patients had mitomycin therapy. Thirteen of them following thiotepa treatment. Twenty-one patients (64%) had good response to therapy. Three patients (9%) had progression of disease, requiring cystectomy. Of those who responded to therapy, none had developed muscle invasive disease so far with mean follow-up of 43 months. Of the group of patients treated with mitomycin, no patient developed myelosuppression.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial carotid artery occlusion with telangiectasia (moyamoya disease) associated with persistent primitive trigeminal artery--case report

A 35-year-old female presented with moyamoya disease coincidentally associated with a persistent primitive trigeminal artery (PPTA). Bilateral encephalo-duro-arterio-synangiosis was performed and the postoperative course was uneventful. Moyamoya disease and PPTA might have a congenital origin, but moyamoya disease may be promoted by a PPTA. The hemodynamics of PPTA during progressive occlusive change in the internal carotid artery in moyamoya disease should be re-evaluated to determine its function in the development of moyamoya vessels.

Stones in horseshoe kidneys: results of treatment by extracorporeal shock wave lithotripsy and endourology

We report the results of 7 patients with calculi in a horseshoe kidney treated by extracorporeal shock wave lithotripsy (ESWL, 9 renal units) and percutaneous nephrolithotripsy (3 renal units) during a 3-year period. In the ESWL only group complete stone clearance was achieved in only 3 patients (50%) after an average of 3 sessions of therapy. On the other hand, complete stone clearance was achieved by percutaneous nephrolithotripsy with minimal complications. The poorer results with ESWL were due to difficulty in ultrasonographic localization of stones as well as poor drainage in these abnormal kidneys. Our experience with the Edap LT01 and the Sonolith 2000 lithotriptors suggests that while reasonable results are possible, treatment probably will require multiple sessions and the eventual outcome is less predictable than in normal kidneys. In contrast, the treatment of complicated stones in a horseshoe kidney presents no additional difficulty.

Clinical profile of elderly urinary incontinence in Singapore: a community-based study

The prevalence of urinary incontinence in the elderly aged 65 years and above was found to be 4.6% (42 out of a total of 919 respondents), in a community-based study in Singapore. Urinary incontinence was defined as leakage of urine on at least two occasions in the previous one month. The clinical profile of 30 out of the 42 (71%) subjects were studied. There was equal distribution of male and female subjects. Eighteen (60%) of the subjects were below 75 years of age. Twenty-five (83.3%) subjects had severe incontinence. Twenty-four (80%) had the incontinence for more than one year. Despite the high percentage of patients with severe incontinence, only nine (30%) used some form of aid. Incontinence in our very old (75 years and above) was not related to frailty or physical dependence. Seven of the subjects (23.3%) were found to have functional incontinence associated with cognitive impairment. These patients were unable to indicate their toilet needs. They also had associated physical disability as well as double incontinence, and their carers were under stress. Ten of the subjects had pure urge incontinence. Seven of them had an underlying central nervous system disorder, suggesting that destrusor hyperreflexia may be the underlying cause for urinary incontinence in this group. All except one in this group had more than one possible precipitating factor for their incontinence. Eleven subjects had symptoms suggestive of outlet obstruction, although only two were found to have proven outlet obstruction. None of the female subjects had pure stress incontinence.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative studies of extracorporeal shock wave lithotripsy by Dornier HM3, EDAP LT 01 and Sonolith 2000 devices

During a 2-year period extracorporeal shock wave lithotripsy (ESWL) was done at our institution in 70 patients with the Dornier HM3, 113 with the EDAP LT 01 and 104 with the Sonolith 2000 lithotriptors. The size and location of stones were comparable in all 3 series, and all treatments were done by the same team of urologists. Complete fragmentation occurred in 79% of the patients treated by the Dornier, 82% treated by the EDAP and 79% treated by the Sonolith devices, with 3-month stone-free rates of 66, 67 and 58%, respectively. Auxiliary procedures were needed in 12% of the patients in the Dornier, 13% in the EDAP and 9% in the Sonolith groups. Repeat treatment was necessary in 4% of the Dornier group, 42% of the EDAP group and 26% of the Sonolith group. Therefore, all 3 lithotriptors are effective in stone disintegration and produce satisfactory results when selection criteria for ESWL are observed. The most significant difference among the 3 lithotriptors is the number of repeat treatments, which reflects the power and energy output of the lithotriptors. In conclusion, the Dornier HM3 device has the advantage of low repeat treatment rate and easier stone localization. The EDAP LT 01 unit has the advantage of lower treatment costs and anesthesia-free treatment with no irradiation. The Sonolith 2000 device has features of the other 2 lithotriptors with a superior ultrasound image.

Organ procurement in Singapore

Kidney transplantation, an accepted therapeutic intervention for patients with end stage kidney failure, was pioneered in Singapore on 8 July 1970 by the University Departments of Surgery and Medicine, University of Singapore. Up to 1987, an average of 4.7 cadaveric kidney transplants were performed annually. The introduction of Sandimmune (cyclosporine) in 1985 significantly increased graft survival and consequently created a demand for more cadaveric kidneys for transplantation. The rate of cadaveric kidney transplants escalated to 31.3 kidney transplants annually for the period 1988 to 1990. This increase can be attributed both to the appointment of full time transplant coordinators beginning April 1986 and the implementation of the Human Organ Transplant Act in July 1987. The Human Organ Transplant Act accounted for more than half of all kidneys procured for transplantation (55/94) for the period 1988 to 1990.

Techniques of ureteric reimplantation in kidney transplantation and its related urological complications

Two common techniques of ureteric reimplantation for kidney transplantation, the Politano-Leadbetter and the extravesical ureteroneocystostomy are described in detail. Correct techniques of donor ureter harvesting, appropriate method of reimplantation and judicious use of double J stent are also emphasised so as to reduce the urological complications which occurred in about 7% to 15% in most series. More than 90% of urological complications are due to urinary fistulae and ureteric obstruction which carry a significant morbidity and mortality. The causation, diagnosis and management of these complications are reviewed. Early diagnosis and early aggressive surgical treatment is the key to a successful outcome.

Ring-enhanced primary intracranial malignant lymphoma--report of two cases

Two nonimmunosuppressed patients with primary intracranial malignant lymphoma demonstrated ring-enhanced lesion on postcontrast CT scans. One patient underwent total removal of the tumor and the other patient biopsy, both followed by whole brain irradiation. Histological examination revealed the tumors contained diffuse large cells and necrosis in the central region. The possible mechanisms of ring enhancement may represent central necrosis of the rapidly growing tumor, but is probably not related to the prognosis.

Malignant fibrous histiocytoma of the occipital bone with intracranial extension--case report

The authors present a rare case of malignant fibrous histiocytoma originating in the cranial bone. A 72-year-old male was admitted with a diffuse painless swelling in the left occipital region but no neurological abnormality. Plain skull x-ray films and computed tomographic scans showed a large tumor in the left temporo-occipital bone. The tumor invading subcutaneous tissue was totally excised and histologically diagnosed as malignant fibrous histiocytoma. Postoperatively, 40-Gy irradiation was given to the left temporo-occipital region. Several months later, however, the tumor recurred in the posterior fossa. Neuroradiological examination showed tumor extension into the occipital bone and muscle and the subdural space of the posterior fossa. A second operation extirpated all tumors except in the cerebellum. He died of pneumonia on the 14th postoperative day. Autopsy revealed malignant fibrous histiocytoma invading into the bilateral cerebellar hemispheres. Radiation and chemotherapy should be given as soon as possible following extensive surgery for malignant fibrous histiocytoma of the cranial bone.

[Spinal arteriovenous malformations in Klippel-Trénaunay-Weber syndrome: case report]

A 19-year-old man was admitted with the chief complaint of a sudden onset of thoracic pain and paraplegia. His right lower limb had progressively enlarged since he was 3 months old. Transient paraparesis had occurred recurrently since the age of 3. Physical examination on admission revealed that there were multiple warts on his face, trunk and right extremities. The right lower limb was thicker and longer than the left one, and the temperature was 1 degree C higher in the right side. Neurological examination revealed paraplegia and severe impairment of all sensory modalities below Th4 with bilateral clonus. Radiological examination showed lordosis of the thoracic spines with thinning of the pedicles of Th4 to Th6. Selective spinal angiography showed a juvenile type of arteriovenous malformation involving the cord of Th2 to Th6 with multiple feeding arteries, and a glomus type of the lower thoracic cord with the feeding arteries from Adamkiewicz's artery and the right Th10 intercostal artery. MRI showed the cord enlargement of Th2 to Th6 and within it the nidus was identified. Spinal arteriovenous malformations associated with Klippel-Trénaunay-Weber syndrome were noticed. The patient underwent interruption of the main feeding artery and removal of the dilated vessels located in the dorsum of the thoracic cord. Postoperative course was uneventful with slight improvement of clinical symptoms. Klippel-Trénaunay-Weber syndrome is manifested by a triad of symptoms: 1) hemihypertrophy of the extremities, 2) cutaneous hemangiomas and 3) arteriovenous fistula or varicose veins of the involved limbs. Nineteen cases of Klippel-Trénaunay-Weber syndrome associated with spinal arteriovenous malformation have been reported. The pathogenesis has been suggested to be due to developmental abnormalities.

In situ extracorporeal shock wave lithotripsy for upper ureteral stones using the EDAP LT-01 lithotriptor

We reviewed 64 cases of upper ureteral stones treated between December 1986 and June 1988. Upper ureteral stones were defined as stones in the ureter distal to the ureteropelvic junction and proximal to the S1 vertebra. All stones were treated in situ with no invasive procedures done before treatment. The over-all success rate in rendering patients free of stones by extracorporeal shock wave lithotripsy monotherapy was 75%. Of the patients 25% required auxiliary procedures, such as percutaneous ultrasonic lithotripsy. The average duration of treatment for each stone was 88 minutes and the average storage energy used was 208 units.

Piezoelectric extracorporeal shock wave lithotripsy by EDAP LT-01: the Singapore experience

One hundred and eighty patients with stones in the calyces, renal pelvis, upper, middle, and lower ureter were treated by piezoelectric extracorporeal shock wave lithotripsy using the EDAP LT-01 lithotripter. The size of the stones treated ranged from 0.5 cm to 6.5 cm with the vast majority (94%) measuring less than 3.0 cm. Forty-eight patients (27%) had multiple stones in the renal collecting system. Successful fragmentation occurred in 79%, partial fragmentation in an additional 17%, and no fragmentation in 4%. Forty percent of patients required repeated treatment with an average of 2.3 sessions. Of those patients treated, none required general anesthesia, however, analgesia was needed in 121 patients (67%). Urosepsis occurred in 4% and 0.5% developed intrarenal hematoma. There was no mortality or loss of renal units in this series. The auxiliary procedure rate was 15% (percutaneous nephrolithotripsy 5%, ureteroscopic manipulation 9%, and open surgery 1%). The 3-month stone-free rate was 64%.

Mechanism of cerebral vasospasm--contractile proteins in smooth muscle of bovine cerebral artery

Understanding of the pathogenesis of cerebral vasospasm requires basic study of the contraction mechanism of cerebral arteries. In this study, the morphological and biochemical properties of actomyosin from bovine cerebral arteries were examined. Arrays of thick and thin filaments were clearly seen on electron micrographs of a cross section of a muscle strip stretched to 1.5 times its normal length in Krebs-Ringer solution. The diameters of the thick and thin filaments were 110.0 +/- 19.9 A and 51.0 +/- 8.0 A, respectively. The average ratio of thick to thin filaments was about 1:15 to 1:16. The gel pattern of Ca2+-sensitive actomyosin extracted from bovine cerebral arteries revealed the presence of myosin, actin, and tropomyosin, but not skeletal troponin. The Mg-ATPase activity of actomyosin was greatly enhanced in the presence of Ca2+. Rapid superprecipitation occurred after the clearing phase, when 1 mM Mg-ATP was added to a suspension of actomyosin with 10(-5) M Ca2+. This superprecipitation did not occur with a lower Ca2+ concentration of 10(-8) M. Intracellular free Ca2+ appears to play a crucial role in the regulation of contraction and relaxation of cerebral arterial smooth muscle.

Punch technique--an alternative approach to the repair of pierced earlobe deformities

The punch technique of repairing pierced earlobe deformities is a practical and simplified alternative to the usual method of repair. The procedure can easily be performed in any dermatology office since the instruments required are very basic. The technique is presented in a series of illustrations, and the results are cosmetically acceptable.

Percutaneous ultrasonic lithotripsy--its role in the management of renal and upper ureteric stones

Percutaneous ultrasonic lithotripsy (PUL), a new technique used in the treatment of renal stones has been shown to be safe and effective with low morbidity. 54 of the 57 patients (95%) were successfully treated by this method and all were done as a single stage procedure. 39 patients (68%) in this series were either unsuitable or had failed extracorporeal shock wave lithotripsy (ESWL). No mortality occurred in this series and one patient with staghorn stone required a nephrectomy due to severe secondary haemorrhage. Though PUL is technically more difficult to perform, it is a better alternative than open renal surgery and is complementary to ESWL especially in the treatment of the more complicated renal stones.