B-cell activating factor BAFF reflects patients' immunological risk profile after kidney transplantation

The B-cell activating factor BAFF plays an important role in the development and maturation of B-lymphocytes, which can contribute to the generation of donor-specific antibodies and thus may influence graft function and graft survival. Inconsistent data on the role of BAFF levels after renal transplantation for the formation of donor-specific antibodies and the contribution for allograft rejection exist. The aim of the current study was to determine to what extent the degree of pre-immunization is reflected by each patient's BAFF levels before transplantation and in the follow-up. Furthermore, the impact of BAFF on allograft rejection frequency as well as severity and resulting allograft function over time was analyzed. Additionally, the impact of viral infections on BAFF levels after transplantation - as a potential confounder - was examined. For this purpose, a group of pre-sensitized patients (PRA>0%, (52±24% on average), n=40) was compared with non-sensitized patients (PRA=0%, n=62) and in a subsequent analysis stratification in accordance to the detected BAFF level was performed. Pre-sensitized patients had significantly higher BAFF levels before transplantation and suffered significantly more often from early steroid-resistant, mainly antibody-mediated rejections. A result which was confirmed also in highly sensitized patients with PRA levels >50%. Additionally, in the follow-up patients with either rising BAFF levels over time or BAFF levels above the median also had significantly more often antibody mediated rejections. Additionally, patients with BAFF levels above detected median even displayed impaired creatinine values as well as an induced eGFR slope up to month 48 after transplantation. The occurrence of viral infections (CMV, BKV) was only an additional influencing factor in the absence of concomitant allograft rejections. Therefore, the B-cell proliferation factor BAFF appears not only to reflect the immunological risk profile of patients in the context of kidney transplantation, it may possibly be further developed as a predictor of patients with an increased risk profile for subsequent allograft rejection and impaired allograft function.

[Comparison of four identical electronic noses and three measurement set-ups]

BACKGROUND

Volatile organic compounds (VOCs) can be used as biomarkers in exhaled air. VOC profiles can be detected by an array of nanosensors of an electronic nose. These profiles can be analysed using bioinformatics. It is, however, not known whether different devices of the same model measure identically and to which extent different set-ups and the humidity of the inhaled air influence the VOC profile.

METHODS

Three different measuring set-ups were designed and three healthy control subjects were measured with each of them, using four devices of the same model (Cyranose 320™, Smiths Detection). The exhaled air was collected in a plastic bag. Either ambient air was used as reference (set-up Leipzig), or the reference air was humidified (100% relative humidity) (set-up Marburg and set-up Munich). In the set-up Marburg the subjects inhaled standardised medical air (Aer medicinalis Linde, AGA AB) out of a compressed air bottle through a demand valve; this air (after humidification) was also used as reference. In the set-up Leipzig the subjects inhaled VOC-filtered ambient air, in the set-up Munich unfiltered room air. The data were evaluated using either the real-time data or the changes in resistance as calculated by the device.

RESULTS

The results were clearly dependent on the set-up. Apparently, humidification of the reference air could reduce the variance between devices, but this result was also dependent on the evaluation method used. When comparing the three subjects, the set-ups Munich and Marburg mapped these in a similar way, whereas not only the signals but also the variance of the set-up Leipzig were larger.

CONCLUSION

Measuring VOCs with an electronic nose has not yet been standardised and the set-up significantly affects the results. As other researchers use further methods, it is currently not possible to draw generally accepted conclusions. More systematic tests are required to find the most sensitive and reliable but still feasible set-up so that comparability is improved.

Stone treatment and coagulopathy

OBJECTIVE

The aim of this retrospective study was to evaluate treatment protocols and results of upper tract stone treatment in patients with clotting disorders.

METHODS

In a 6-year period, 6,827 stone interventions (ESWL or endourologic procedures) were performed in 5,739 patients. Thirty-five (0.61%) patients suffered from a variety of systemic clotting disorders or were anti-coagulated. Clotting disorders were corrected by specific therapy prior to any intervention. A total of 76 interventions were performed consisting of ESWL, ureteroscopy (URS), percutaneous nephrolithotomy (PNL), ureteric stenting or percutaneous nephrostomy.

RESULTS

All patients became stone-free within 3 months or had clinically insignificant residual fragments. Severe complications were observed in 10/76 (13.1%) interventions. ESWL was successful in 88.9% (16/18) of patients, but associated with a 33.3% (6/18) complication rate; 27.8% (5/18) of patients required auxiliary procedures. URS and PNL were successful in all cases and complications occurred in 0% (0/7) and 33% (1/3) of patients, respectively. Time to complete stone clearance after ESWL was 32.0+/-49.3 days compared with a mean of 19.4+/-28.6 days in a non-coagulopathy control group; no difference was observed for endourologic procedures. Average costs of treatment in patients undergoing ureteroscopy was higher in patients with coagulopathy (4,611 versus 2,342); however, the difference was less pronounced compared with ESWL (6,070 versus 1,731).

CONCLUSION

Patients with coagulopathy have a higher rate of complications despite apparently normal clotting parameters during treatment and hospitalisation was prolonged. The efficacy of ESWL was lower in patients with coagulopathy and we currently favour endoscopic procedures for stone removal in this patient group.

Evolutionary stability concepts for N-species frequency-dependent interactions

The classical static concept of an evolutionarily stable strategy (ESS) for a single species gives rise to two new notions when there are more than two species (called an N-species ESS and RL-stability). The paper relates these to the dynamic stability of monomorphic and polymorphic evolutionary systems. It is shown that RL-stability implies the global asymptotic stability of either system with or without mutations. However, the N-species ESS only implies stability of the monomorphic system.

The impact of urinary extravasation after radical retropubic prostatectomy on urinary incontinence and anastomotic strictures

OBJECTIVE

The aim of this study was to determine the relevance of urinary extravasation as proven by cystogram 18 days after radical retropubic prostatectomy for the degree of postoperative urinary incontinence and the incidence of anastomotic strictures.

PATIENTS AND METHODS

A total of 225 patients underwent radical retropubic prostatectomy at our institution during a 30-month period, 215 of whom received a cystogram a mean 18 days following surgery. Three and 6 months after surgery these 215 patients were evaluated regarding the degree of urinary incontinence and the presence of anastomotic strictures.

RESULTS

The cystogram demonstrated a watertight anastomosis in 89% (n = 195; group I), the remaining 11% (n = 24; group II) showed urine extravasation. Groups I and II were comparable with respect to age, preoperative serum levels of prostate-specific antigen (PSA), tumor grade and pathological staging. Six months after surgery, there was no statistically significant (p > 0.05) difference between both groups regarding the degree of urinary incontinence and the presence of anastomotic strictures.

CONCLUSIONS

The presence of urine extravasation 18 days after radical retropubic prostatectomy has no impact on postoperative urinary incontinence and the incidence of anastomotic strictures. Based on these data it is not indicated to leave the catheter in situ beyond that point of time.

Frequency of urolithiasis in individuals seropositive for human immunodeficiency virus treated with indinavir is higher than previously assumed

PURPOSE

Indinavir was approved by the Food and Drug Administration in 1996 as a human immunodeficiency type 1 protease inhibitor to treat human immunodeficiency virus infection. Prompted by the high number of patients receiving indinavir who present with renal colic at our institution, we performed a detailed investigation of the true frequency of urolithiasis during indinavir treatment.

MATERIALS AND METHODS

We evaluated 105 patients with a mean age of 38.1 years who were treated with indinavir from 1996 to 1997. Before indinavir treatment was initiated all patients underwent renal ultrasonography, urinalysis, and determination of serum sodium, potassium, calcium, uric acid and creatinine. It was recommended that all patients drink 2 l of fluids daily, and all remained under continuous surveillance.

RESULTS

Metabolic evaluation and ultrasonography showed no abnormality in any case. A stone episode occurred in 13 men (12.4%) as renal colic during observation. Colic recurred in 1 patient after 2 and 5 months, and in 1 after 2 months. Median duration of indinavir treatment until an acute stone episode was 21.5 weeks (range 6 to 50). A total of 12 stones passed spontaneously. Three patients underwent ureteroscopic calculous removal and 1 was treated with extracorporeal shock wave lithotripsy.

CONCLUSIONS

Despite adequate patient information and compliance the rate of nephrolithiasis during indinavir therapy was 12.4%.

Convergence of multilocus systems under weak epistasis or weak selection

The convergence of multilocus systems under viability selection with constant fitnesses is investigated. Generations are discrete and nonoverlapping; the monoecious population mates at random. The number of multiallelic loci, the linkage map, dominance, and epistasis are arbitrary. It is proved that if epistasis or selection is sufficiently weak (and satisfies a certain nondegeneracy assumption whose genericity we establish), then there is always convergence to some equilibrium point. In particular, cycling cannot occur. The behavior of the mean fitness and some other aspects of the dynamics are also analyzed.

Multifocality of transitional cell carcinoma results from genetic instability of entire transitional epithelium

OBJECTIVES

Multifocality of transitional cell carcinoma (TCC) has been attributed to seeding of exfoliated tumor cells or to a general sensitivity of the entire urothelium to carcinogenic stimuli. By contrast, TCC has been shown to evolve as a consequence of genetic defects and chromosomal instability. We analyzed chromosomal patterns, total DNA content, and p53 and Ki67 expression in malignant and normal transitional cells to evaluate their relationship to the development of multifocal TCC.

METHODS

Included in the study were 47 patients, 16 women and 31 men, with a mean age of 70.04 years (range 37 to 83). Of 47 patients, 45 had TCC of the urinary bladder and 7 of those had synchronous ureteral involvement. Two patients had ureteral TCC and a history of TCC of the bladder. Using fluorescence in situ hybridization, numerical aberrations of chromosomes 7, 9, and 17 were detected in imprint specimens of histologically verified tumor and "normal" urothelium and were compared with static ploidy and p53 and Ki67 expression.

RESULTS

Chromosome 7 was altered in 93.6%, chromosome 9 in 63.8% (including monosomy), and chromosome 17 in 87.2% of the 47 analyzed tumor and normal imprints. Differences between tumor and normal epithelium were observed in aberrational frequencies (number of cells showing chromosomal aberrations calculated on 200 cells counted, given in percentages). DNA content was aneuploid in all tumor specimens, but diploid in 20 (42.5%) of 47 normal specimens, according to lower aberration frequencies in these patients. p53 detection was positive in 82.9% of the tumor specimens and 76.6% of the normal specimens. Ki67 was positive in 87.2% of the tumor imprints and in 72.3% of the normal specimens.

CONCLUSIONS

These data suggest a general genetic instability as a reason for multifocality in the entire transitional epithelium.

N-acetylneuraminic acids (nana): a potential key in renal calculogenesis

N-Acetylneuraminic acids (NANA) promote binding of calcium ions to macromolecules and cells, increase the intrinsic viscosity of glycoproteins and facilitate gel formation in water. Since these properties are crucial in urinary calculogenesis, we evaluated NANA levels in urine and serum as well as their expression in kidney tissues. Using a modified thiobarbituric acid assay, the evaluation of free and bound NANA in 24-h urine samples revealed a ratio of 1.87 in 33 non-stone-formers but a reversed ratio of 0.84 in 41 recurrent calcium oxalate stone-formers. Time kinetics revealed a gradual rise in NANA expression until 48 h of culture and a significantly higher release into supernatants of papillary renal epithelial cells (REC) when compared with cortical REC. To examine NANA distribution in kidney tissues, paraffin-embedded biopsies from five normal and six stone-forming kidneys were labeled with the biotinylated NANA-specific lectins Maackia amurensis (MAA) and Sambucus nigra (SNA). Immunohistochemistry revealed intense luminal MAA reactivity of distal tubular REC and collecting ducts in 96.7% and 91.5% of normal and stone-forming kidneys respectively. By contrast, there was a marked difference between normal and stone-forming kidneys for SNA reactivity (17.7% vs 95%) at the same locations. Finally, the glycocalyx of recurrent stone-formers showed altered sialylglycoside linkages [alpha(2,6) instead of alpha(2,3)] that may indicate an altered REC function. Given the calcium-binding potential of NANA, their increased local concentration within the glycocalyx layer in the distal nephron may either initiate stone formation or facilitate attachment of microcrystals to REC.

Does topical instillation therapy influence chromosomal aberrations in superficial bladder cancer?

PURPOSE

Patients with a high risk for superficial bladder cancer are treated by topical immuno-or chemotherapy after transurethral resection to reduce the chance of recurrence and/or progression. The aim of this study was to analyse if cytogenetical abnormalities, which are known to be constantly related to bladder cancer, are modified or eliminated by topical immuno- or chemotherapy.

MATERIALS AND METHODS

Using fluorescence in situ hybridization (FISH), the influence of topical instillation therapy with Bacillus Calmette-Gúerin (BCG) and Mitomycin C (MMC) on numerical aberrations of chromosomes 7, 9 and 17 was investigated in 25 patients with transitional cell cancer (TCC) of the bladder. Data were compared with histological and clinical outcome. Fifteen TCC patients with similar histological criteria without instillation therapy served as controls. Median follow-up was 30 +/- 2 months.

RESULTS

After BCG treatment 10 of 15 patients (66.6%) developed recurrent and 2/15 (13.3%) progressive disease. Three of 15 patients (20.0%) had no evidence of disease. Numerical aberrations did not change in 8 of the 15 BCG patients (53.3%) and changed to a more aggressive pattern in 40.0% (6/15). Five of 10 MMC treated patients (50.0%) developed a recurrent tumor, 2/10 (20.0%) progressed and 3/10 (30.0%) had no evidence of disease. Four of 10 (40.0%) of these patients showed stable and 5/10 (50.0%) progressive chromosomal patterns. Only one patient in each group with primary chromosomal alterations changed to a regular diploid chromosomal pattern after therapy according to a complete clinical remission.

CONCLUSION

Even though topical immuno- and chemotherapy may be useful to delay recurrence and progression, chromosomal patterns remain basically unstable.

[Phytotherapeutic aspects of diseases of the circulatory system. 6. Leuzea carthamoides (WILLD.) DC: the status of research and possible use of the taxon]

Leuzea carthamoides (WILLD.) DC., Asteraceae, has become an important taxon usable in human practice and animal production in recent years. Originally an endemic plant of southern Siberia, now it is widely grown not only in the Union of Independent States, once the original region of introduction, but also in central and eastern Europe. The principal constituents of the whole plant are ecdysteroids (5 beta-cholest-6-on-7-ene derivatives) and flavonoids. In addition, the aerial part contains sesquiterpenic lactones of the guajanolide type, and the roots contain polyines (on the thiophene base). The present paper comprehensively discusses the occurrence, content and biological activity of these substances, the preparations manufactured from the plant, their use in therapeutic practice, food manufacture and animal production in the world and the Czech Republic. The plant has certainly become a taxon with prospects in the Czech Republic, particularly as the source of 20-hydroxyecdysone, which is getting into the limelight in the world.

Late urological complications and malignancies after curative radiotherapy for gynecological carcinomas: a retrospective analysis of 10,709 patients

PURPOSE

A retrospective study was done to analyze late urological complications following curative radiotherapy of primary gynecological carcinomas. All patients were treated at a single center and with the same radiotherapeutic regimen. The incidence of other carcinomas in these patients was also evaluated.

MATERIALS AND METHODS

A total of 10,709 patients was treated using combined telebrachytherapy (dosage 67.5 Gy.) during an observation period of 22 years.

RESULTS

Severe late complications were seen in 1.24% (133 of 10,709) of the patients, including irradiated bladder (65 cases, mean interval since treatment 6.7 years). Complications required surgery in 118 of 133 patients with a perioperative mortality of 4.2% (5 of 118). Overall in 4.27% (457 of 10,709) of the patients another malignancy developed after (29.1%), during (26.3%) and before (44.6%) radiotherapy. Subsequent malignancies after treatment were predominantly seen in the genital region (88.4%) but they were also in the irradiated nongenital area (0.13%, 14 of 10,709). Of the latter patients 6 had urothelial bladder cancer, which represents a relative risk of 4.66 (based on the Austrian female population) to develop bladder cancer after radiotherapy for gynecological cancer.

CONCLUSIONS

Late urological complications after radiotherapy of the pelvis are rare but severe. Surgical therapy of irradiated tissues has a higher complication rate compared to surgery on nonirradiated tissue.

Fluorescence in situ hybridization identifies more aggressive types of primarily noninvasive (stage pTa) bladder cancer

PURPOSE

We evaluated the genetic changes in cytological specimens of bladder cancer by fluorescence in situ hybridization, and related them to stage and grade of the tumor, ploidy, p53 and Ki-67 expression, and clinical outcome to determine a simple method to identify tumors with a poorer prognosis.

MATERIALS AND METHODS

Using fluorescence in situ hybridization the numerical aberrations of chromosomes 7, 9 and 17 in barbotages and imprints of 50 patients with transitional cell cancer of the bladder were determined. Of the patients 29 had a primary stage pTa tumor, while 21 with stage pT1 or greater disease formed the control group. Data were compared to ploidy status, and Ki-67 and p53 immunoreactivity.

RESULTS

Repeated monosomy 9 and haploid or diploid status on static ploidy determination were found in patients with primary stage pTa tumors without recurrence. Immunoreactivity of p53 was negative in all of these patients, while there was a low percentage of positive staining for Ki-67. Patients with recurrent and progressive disease had a high incidence of trisomy 7 and 17, aneuploid status and high positivity for both immunological markers. For chromosomes 7 and 17, and ploidy status bivariate analysis showed a significant difference.

CONCLUSIONS

The evaluation of chromosomal aberrations in barbotage and imprint specimens clearly establishes a relationship between chromosomal defects and aggressiveness of the tumor. The majority of nonaggressive stage pTa transitional cell carcinomas can be distinguished from potentially lethal cases by fluorescence in situ hybridization at a diagnostic point when the grading is not yet prognostic.

Evolutionary dynamics for bimatrix games: a Hamiltonian system?

We review some properties of the evolutionary dynamics for asymmetric conflicts, give a simplified approach to them, and present some new results on the stability and bifurcations occurring in these conservative systems. In particular, we compare their dynamics to those of Hamiltonian systems.

The adaptive advantage of phenotypic memory in changing environments

The adaptive value of carry-over effects, the persistence of induced phenotypes for several generations despite the change in the conditions that first induced these phenotypes, is studied in the framework of a simple model. Three different organismal strategies-non-inducible (genetic), completely inducible (plastic), and intermediate (carry-over)-are compared in fitness terms within three different environments. Analytical results and numerical simulations show that carry-over effects can have an advantage in stochastic environments even over organisms with high adaptive plasticity. We argue that carry-over effects represent an adaptive mechanism on the ecological timescale that fills the gap between short-term individual adaptations and long-term evolutionary adaptations. An extension of the concept of plasticity to incorporate the time dimension and include the stability of induced phenotypes through both clonal and sexual generations, is suggested.

High expression of a CD38-like molecule in normal prostatic epithelium and its differential loss in benign and malignant disease

PURPOSE

We characterize an undescribed antigen on prostatic epithelial cells, which is recognized by anti-CD38.

MATERIALS AND METHODS

Normal (3 cases), benign hyperplastic (10) and carcinomatous (10) prostatic tissues were analyzed using immunohistochemistry, immuno-electron microscopy and the Western blot test.

RESULTS

Comparison of prostatic and lymphatic CD38 antigen revealed identical bands at 45 kD. Electron microscopy demonstrated anti-CD38 reactivity on the cytoplasmic membrane and within the secretory vacuoles. Double labeling with anti-cytokeratin types 5/15 and 8/18 confirmed that basal and secretory normal prostatic epithelial cells express CD38. By contrast, a complete loss was found in malignant (52.8%), tumor-surrounding nonmalignant (16.3%) and benign prostatic hyperplasia derived glands (3.7%).

CONCLUSIONS

CD38 is a novel prostatic antigen. Its role in intracellular calcium mobilization may contribute to smooth muscle cell contraction and/or sperm motility.

Keratoconus detected by videokeratography in candidates for photorefractive keratectomy

BACKGROUND

Patients with corneal shape abnormalities should be identified prior to photorefractive keratectomy (PRK). We used videokeratography screening to detect subclinical corneal abnormalities, including keratoconus, which might have been missed by conventional clinical evaluation.

METHODS

One hundred forty-six apparently normal myopic eyes (-1.00 to -7.00 diopters [D] with less than 1.50 D of cylinder) of 91 consecutive patients who were candidates for PRK were screened by videokeratography.

RESULTS

In 6 of 91 patients (7 of 146 eyes), unsuspected corneal shape abnormalities were detected by videokeratography. Two patients had definite keratoconus and three were classified as keratoconus suspects by inferior corneal steepening (Rabinowitz I-S index ranging from 1.62 to 6.20 D). One patient had early pellucid marginal degeneration.

CONCLUSIONS

Keratoconus suspects and contact lens-induced changes resembling keratoconus are present in the "normal" myopic population that presents for refractive surgery. Videokeratographic screening is the only effective means of identifying these and other corneal shape abnormalities.

Electrohydraulic versus pneumatic disintegration in the treatment of ureteral stones: a randomized, prospective trial

The efficacy and safety of electrohydraulic versus pneumatic lithotripsy in the treatment of ureteral stones were evaluated in a prospective, randomized study. A total of 72 patients with stones not capable of passing spontaneously and unsuitable for extracorporeal shock wave lithotripsy was randomized to either method (34 to electrohydraulic lithotripsy and 38 to pneumatic lithotripsy). While both techniques were equivalent in efficacy (85.3% for electrohydraulic and 89.5% for pneumatic lithotripsy), the perforation rates were significantly different (17.6 versus 2.6%, respectively). Although the long-term results revealed no significant differences, pneumatic lithotripsy, as the markedly safer and easier to handle technique, is currently the method of choice at our stone center for ureteral calculi requiring treatment but not suitable for extracorporeal shock wave lithotripsy.

Results of excimer laser photorefractive keratectomy for the correction of myopia

PURPOSE

This report summarizes the authors' 3-year experience with excimer laser photorefractive keratectomy on 240 eyes of 161 patients.

METHODS

With constant laser emission parameters, nitrogen flow across the cornea was used on 79 eyes, whereas 161 eyes had no nitrogen flow. Of the 240 eyes, 74 were operated on without suction ring fixation. Postoperative pain management included patching and oral analgesics in 77 eyes and the use of topical diclofenac or ketorolac and a therapeutic soft contact lens in 163 eyes. Follow-up ranged from 1 month (206 eyes) to 36 months (10 eyes).

RESULTS

At 3 months, 88% (144 eyes) had uncorrected visual acuity of 20/40 or better; 86% (151 eyes) had corrected visual acuity to within +/- 1 diopter of intended correction, and 10% (17 eyes) lost two or more lines of best-corrected visual acuity. At 12 months, 89% (122 eyes) achieved uncorrected visual acuity of 20/40 or better, 79% (115 eyes) had corrected visual acuity to within +/- 1 diopter of intended correction, and 4% (6 eyes) lost two or more lines of best-corrected visual acuity. At 24 months, 92% (44 of 48 eyes) had uncorrected visual acuity of 20/40 or better, 86% (44 of 51 eyes) had corrected visual acuity to within +/- 1 diopter of intended correction, and 5% (2 eyes) lost two or more lines of best-corrected visual acuity. At 36 months, 90% (9 eyes) achieved an uncorrected visual acuity of 20/40 or better, 90% (9 eyes) had corrected visual acuity to within +/- 1 diopter of intended correction, and no eyes lost two or more lines of best-corrected visual acuity.

CONCLUSIONS

The results obtained with one procedure are within accepted standards of accuracy for refractive surgery, and there is the potential for refinement of the final optical correction. Complication rates are low and are not vision threatening. They included increased intraocular pressure, epithelial "map dot" changes, and recurrent corneal erosion syndrome, "central islands," and others. Photorefractive keratectomy appears to be a safe procedure over the short and medium term.

Value of repeated analyses of 24-hour urine in recurrent calcium urolithiasis

OBJECTIVES

The value of repeated analyses of 24-hour urine collections for daily excretion of calcium, uric acid, citrate, phosphorus, and creatinine and for volume and pH performed to detect and classify metabolic disorders in a selected group of calcium stone formers with striking recurrence rates was assessed in a retrospective study.

METHODS

A total of 441 urinalyses made over a mean period of 80.4 months of samples obtained from 49 patients were reviewed. Fifty-nine percent of patients were initially found to have metabolic disorders (absorptive hypercalciuria types I and II, hyperuricuria, hypocitraturia) and therefore received specific drug therapy (allopurinol, thiazide, alkali citrate, orthophosphate) for a mean of 45.7 months (group I). The remaining patients were classified as metabolically inactive and were given general metaphylactic instructions (group II).

RESULTS

In 73% of patients recurrent stones developed, with no statistically significant difference between the two groups (79% vs 65%). In 55% of group I patients, urinalyses continued to yield abnormal findings during follow-up; however, subsequent abnormal findings were also seen in 40% of the metabolically inactive group II patients. Overall, metabolic disorders were observed at some point in 75% of patients. Only 27% remained recurrence free, and 62% thereof also had pathologic urinary findings.

CONCLUSIONS

It does not appear that drug treatment in recurrent calcium urolithiasis based on urinary findings is superior to simple general metaphylactic recommendations, nor that repeated analyses of 24-hour urine collections furnish additional information on the risk of recurrent stone formation or on the presence of risk factors leading to recurrence in the long-term course of disease.

Alkali citrate prophylaxis in idiopathic recurrent calcium oxalate urolithiasis--a prospective randomized study

OBJECTIVE

To assess the efficacy of alkali citrate therapy in patients suffering from recurrent idiopathic calcium oxalate stone formation.

PATIENTS AND METHODS

Fifty patients suffering from active stone formation who had had at least one stone annually over the previous 3 years were recruited and randomly divided into two groups. They were given either general prophylactic instructions, i.e. abundant liquid intake and dietary restrictions (group I, n = 25)--or were additionally treated with alkali citrate (group II, n = 25).

RESULTS

In group I, the rate of stone formation was reduced from 1.8 to 0.7 stones per patient per year. Similar results were obtained for group II, the corresponding figures being 2.1 and 0.9. There was a statistically significant higher urinary citrate excretion in group II than in group I. No difference was seen between the two groups regarding recurrent stone formation (Student's t-test). Stone formation decreased in both groups (group I 27%, group II 31%). Subjectively, 56% of group II patients, all of whom had previously experienced severe colic, reported spontaneous stone elimination to be painless, whereas in group I all but one patient suffered pain.

CONCLUSION

An objective benefit of alkali citrate could not be established.

Mutation load and mutation-selection-balance in quantitative genetic traits

Haldane (1937) showed that the reduction of equilibrium mean fitness in an infinite population due to recurrent deleterious mutations depends only on the mutation rate but not on the harmfulness of mutants. His analysis, as well as more recent ones (cf. Crow 1970), ignored back mutation. The purpose of the present paper is to extend these results to arbitrary mutation patterns among alleles and to quantitative genetic traits. We derive first-order approximations for the equilibrium mean fitness (and the mutation load) and determine the order of the error term. For a metric trait under mutation-stabilizing-selection balance our result differs qualitatively from that of Crow and Kimura (1964), whose analysis is based on a Gaussian assumption. Our general approach also yields a mathematical proof that the variance under the usual mutation-stabilizing-selection model is, to first order, micro/s (the house-of cards approximation) as micro/s tends to zero. This holds for arbitrary mutant distributions and does not require that the population mean coincide with the optimum. We show how the mutant distribution determines the order of the error term, and thus the accuracy of the house-of-cards approximation. Upper and lower bounds to the equilibrium variance are derived that deviate only to second order as micro/s tends to zero. The multilocus case is treated under the assumption of global linkage equilibrium.

[Ultrasound diagnosis of persistent varicocele after sclerotherapy]

252 consecutive patients with left-sided idiopathic varicocele were admitted into this prospective study. 30 patients did not receive a transcatheter sclerotherapy on account of their venous morphology on the selective phlebogram. Ultrasound examinations including Doppler sonography were performed before and 1, 3, and 6 to 12 (average 10) months after transcatheter sclerotherapy of the varicocele. For evaluation of therapeutic success the maximal diameter of the pampiniform plexus, the maximal diameter of the largest vein of the plexus, and, by means of Doppler ultrasound, reflux were measured. A continual decrease of these parameters was observed approximately one year after sclerotherapy. 9% of patients (20 patients) had a persisting varicocele. A premature decision for repeat sclerotherapy or operative correction of possibly persisting varicoceles can be avoided by employing a sonographical follow-up of more than 10 months.

The 'stone clinic effect': myth or reality?

Sixty-six active recurrent stone formers (RSF), i.e., with at least one stone annually over 3 years prior to the first examination at our stone clinic, were retrospectively evaluated. All received specific drug metaphylaxis which was discontinued after 5.5 +/- 2.1 years (period 1). They were reclassified according to the above definition into active and inactive RSF and were then left on a general metaphylactic regimen with regular urological follow-up every 6 months (period 2). 32 patients observed these recommendations for 5.7 +/- 2.6 years (group 1), 34 did not. 20 of these 34 could be reexamined after 6.3 +/- 2.2 years (group 2). Group 1 comprised 10 active and 22 inactive, group 2 comprised 1 active and 19 inactive RSF. While the recurrence rates among the inactive RSF of groups 1 and 2 decreased significantly during period 2, a statistically significant difference between them was not observed. Conversely, there was only a slight reduction of the recurrence rate in the active RSF. Both findings argue against a stone clinic effect. Interviews of the patients showed that stone formation was periodical for a mean of 12 +/- 8 years, after which it gradually faded out. This period is termed 'phase of regular stone formation' and appears to be an autonomous process that cannot usually be influenced by metaphylactic measures. This could explain the wide variability of reported success rates for the various metaphylactic regimens, as they would merely reflect the number of stone formers who are in their phase of regular stone formation.

Management of ureteric stones

Based on experience with over 2,000 patients, the treatment of ureteric stones today relies on extracorporeal shock wave lithotripsy (ESWL) in situ and ureteroscopy with semirigid, ultrathin ureteroscopes combined with pneumatic or laser lithotripsy. All stones in the upper and larger stones in the distal third of the ureter are preferably treated by ESWL in situ, whereas smaller stones in the distal ureter are better treated by endoscopy. Midureteric stones continue to be the domain of primary ureteroscopy; in cases of moderate obstruction in asymptomatic patients, it may also be acceptable to wait for the stone to pass into the distal ureter spontaneously to be treated by ESWL in situ there. Manipulation of the stone back into the kidney and treating it by ESWL there (push back/ESWL) offers no advantage over ESWL in situ, as results are not better yet morbidity is higher. 'Blind' instrumentation has lost all justification, and incisional ureteric lithotomy is no longer indicated but in exceptional cases.

Color flow Doppler sonography for extracorporeal shock wave lithotripsy

This report documents the usefulness of color Doppler sonography for early verification of urinary stone fragmentation during extracorporeal shock wave lithotripsy with ultrasonographic focusing. In the experimental study lithotripsy was performed on human urinary stones placed in pig kidneys. Increasing color flow within the stone mass created by movement of small fragments indicated fragmentation earlier than pixel movement on the standard gray scale sonogram. The success of treatment was demonstrated macroscopically. In the clinical study 25 patients with radiopaque kidney stones were treated by color Doppler guided shock wave lithotripsy and compared to a control group of 32 patients with similar stone characteristics in whom the end point of treatment was chosen based on B-mode sonography alone. The amount of color flow within the stone reflex determined the end point of treatment. The degree of fragmentation was confirmed by fluoroscopy immediately after treatment. Disintegration was successful in all cases and fragments passed spontaneously. Color Doppler imaging during shock wave lithotripsy provides reliable information on the spatial and temporal characteristics of stone fragmentation, and is superior to B-mode sonography by providing more immediate, objective information on stone fragmentation and allowing better evaluation of the focal zone. With the help of this technique, the number of applied shock waves could be reduced by 20% compared with the control group.

Plasma sialic acid in patients with prostate cancer

Serum sialic acid (N-acetylneuraminic acid) was evaluated as a tumour marker for prostate cancer and compared with serum prostate specific antigen (PSA). The records of 35 patients suffering from prostate cancer (9 with bone metastases) were analysed and compared with those of 21 healthy individuals. Total serum sialic acid was significantly elevated among the cancer patients. Levels in patients with distant metastases were significantly higher than in those with locally restricted disease and normal individuals, whereas no such difference was seen between the latter 2 groups. A direct association between serum sialic acid and tumour T category and grade could not be established. The difference between the cancer and the control groups was reflected more significantly by PSA. As sialic acid lacks tumour specificity, it is not helpful in screening for prostate cancer, yet might contribute towards the early detection of tumour progression and metastases during both therapy and follow-up.

Rare-earth elements in urinary calculi

In vitro studies have demonstrated that trace elements have inhibitory as well as stimulatory effects on the crystallization of urinary stones. Little is known about the activities of rare-earth elements (REEs) in the human body. Although their physiological role is unclear, an effect on calcium transport mechanisms is discussed. In the present study, ten kidney stones (six oxalate and four phosphate stones) were analyzed by neutron-activation analysis for their REE patterns. Urinary stones are capable of concentrating these elements, and some fractionation into light and heavy REEs appears to take place during deposition. Significantly elevated concentrations of heavy REEs such as europium, terbium, and lutetium were detected in phosphate stones as compared with oxalate stones (P < 0.005).

ESWL in situ or ureteroscopy for ureteric stones?

As documented by follow-up data on ureteric stones in 1259 ureteric units treated, ESWL in situ on advanced lithotriptors with stone location by ultrasonography and fluoroscopy was successful without any retrograde ureteric manipulation in 98% of stones in the upper, 71% in the iliac, and 84% in the distal ureter; 85% of the units were stone-free within 3 months: ancillary measures were needed in 11% and the stone-free state was reached after a median of 39 days. The results obtained with treatment after manipulation of the stone from the upper and mid-ureter by retrograde instrumentation were similar, but ancillary measures were needed in 20% of cases. Endoscopic management with rod-lens ureteroscopes was highly efficient in the distal and mid-ureter, but involved a complication rate of about 11% and required general anaesthesia. In the upper ureter it was abandoned in favour of the two former methods. Endoscopic stone removal has been greatly facilitated by the development of ultrathin, semirigid ureteroscopes 6.2-9 F in diameter, as well as by laser and pneumatic lithotriptors that operate through their minute working ports. Of the stones impacted in 127 ureteric units, 97% were successfully managed at the first attempt, involving an overall complication rate of 6%.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of ureteric calculi (minimally invasive therapy of ureteric stones)

As documented with results obtained in 1685 patients the treatment of ureteric stones is today based on ESWL in situ and ureteroscopy with semirigid, ultrathin ureteroscopes and laser lithotripsy. All stones in the upper third of the ureter and larger stones in the distal third of the ureter are preferably treated with ESWL in situ whereas smaller stones in the distal ureter are better treated endoscopically. Midureteric stones remain the domain of primary ureteroscopy; with moderate obstruction in the asymptomatic patient it may also be acceptable to wait for the stone to pass into the distal ureter spontaneously to be treated by ESWL in situ there. Manipulating stones back into the kidney and treating them by ESWL there (pushback/ESWL) offers no advantage over ESWL in situ, as the results are similar, yet morbidity is higher. Blind instrumentation and open surgery have lost all justification.

One-year results of excimer laser photorefractive keratectomy for myopia

BACKGROUND

Excimer laser photorefractive keratectomy for the correction of myopia is presently under investigation in the United States by the Food and Drug Administration (FDA). The Phase II-B FDA study is being conducted on 75 normally sighted myopic eyes utilizing three currently available excimer lasers. This report presents the 1-year results on 12 myopic eyes treated with the VISX excimer laser system at the Ellis Eye Center at Cedars-Sinai Medical Center in Los Angeles under the Phase II-B FDA protocol.

METHODS

Twelve eyes of 12 patients with myopia between -1.75 and -5.00 diopters underwent 193 nm argon/fluoride excimer laser photorefractive keratectomy. The epithelium was mechanically removed, and fixation was accomplished with a suction ring which provided nitrogen flow across the corneal surface. The computer controlled corneal ablations were 5.00 mm in diameter and were accomplished with an iris diaphragm closing from large to small.

RESULTS

The preoperative spherical equivalent myopia was -3.50 D (SD = 1.02) and the postoperative myopia was -0.25 (SD = 0.48). Eleven of the 12 patients achieved an uncorrected visual acuity of 20/30 or better and were corrected to within +/- 0.50 D of emmetropia. All corneas demonstrated a mild reticular subepithelial haze which was barely visible at 1 year. There were no vision-threatening complications and none of the eyes experienced a loss of best corrected visual acuity.

CONCLUSIONS

In this small trial, the excimer laser appears to be capable of accurately changing the refractive power of the cornea for the correction of myopia with minimal side effects. Only when larger numbers of patients undergo the procedure will we be able to determine the safety and efficacy of photorefractive keratectomy as a refractive surgical procedure.

Primary small cell carcinoma of the urinary bladder. Report of a case with immunohistochemical analyses

A case of primary small cell carcinoma of the urinary bladder is reported. The light-microscopic diagnosis was supported by immunoreactivity for HISL-19 (marker for peptide-hormone-producing cells) and for neuron-specific enolase (NSE), demonstrating the neuroendocrine differentiation of this rare bladder tumor. Serum NSE, which was significantly elevated, can be a marker for disease extent and response to therapy.

Evaluation on HIV serology and immune-stimulation on patients in Tanzania

Antibodies against human immunodeficiency virus, other infectious agents and neopterin levels were determined in 253 patients in a rural area of North-West Tanzania. Seroprevalence for HIV was 3.2%. In one case serology was positive for HIV-1 and HIV-2 antibodies and questions whether there was a real double infection or a cross reaction not only concerning core region proteins but also transmembrane protein. The specificity in the diagnosis of HIV-infection is markedly increased with newer serological methods using recombinant peptides but did not improve sensitivity on African sera. Neopterin was determined as a sensitive indirect marker for the activation of T-cells and is therefore correlated with the susceptibility of HIV infection and with progression of disease. High seroprevalence rates for various infectious agents were determined and may explain the high rate of elevated neopterin levels in 80% of the Africans. Neopterin levels were even higher in HIV patients. Viral p24 antigen was found only in two persons, one of whom had no antibodies detectable.

Trace elements and urinary stone formation: new aspects of the pathological mechanism of urinary stone formation

The urinary stone, serum and 24-hour urine concentrations of 14 trace elements were determined in urinary stone patients by inductively coupled plasma atomic-emission spectroscopy. The data obtained for 25 active stone patients and 32 whose last stone episode had occurred at least 12 months previously were compared with those of 25 healthy individuals. Urinary nickel, manganese and lithium excretion, and serum nickel, manganese and cadmium concentrations were statistically significantly lower for active stone patients compared to those with previous stone episodes and healthy individuals. No difference in the concentrations of trace elements could be found, however, for patients with previous stone episodes and healthy individuals. Nickel, manganese, lithium and cadmium could be of significance in the pathological mechanism of stone formation, not from mineralogical or crystallographic viewpoints but for the smooth flow of enzymatic reactions in biological systems.

Value of routine citrate analysis and calcium/citrate ratio in calcium urolithiasis

24-hour urinary citrate excretion was measured in 176 calcium oxalate stone formers and 100 normal controls. A statistically significant difference (p less than 0.03) could be found between the two groups. When stone formers were divided into a group of 69 patients with recurrent calcium urolithiasis (RCU) and a group of 106 patients with a single stone episode, the latter did not differ from the control group, while in RCU a significantly lower citrate excretion compared with controls (p less than 0.005) could be found. Thus, patients with RCU could benefit from alkali citrate prophylaxis. A female-male difference in citrate excretion could not be found in either the control group or stone formers. Recurrent stone formers presented a significantly higher calcium/citrate ratio compared with controls, which would indicate an increased risk for stone formation. The value of routine citrate analysis is limited, however, by the great, variability of citrate levels in stone formers and controls.

Malignant hemangiopericytoma of the pelvis. Report of a case with urological implications and immunohistochemical analysis

A case of a malignant hemangiopericytoma located in the pelvic fossa of a 50-year old man is reported. The tumor displaced the urinary bladder and caused bilateral hydronephrosis. Light microscopic diagnosis was followed by immunohistochemistry. After surgery the patient was successfully treated by chemotherapy and irradiation. This paper reviews clinicopathological features in respect of prognosis and a possible treatment.