Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Hypoxic human proximal tubular epithelial cells undergo ferroptosis and elicit an NLRP3 inflammasome response in CD1c+ dendritic cells

Inflammasomes are multiprotein platforms responsible for the release of pro-inflammatory cytokines interleukin (IL)-1β and IL-18. Mouse studies have identified inflammasome activation within dendritic cells (DC) as pivotal for driving tubulointerstitial fibrosis and inflammation, the hallmarks of chronic kidney disease (CKD). However, translation of this work to human CKD remains limited. Here, we examined the complex tubular cell death pathways mediating inflammasome activation in human kidney DC and, thus, CKD progression. Ex vivo patient-derived proximal tubular epithelial cells (PTEC) cultured under hypoxic (1% O₂) conditions modelling the CKD microenvironment showed characteristics of ferroptotic cell death, including mitochondrial dysfunction, reductions in the lipid repair enzyme glutathione peroxidase 4 (GPX4) and increases in lipid peroxidation by-product 4-hydroxynonenal (4-HNE) compared with normoxic PTEC. The addition of ferroptosis inhibitor, ferrostatin-1, significantly reduced hypoxic PTEC death. Human CD1c⁺ DC activated in the presence of hypoxic PTEC displayed significantly increased production of inflammasome-dependent cytokines IL-1β and IL-18. Treatment of co-cultures with VX-765 (caspase-1/4 inhibitor) and MCC950 (NLRP3 inflammasome inhibitor) significantly attenuated IL-1β/IL-18 levels, supporting an NLRP3 inflammasome-dependent DC response. In line with these in vitro findings, in situ immunolabelling of human fibrotic kidney tissue revealed a significant accumulation of tubulointerstitial CD1c⁺ DC containing active inflammasome (ASC) specks adjacent to ferroptotic PTEC. These data establish ferroptosis as the primary pattern of PTEC necrosis under the hypoxic conditions of CKD. Moreover, this study identifies NLRP3 inflammasome signalling driven by complex tubulointerstitial PTEC-DC interactions as a key checkpoint for therapeutic targeting in human CKD.

Metabolite profiles evaluated, according to sex, do not predict resting energy expenditure and lean body mass in healthy non-obese subjects

PURPOSE

Differences in resting energy expenditure (REE) between men and women mainly result from sex-related differences in lean body mass (LBM). So far, a little is known about whether REE and LBM are reflected by a distinct human metabolite profile. Therefore, we aimed to identify plasma and urine metabolite patterns that are associated with REE and LBM of healthy subjects.

METHODS

We investigated 301 healthy male and female subjects (18-80 years) under standardized conditions in the cross-sectional KarMeN (Karlsruhe Metabolomics and Nutrition) study. REE was determined by indirect calorimetry and LBM by dual X-ray absorptiometry. Fasting blood and 24 h urine samples were analyzed by targeted and non-targeted metabolomics methods using GC × GC-MS, GC-MS, LC-MS, and NMR. Data were evaluated by predictive modeling of combined data using different machine learning algorithms, namely SVM, glmnet, and PLS.

RESULTS

When evaluating data of men and women combined, we were able to predict REE and LBM with high accuracy (> 90%). This, however, was a clear effect of sex, which is supported by the high degree of overlap in identified important metabolites for LBM, REE, and sex, respectively. The applied machine learning algorithms did not reveal a metabolite pattern predictive of REE or LBM, when analyzing data for men and women, separately.

CONCLUSIONS

We could not identify a sex independent predictive metabolite pattern for REE or LBM. REE and LBM have no impact on plasma and urine metabolite profiles in the KarMeN Study participants. Studies applying metabolomics in healthy humans need to consider sex specific data evaluation.

Clinical Value of a Mucin-Like Carcinoma-Associated Antigen (MCA) in Patients with Carcinomas of the Kidney and the Urinary Collecting System

A new tumor marker, mucin-like carcinoma-associated antigen (MCA), was evaluated in thirty-four patients with renal cell carcinomas andforty patients with carinomas of the urinary collecting system. In the first group, specificity was 95%, sensitivity 65%, the predictive value for positive diagnosis was 94%, andfor negative diagnosis 72%. In the second group specificity was 83%, sensitivity 71%, predictive value for positive diagnosis was 63%, and for negative diagnosis 88%. Receiver operating characteristic curves indicated that the maximum amount of information was greater in patients of the first group than the second (0.379 vs. 0.332 bits). In the light of these data, the MCA test can be recommended for assessing metastatic spread in patients particularly with renal cell carcinomas.

Performance of a High-Sensitivity Rapid Diagnostic Test for Plasmodium falciparum Malaria in Asymptomatic Individuals from Uganda and Myanmar and Naive Human Challenge Infections

Sensitive field-deployable diagnostic tests can assist malaria programs in achieving elimination. The performance of a new Alere™ Malaria Ag P.f Ultra Sensitive rapid diagnostic test (uRDT) was compared with the currently available SD Bioline Malaria Ag P.f RDT in blood specimens from asymptomatic individuals in Nagongera, Uganda, and in a Karen Village, Myanmar, representative of high- and low-transmission areas, respectively, as well as in pretreatment specimens from study participants from four Plasmodium falciparum-induced blood-stage malaria (IBSM) studies. A quantitative reverse transcription PCR (qRT-PCR) and a highly sensitive enzyme-linked immunosorbent assay (ELISA) test for histidine-rich protein II (HRP2) were used as reference assays. The uRDT showed a greater than 10-fold lower limit of detection for HRP2 compared with the RDT. The sensitivity of the uRDT was 84% and 44% against qRT-PCR in Uganda and Myanmar, respectively, and that of the RDT was 62% and 0% for the same two sites. The specificities of the uRDT were 92% and 99.8% against qRT-PCR for Uganda and Myanmar, respectively, and 99% and 99.8% against the HRP2 reference ELISA. The RDT had specificities of 95% and 100% against qRT-PCR for Uganda and Myanmar, respectively, and 96% and 100% against the HRP2 reference ELISA. The uRDT detected new infections in IBSM study participants 1.5 days sooner than the RDT. The uRDT has the same workflow as currently available RDTs, but improved performance characteristics to identify asymptomatic malaria infections. The uRDT may be a useful tool for malaria elimination strategies.

Ultrafast energy transfer and structural dynamics in DNA

Ultrafast structural dynamics concomitant to excitation energy transfer in DNA has been studied using a pair of pyrene-labeled DNA bases. The temporal evolution of the femtosecond pump-probe spectra reveals the existence of two electronic coupling pathways, through-base stack and through-space, which lead to excitation energy transfer and excimer formation even when the labeled DNA bases are separated by one AT base pair. The electronic coupling which mediates through-base stack energy transfer is so strong that a new absorption band arises in the excited-state absorption spectrum within 300 fs. From the analysis of time-dependent spectral shifts due to through-space excimer formation, the local structural dynamics and flexibility of DNA are characterized on the picosecond and nanosecond time scale.

Microarrays of bladder cancer tissue are highly representative of proliferation index and histological grade

The number of genes suggested to play a role in cancer biology is rapidly increasing. To be able to test a large number of molecular parameters in sufficiently large series of primary tumours, a tissue microarray (TMA) approach has been developed where samples from up to 1000 tumours can be simultaneously analysed on one glass slide. Because of the small size of the individual arrayed tissue samples (diameter 0.6 mm), the question arises of whether these specimens are representative of their donor tumours. To investigate how representative are the results obtained on TMAs, a set of 2317 bladder tumours that had been previously analysed for histological grade and Ki67 labelling index (LI) was used to construct four replica TMAs from different areas of each tumour. Clinical follow-up information was available from 1092 patients. The histological grade and the Ki67 LI were determined for every arrayed tumour sample (4x2317 analyses each). Despite discrepancies in individual cases, the grade and Ki67 information obtained on minute arrayed samples were highly similar to the data obtained on large sections (p<0.0001). Most importantly, every individual association between grade or Ki67 LI and tumour stage or prognosis (recurrence, progression, tumour-specific survival) that was observed in large section analysis could be fully reproduced on all four replica TMAs. These results show that intra-tumour heterogeneity does not significantly affect the ability to detect clinico-pathological correlations on TMAs, probably because of the large number of tumours that can be included in TMA studies. TMAs are a powerful tool for rapid identification of the biological or clinical significance of molecular alterations in bladder cancer and other tumour types.

Influence of pneumoperitoneum and patient positioning on respiratory system compliance

STUDY OBJECTIVE

To investigate the influence of pneumoperitoneum (PP) and posture on respiratory compliance and ventilation pressures.

DESIGN

Prospective, single blind trial.

PATIENTS

10 female ASA physical status I and II patients scheduled for elective gynecologic laparoscopy.

SETTING

University medical center.

INTERVENTIONS

Anesthesia was performed as total IV anesthesia (TIVA) with propofol, alfentanil, and atracurium. After induction of anesthesia and orotracheal intubation, the lungs were ventilated to maintain partial pressure of CO(2) (P(ET)CO(2)) of 30 +/- 3 mmHg. Ventilation was kept constant. As gas mixture oxygen and air 1:1 was used without positive end-expiratory pressure (PEEP).

MEASUREMENTS

Measurements were taken before and after creation of pneumoperitoneum with an intraabdominal pressure (IAP) of 10 mmHg, of 15 mmHg in 20 degrees head-down tilt, then in 20 degrees head-up tilt, and after deflation of PP. We determined peak inspiratory pressure (PIP), mean airway pressure (mPaw), P(ET)CO(2), expiratory minute volume (V(E)), heart rate (HR), and systolic (SBP), diastolic (DBP), and mean arterial pressure (MAP). Respiratory system compliance (C(eff rs)) was calculated as quotient of tidal volume (V(T)) and PIP.

MAIN RESULTS

After creation of PP (IAP 10 mmHg), there was a significant increase of median PIP (3 cmH(2)O), mPaw (1 cm H(2)O) and arterial pressure (BP), (MAP by 7 mmHg), C(eff rs) decreased by 6 mL. cm H(2)O(-1). Increase of IAP to 15 mmHg led to a further increase of PIP (2 cm H(2)O) and mPaw (1 cm H(2)O), and a further decrease of C(eff rs) by 5 mL cm H(2)O(-1); BP decreased (MAP by 5.5 mmHg). Head-up or head down positions showed no significant hemodynamic or pulmonary changes. P(ET)CO(2)increased from 29.5 to 36 mmHg at an IAP of 15 mmHg, but then no further changes were noticed. Five minutes after deflation of pneumoperitoneum all values returned to baseline levels.

CONCLUSIONS

Creation of PP at an IAP of 15 mmHg reduced respiratory system compliance, and increased peak inspiratory and mean airway pressures, which quickly returned to normal values after deflation. Head-down or head-up position did not further alter those parameters.

Microarrays of bladder cancer tissue are highly representative of proliferation index and histological grade

The number of genes suggested to play a role in cancer biology is rapidly increasing. To be able to test a large number of molecular parameters in sufficiently large series of primary tumours, a tissue microarray (TMA) approach has been developed where samples from up to 1000 tumours can be simultaneously analysed on one glass slide. Because of the small size of the individual arrayed tissue samples (diameter 0.6 mm), the question arises of whether these specimens are representative of their donor tumours. To investigate how representative are the results obtained on TMAs, a set of 2317 bladder tumours that had been previously analysed for histological grade and Ki67 labelling index (LI) was used to construct four replica TMAs from different areas of each tumour. Clinical follow-up information was available from 1092 patients. The histological grade and the Ki67 LI were determined for every arrayed tumour sample (4x2317 analyses each). Despite discrepancies in individual cases, the grade and Ki67 information obtained on minute arrayed samples were highly similar to the data obtained on large sections (p<0.0001). Most importantly, every individual association between grade or Ki67 LI and tumour stage or prognosis (recurrence, progression, tumour-specific survival) that was observed in large section analysis could be fully reproduced on all four replica TMAs. These results show that intra-tumour heterogeneity does not significantly affect the ability to detect clinico-pathological correlations on TMAs, probably because of the large number of tumours that can be included in TMA studies. TMAs are a powerful tool for rapid identification of the biological or clinical significance of molecular alterations in bladder cancer and other tumour types.

Association of an RNA kissing complex analyzed using 2-aminopurine fluorescence

The fluorescent probe, 2-aminopurine-2'-O-methyl riboside (2-AP) has been selectively incorporated at adenosine positions in stem-loops (so called R1inv and R2inv), derived from the ColE1 plasmid encoded RNA I and RNA II transcripts, that interact to form stable loop-loop kissing complexes and bind the RNA one modulator (Rom) protein, such that fluorescence-detected stopped-flow and equilibrium methods could be used to study the detailed mechanism of this RNA-RNA interaction. Formation of loop-loop kissing complexes between R1inv and R2inv hairpins, substituted with 2-AP at positions in the complementary loops, results in a 5-10-fold fluorescence emission decrease (F(max) = 370 nm), which provides a sensitive measure for the binding reaction. The 2-AP substituted complexes are found to have equilibrium binding properties (average K(D) = 2.6 +/- 1.7 nM) and affinity for Rom (average K(D) = 60 +/- 24 nM) that are similar to complexes formed with equivalent unlabeled hairpins. Using stopped-flow experiments, it was found that the 2-AP probes experienced at least three different microenvironments during association of the RNA complex, thus suggesting a kinetic intermediate in the kissing pathway. In contrast, dissociation of the complex was found to fit a single exponential decay (average k(off) = 8.9 x 10(-5) s(-1)). Consistent with these observations, a two-step mechanism for RNA loop-loop complex association is proposed in which the complementary loops of R1inv and R2inv first base pair to form the loop-loop helix (average k(1) = 0.13 microM(-1)s(-1)) in the initial encounter reaction, and subsequently isomerize to the final tertiary fold in a second slower step (average k(2) = 0.09 s(-1)), where the helical stacking around the junctions is optimized.

Influence of pneumoperitoneum and patient positioning on preload and splanchnic blood volume in laparoscopic surgery of the lower abdomen

STUDY OBJECTIVE

To determine the hemodynamic effects of pneumoperitoneum and patient positioning during laparoscopic surgery of the lower abdomen.

DESIGN

Prospective study.

SETTING

University-affiliated medical center.

PATIENTS

10 ASA physical I and II female patients scheduled for laparoscopic surgery of the lower abdomen.

INTERVENTIONS

Patients were anesthetized with propofol and an alfentanil infusion, then intubated, and normoventilated.

MEASUREMENTS

After intubation, a transesophageal multiplane probe for measurements of right (RVESA) and left (LVESA) ventricular end-systolic and end-diastolic areas (RVEDA and LVEDA) and ejection fraction area (RVEFa, LVEFa) was introduced; heart rate (HR) and noninvasive blood pressure (BP) were recorded every minute. Ventilation was not changed during the measurements. A transvaginal ultrasound probe was inserted to measure the diameter of the common iliac vein. Measurements were performed 15 minutes after induction of anesthesia and while patients were in the supine position (P 0), 10 minutes after CO(2) insufflation to 10 mmHg IA pressure (P 10), 10 minutes after a further increase to 15 mmHg (P 15), 10 minutes after 20 degrees Trendelenburg (P 15 T), and 20 degrees reverse Trendelenburg positions (P 15 RT). Data are shown as medians, 25th to 75th percentiles, and comparisons between P 0, P 10, P 15, and P15 T were made with the Friedman test, followed by Wilcoxon test, when significant. Data at P 15 T, P 15 RT, and P 15 were compared using the Wilcoxon test, with a p-value < 0.05 regarded as significant.

MAIN RESULTS

Pneumoperitoneum at 10 mmHg abdominal pressure caused a significant increase of LVESA by 78% (RVESA: 61%) and LVEDA by 48.5% (RVEDA: 45%). The diameter of the common iliac vein was decreased by 6%. A further increase of abdominal pressure to 15 mmHg led to an additional increase of 20% (LVESA) and 17% (LVEDA). Mean arterial pressure increased by a significant 7% at P 10, decreasing subsequently by 5% at P 15. The Trendelenburg position did not alter any hemodynamic findings. Reverse Trendelenburg position, however, caused a significant LVEDA-and RVEDA-decrease by 18% and 27%, respectively, and an increase in the diameter of the common iliac vein by 22%. The LVEFa and RVEFa decreased significantly after abdominal CO(2) insufflation by 18% each (P 10) without further change.

CONCLUSIONS

The lithotomy position and subsequent pneumoperitoneum increased preload, probably as a result of blood shifting from the abdomen to the thorax by compression of splanchnic vessels caused by the pneumoperitoneum. Careful fluid management, maintaining low abdominal pressure, and use of the reverse Trendelenburg position are favored to prevent adverse hemodynamic effects in laparoscopic surgery.

High-throughput tissue microarray analysis of 3p25 (RAF1) and 8p12 (FGFR1) copy number alterations in urinary bladder cancer

Studies by comparative genomic hybridization revealed that the chromosomal regions 3p25 and 8p11-p12 are recurrently amplified in bladder cancer. To investigate the prevalence of DNA copy number alterations in these chromosomal regions and study their clinical significance, we used probes for the RAF1 (3p25) and FGFR1 (8p12) genes for fluorescence in situ hybridization. A tissue microarray containing 2317 tumors was analyzed. The analysis revealed RAF1 amplification in 4.0% and FGFR1 amplification in 3.4% of interpretable tumors. In addition, deletions were found at the 3p25 locus in 2.2% and at the 8p11-12 locus in 9.9% of interpretable tumors. Both amplifications and deletions of RAF1 and FGFR1 were significantly associated with high tumor grade (P < 0.0001), advanced stage (P < 0.0001), and poor survival (P < 0.05) if tumors of all of the stages where analyzed together. RAF1 amplifications were associated with subsequent tumor progression in pT1 carcinomas (P < 0.05). The marked differences in the frequency of all of the analyzed changes between pTa grade 1/grade 2 and pT1-4 carcinomas support the concept of these tumor groups representing different tumor entities.

How covert are covertly manipulated diets?

OBJECTIVE

To quantitatively assess subjects' ability to detect hedonic (palatability), sensory and nutritional differences between covertly manipulated high-fat (HF) and low-fat (LF) diets. SUBJECTS AND DIETS: This study examined the response of 16 subjects (eight men, eight women) to 20 LF and 20 HF versions of manipulated foods. Average percentage protein:fat:carbohydrate (by energy) and energy density (ED) of the two diets were 13:25:62, 371 kJ/100 g and 13:50:37, 672 kJ/100 g, respectively.

PROTOCOL

Subjects were asked to simultaneously assess the HF and LF versions of each food in terms of (i) subjective pleasantness of each food, (ii) perceived differences in appearance, smell, taste and texture of the foods, and (iii) for each sample to assess whether it was high or low in energy, protein, carbohydrate, fat, fibre, sugar and salt.

ANALYSIS

Perceived pleasantness of HF and LF versions of the foods was compared by analysis of variance. Comparisons used chi-squared tests of independence to assess departure from the null hypothesis of no perceived difference in remaining parameters (ii-iii).

RESULTS

On average, subjects exhibited no significant preference for LF or HF versions of the foods (no difference 15 foods, three HF foods more pleasant, two LF foods more pleasant (P<0.03)). On average there were no general differences in comparison of sensory attributes that were consistently ascribable to the LF or HF foods, although there were numerous significant differences for individual foods. Subjects appeared unable to distinguish the HF foods as being HF (66% of estimates) and guessed correctly 33% of the time. They were better able to categorize the LF foods correctly (53% correct). On aggregate 43% of HF and LF foods were correctly identified. Subjects appeared able to detect sensory differences between foods but not to relate them to energy or nutrient content of these foods.

CONCLUSIONS

These data suggest that subjects are on average not able to perceive large differences in the fat content of diets manipulated in this manner. In general the assumption that the manipulation of such foods is covert appears to hold, but subjects were far better at correctly identifying certain food types (dairy-based) over others.

[Hemodynamic effects of pneumoperitoneum in lithotomy position]

AIM OF STUDY

The study investigates the haemodynamic effects of the varying intraabdominal pressures and patient positions during gynecological procedures employing pneumoperitoneum in lithotomy positions.

METHODS

TEE was used to determine end-diastolic and end-systolic left ventricular surface areas and ejection fractions were calculated from these data. To evaluate intraabdominal volume shifts the diameter of the internal iliac vein was measured by mean of vaginal ultrasound.

RESULTS

In the horizontal lithotomy position both LVEDA and LVESA increased when intraabdominal pressure increased by 10 and 15 mmHg, respectively. LVAEF significantly decreased when intraabdominal pressure increased by 15 mmHg. Also DVII decreased. In Trendelenburg position there was no change in LVEDA, LVESA, LVAEF and DVII. In Anti-Trendelenburg position LVEDA and LVESA decreased. However, LVAEF remained constant and DVII increased.

CONCLUSION

The increase of the intraabdominal pressure in the lithotomy position results in an increase in intrathoracic volume and an decrease in LVAEF via elevation of the the lower extremities and compression of the splanchnic vessels. There are no changes in Trendelenburg position. However, in Anti-Trendelenburg position, gravity results in a decrease in intrathoracic blood volume. In the decreased, dilatated heart the increase in intrathoracic volume may increase myocardial wall tension and hence oxygen demand, ultimately leading to an acute heart failure. As a result laparoscopic procedures in horizontal lithotomy position should be avoided in patients with dilatative cardiomyopathy.

Cyclin D1 overexpression lacks prognostic significance in superficial urinary bladder cancer

The biological behaviour of urinary bladder neoplasms cannot be adequately predicted by histological criteria alone. Cyclin D1 is a cell-cycle regulating protein known to be overexpressed in a proportion of bladder carcinomas. To evaluate the prognostic significance of cyclin D1 expression and its relationship with tumour phenotype, 392 bladder carcinomas were analysed by immunohistochemistry. Clinical follow-up information was available in 337 patients with superficial bladder tumours (stages pTa/pT1). Cyclin D1 positivity was seen in 176 of 392 carcinomas. Cyclin D1 overexpression was strongly linked to papillary tumour growth, low stage, and low histological grade (p<0.005 each). Multivariate analysis showed that papillary tumour growth was the only parameter which was independently linked to cyclin D1 positivity. There was no significant difference in proliferative activity (Ki67 labelling index) between cyclin D1-negative and -positive tumours. Cyclin D1 positivity was not linked to the risk of recurrence or tumour progression, either in pTa or in pT1 carcinomas. It is concluded that cyclin D1 positivity distinguishes a large subgroup of papillary bladder tumours, but there is no evidence of prognostic significance for increased cyclin D1 expression.

Polysomies but not Y chromosome losses have prognostic significance in pTa/pT1 urinary bladder cancer

A disturbed cellular DNA content is of potential diagnostic and prognostic relevance in urinary bladder cancer. To evaluate the prognostic significance of individual chromosomal aberrations in superficial bladder cancer, specimens of 105 tumors (67 pTa, 38 pT1) were examined by fluorescence in situ hybridization (FISH). FISH allows quantitation of chromosomes on a cell by cell level. Centromere probes for the chromosomes Y, 1, and 17 were used. There was a strong association between polysomies of the chromosomes 1 (found in 46% of tumors) and 17 (40% of tumors, P < .0001). Polysomies (1 and 17) were significantly more frequent in pT1 than in pTa tumors (P < .0001 each). In pTa tumors, polysomies of both chromosomes were linked to a high risk of recurrences; polysomy 17 was associated with an increased risk of progression (P < .05 each). There was no significant association between polysomies and an unfavorable prognosis in pT1 carcinomas. Previous studies had suggested a prognostic role of Y losses in bladder cancer. However, Y losses were not linked to recurrences or tumor progression in pTa or pT1 tumors of 67 male patients. These data show that marked genetic differences exist between pTa and pT1 carcinomas. They also indicate that polysomies of different chromosomes may have prognostic relevance in pTa urinary bladder cancer.

Construction of improved plasmid vectors for promoter characterization in Pseudomonas aeruginosa and other gram-negative bacteria

We report the construction of two broad host range promoter-probe plasmid vectors for rapid analysis of promoters in Gram-negative bacteria. The new vectors, pME4507 and pME4510, carry carbenicillin and gentamycin resistance genes, respectively, and are small sized (4 kb) with a flexible multiple cloning site to facilitate directional cloning of putative promoter elements. The vectors allow rapid plate-based screening for promoter activities, using beta-galactosidase as the reporter enzyme. In the absence of an inserted promoter fragment, they display very low background activity, making them a useful tool for analysis of low expression level promoters.

Preoperative predictors of recurrent atrial fibrillation late after successful mitral valve reconstruction

OBJECTIVE

Late outcome after mitral valve repair was examined to define preoperative predictors of recurrent atrial fibrillation late after successful mitral valve reconstruction.

METHODS

One hundred and eighty-nine patients, 112 with preoperative sinus rhythm and 72 with preoperative chronic or intermittent atrial fibrillation, were followed for 12.2 +/- 10 years after valve repair. Clinic, hemodynamic end echocardiographic data were entered into Cox-regression and Kaplan-Meyer analysis to assess predictors for recurrent atrial fibrillation late after successful mitral valve repair.

RESULTS

Univariate and multivariate predictors for recurrent atrial fibrillation late after successful mitral valve reconstruction were preoperative atrial fibrillation (P = 0.0001), preoperative antiarrhythmic drug treatment (P = 0.005), heart rate (P = 0.01), left ventricular ejection fraction (P = 0.01) and increased left ventricular posterior wall thickness (P = 0.05). Patients > 57.5 years with a mean pulmonary artery pressure > or =23 mm Hg and a history of preoperative antiarrhythmic drug treatment had an odds ratio of 53.33 (95% confidence limits 6.12-464.54) for atrial fibrillation late after successful mitral valve repair.

CONCLUSION

Older patients with a history of atrial fibrillation, antiarrhythmic treatment or an elevated pulmonary artery pressure may present atrial fibrillation late after successful mitral valve repair. They could be considered for combined mitral valve reconstruction and surgery for atrial fibrillation even though sinus rhythm is present preoperatively.

[Anesthesia in laparoscopies: an overview]

In the last few years laparoscopic surgery requiring a different method of anesthesia from laparotomic procedures has been increasingly carried out. Since laparoscopic cholecystectomy was first described in 1985 almost all abdominal organs can now be operated on laparoscopically. At the same time the spectrum of the patients has changed from those who are young and healthy to older ones with many accompanying illnesses. In addition, the length of time this operations require has greatly increased. Consequently the number of critical incidents relevant to anaesthesia, during laparoscopy, has risen. Therefore new studies had been worked out which lead to a better understanding of pathophysiological changes during pneumoperitoneum.

[Glomerular hyperfiltration following unilateral nephrectomy in healthy subjects]

23 living related kidney transplant donors were prospectively studied to determine the degree of hyperfiltration which occurs after uninephrectomy and to monitor potential consequences of this procedure such as hypertension, microalbuminuria or renal functional impairment. Standard inulin and PAH clearance studies were performed immediately before (n = 23), one week after (n = 22) and one year after nephrectomy (n = 12). Hyperfiltration was defined as the ratio of (post-nephrectomy inulin clearance)/(0.5 x pre-nephrectomy inulin clearance), hyperperfusion was defined in an analogous way for PAH clearance. One week after uninephrectomy, hyperfiltration averaged 134 +/- 6% (SEM) and hyperperfusion was 138 +/- 6%. The degree of hyperfiltration did not correlate with donor age. One year after nephrectomy, hyperfiltration was nearly unchanged (130 +/- 7%) whereas hyperperfusion had significantly decreased to 119 +/- 8% (p less than 0.05). Blood pressure did not increase after nephrectomy and no new cases of hypertension were observed during follow-up. In contrast, there were two new cases of microalbuminuria at one week and one year after nephrectomy. Further follow-up of these kidney donors is warranted.

[Cutaneous reconstruction of external genital organs: an older method still in current use]

The authors present four patients with cutaneous defects of the genital organs, one with a degloving injury to the penis, one with Fournier's gangrene, one with massive lymphoedema and one with a full thickness burn. In those four cases, a stable coverage was obtained through skin grafts, maintained by an external splint. The use of this older method gave an excellent esthetic and functional result.

Intermittent urethral self-catheterisation: long term results (bacteriological evolution, continence, acceptance, complications)

Forty six (9%) out of 520 patients from the years 1976 to 1982 who used intermittent urethral self-catheterisation (IUSC) as the method of bladder drainage at the moment of discharge from the Swiss Paraplegic Centre of Basel were analysed during their rehabilitation period, on discharge, 3, 6 months later and again 5 years later regarding bacteriological changes and urinary tract infections, behaviour of some problem germs such as Proteus, Klebsiella and Pseudomonas, sterile versus clean catheterisation, catheterisation frequency, complications, continence and acceptance of this method. Only 22 patients continue IUSC, 5 have died, 6 use indwelling catheters and 13 are voiding their neurogenic bladder with other methods. Average time on IUSC was 6.6 years (0.5-13 years) in the women's group and 4.6 years (0.5-12 years) in the men's group. Of the remaining 22 patients on IUSC, 23% have sterile urines, 36.5% are infected with E. coli and Enterococci, 4.5% with Staphylococci and the remaining 36% still show the problem germs Pseudomonas (4.5%), Proteus (13.5%) and Klebsiella (18%), but there was a reduction from 19 cases with problem germs in 1983 to 11 cases in 1988. In 1988 5% women and 4% men changed from sterile to clean IUSC (2 out of 11 men using the same catheter for at least 1 week and 2 out of 10 women). The complication rate was astonishingly low during IUSC: being only 4.3% (2 male patients, one with stricture of the urethra and epididymitis, one with autonomous dysreflexia with bladder overdistension). No anti-cholinergic or alpha-stimulating agents were used nor continuous antibiotic-prophylaxis and only in one female patient was a bladder denervation procedure performed. No deterioration of the upper urinary tract was observed. The degree of continence remained stable throughout the follow-up, and the same applies to the acceptance of IUSC. The authors conclude that IUSC can be of great help in neuropathic bladder rehabilitation provided that the patients are properly selected, motivated and well instructed and followed throughout the years.

[Familial adult cystic kidneys and malignant teratomas after kidney transplantation with cyclosporin therapy]

We report on two brothers with adult polycystic kidney disease, malignant teratomas and other genital malformations. Because of the unusual accumulation of malformations of embryologically related organs, we postulate a connection between malformations of the kidneys and the genital tract, on the one hand, and teratomas on the other. No genetic coherence is known so far. It is unlikely that immunosuppression with cyclosporin after transplantation had caused these tumours.

Carcinosarcoma of the prostate in combination with adenocarcinoma of the prostate and adenocarcinoma of the seminal vesicles. A case report with immunocytochemical analysis and review of the literature

A unique triad of a carcinosarcoma and an adenocarcinoma of the prostate as well as an adenocarcinoma of the seminal vesicles in a 67-year-old man is reported. The carcinosarcoma was investigated by immunohistochemical methods. The mesenchymal parts of the sarcoma showed chondromatous differentiation expressed by S-100 protein and vimentin. The undifferentiated epithelial elements of the carcinosarcoma reacted positively to the panepithelial antibody lu-5 and to carcinoembryonic antigen (CEA). The adenocarcinoma of the prostate stained with antibodies to panepithelial antigen (lu-5), prostatic acid phosphatase, prostate specific antigen and CEA, whereas the adenocarcinoma of the seminal vesicles reacted only to lu-5 and CEA. The literature is reviewed.

Does microinvasion of the capsule and/or micrometastases in regional lymph nodes influence disease-free survival after radical prostatectomy?

Since 1976, 126 patients with clinically localised carcinoma of the prostate have been managed by radical retropubic prostatectomy. All patients with tumour spread beyond the capsule or metastasis in lymph nodes received radiotherapy. Tumour category pT3 was divided into invasion of the capsule or infiltration of the seminal vesicle. The disease-free 10-year survival rate in patients with minimal invasion of the capsule was 72% and in patients with infiltration of the seminal vesicles it was 26%. Unilateral lymph node metastases were classified as microscopic disease or macroscopic infiltration. The disease-free 10-year survival rate in patients with metastasis in 1 lymph node (micro- and macro-metastasis) was 65% in contrast to 0% in patients with bilateral disease.

[Transplantation of kidneys of relatives]

In the last few decades kidney transplants have shown an increasing survival rate of about 85% after one year. The growing demand for transplants is limited by the insufficient availability of kidneys and the living donor represents a possible means of reducing the discrepancy between supply and demand. We report here results of 41 transplantations from related, living donors. The overall transplant survival rate at one year was 91% and at 5 years 71%. In the group treated with cyclosporine the survival rate was 92% at 5 years. The mean serum creatinine levels at the latest follow-up was 115 mumol/l, while the mean blood pressure was 139/82 mmHg. Donor nephrectomy resulted neither in morbidity nor mortality. An extensive follow-up study of 8 donors revealed normal values for both blood pressure and serum creatinine. Careful donor selection is crucial in order to guarantee the voluntary nature of donation and, thus, to avoid the risk of commercialism.

[What does the omentum plug accomplish in colorectal tumor surgery? A 10-year follow-up]

In 23 of 47 patients who underwent surgery for malignant colorectal tumors between January 1978 and December 1986, the residual cavity was treated with a pedicled omental plug after radical resection of the tumor-bearing areas. There was advanced transmural tumor spread in 13 omentum patients and in 9 operated without using omentum. The other patients had equally distributed T2 and T3 stage tumors. Complications were similar in both groups, but perineal infection was slightly less frequent and less significant in the omentum group. Hospitalization was 23 days in patients with the omental plug and 34 days in the others. Life quality, as shown by the activity index, was better in the omentum group. 30-day postoperative mortality was 8.5% in both groups. Individual survival after surgery was 23 months with the omental plug, compared with 15 months in patients without this procedure. At 5 years, however, survival rate was similar. Postmortem revealed no tumor spread alongside the transposed omentum, which had changed to a mesentery-like structure. From these results it is clear that the omentum plug does not achieve cure in carcinoma or longterm survival, but improves the complication rate and individual survival time. We can therefore recommend this procedure as palliative treatment, since even extensive defects can be covered effectively by omentum.

[Functional disorders of bladder emptying in adulthood]

Functional voiding problems can be divided into three different groups: neurogenic dysfunction, myogenic dysfunction and true functional impairment of micturition in the sense of a psychosomatic disorder. Patients should be classified in the latter group only, if somatic disorders are excluded by conscientious urologic examination. Treatment of these patients is very time-consuming and difficult. Pure myogenic dysfunction occurs with rare generalised muscle disease only. Neurogenic dysfunction represents the majority of cases. Investigations in the Swiss Centre for Paraplegics and some new publications point out fundamental tendencies in the therapy and rehabilitation of neurogenic bladder dysfunction.

Regional cerebral blood flow in man at rest and during exercise

Regional cerebral blood flow (rCBF) of the left hemisphere was measured in 12 healthy young men at rest and during physical work on a bicycle ergometer in the supine position at work-load levels of 25 W or 100 W using the intravenous 133Xe method. Regional mean cerebral blood flow, regional gray-matter flow, and relative gray-matter weight was determined for six regions of interest. Arterial blood pressure, pulse frequency and expiratory CO2 concentration were recorded. Cerebral blood flow in all regions was significantly (P less than 0.001) higher during exercise than at rest. The increase in the 100 W group (24.7%) was significantly (P less than 0.05) greater than in the 25 W group (13.5%), but resting blood flow levels and alveolar CO2 concentrations were also different in both groups. Mean arterial blood pressure, pulse frequency and alveolar CO2 concentrations, but not arterial pCO2, were significantly higher during exercise and there was a faster washout of whole-body xenon. The CBF increase was interpreted as a combined effect of elevated systemic blood pressure and functionally activated brain metabolism. There was no evidence of impaired cerebral autoregulation.

Tissue polypeptide antigen (TPA) and prostatic acid phosphatase in serum of prostatic cancer patients

Tissue polypeptide antigen (TPA) and prostatic acid phosphatase were both detected by radioimmunoassay in the sera of a male population (age greater than 45 years) consulting the clinic for urological problems or check-up on treatment. Increased concentrations of TPA were associated mostly with advanced stages of prostatic carcinomas, parallel to PAP. Some enhanced TPA concentrations were detected with haematuria and adenomas of the prostate.

[Phenacetin abuse. VII: Urinary tract tumors in dialysis patients and patients with kidney grafts]

From 1965 to 1981, 9 out of 346 patients treated by chronic hemodialysis or kidney transplants had tumours of the lower urinary tract. All the tumour patients belonged to the analgesic abusers group (n = 87). The frequency of urinary tract tumours in this analgesic abusers group does not differ from the frequency in analgesic abusers in general (about 10%). In the 9 analgesic abusers a total of 18 urothelial tumours were recorded: 4 tumours of the renal pelvis, 3 of the ureter and 8 tumours of the urinary bladder. One female patient had a tumour of the urethra. Diagnostic and therapeutic problems are discussed on the basis of two case histories. Our experience in recent years is summarized in a program for tumour-screening, diagnosis and therapy for analgesic abusers treated by dialysis and kidney transplantation.

[Prognostic significance of clinical and morphological parameters in prostate cancer]

In 269 patients with carcinoma of the prostate, a retrospective statistical evaluation was done to correlate prognosis with different clinical and morphological criteria. All prostate biopsies were reviewed, the clinical staging redone and compared to survival of the patients. The most reliable criteria for prognostic prediction are clinical staging (rectal palpation, radiological examination and prostatic acid phosphatase). The morphologic parameters (histologic type of tumor, perineural invasion and perifocal inflammation) are of additional but of limited value.

[Diagnostic accuracy of prostate needle biopsies in cancer of the prostate]

The carcinoma of the prostate can be diagnosed with high certainty in needle biopsy. Among 450 cases only one false diagnosis was found. Under routine diagnostic conditions, semiquantitative evaluation showed that 50% of the investigated morphological parameters in carcinomas of the prostate can be reproduced by one and the same or different investigators with a sufficiently high degree of certainty. Comparison between needle biopsy and transurethral resection material showed that the overall coincidence of tumor classification (according to the predominant part of tumor) was only 50%. The authors conclude that tumor therapy should not predominantly be based on morphology present in a single needle biopsy.

[Management of intra-abdominal abscesses and space with pedicled omentoplasty]

The greater omentum is an organ of excellent absorption ability and or infect defence. Transposition at vascular pedicle is a simple and very useful procedure. According to our experience with 8 patients it is most suitable to fill hollow spaces for example in the liver (echinococcus cysts); it is also very useful for covering huge contaminated irradiation defects frequently occurring with pelvic exenteration.

Autoregulation in rats with transplanted supernumerary kidneys

Autoregulation of mammalian renal function is implicit in the fact that a few hours after removal of one kidney the activity of the intact nephrons in the other kidney suddenly increases, both in glomerular filtration and tubular reabsorption. There follows a slower but easily measured increase in renal mass-compensatory hypertrophy in each residual nephron. That response to a reduction of nephrons has been well studied, but the adaptation of normal renal function to additional nephrons could not be tested until microsurgical techniques made it possible to transplant one or two additional kidneys into normal rats. We report here sequential measurements of the total renal function of rats with three and four kidneys. Our results indicate that autoregulation maintains total renal function at normal levels in spite of a doubling in the number of nephrons and apparent renal mass.

[Phenacetin abuse IV. Are cytological urine studies successful and usable in the prevention of tumors in phenacetin abusers?]

971 samples of urine and washes of the urinary bladder in 643 patients were investigated cytologically. Urothelial carcinoma was present in 27 patients. In 11 cases the carcinoma was diagnosed by urinary cytology; 7 of the carcinomas were localized in the urinary bladder, 3 in the renal pelvis and 1 in the ureter. By contrast, all 19 tumors diagnosed in washes were localized in the urinary bladder. Diagnostic sensitivity was 100% in urine and about 75% in bladder washes. In 5 other patients cytologic diagnosis of carcinoma could not be confirmed by histology. In 4 of these, urothelial papillomas were present and in 1 patient a carcinoma of the bladder had been resected previously. Thus, the diagnostic accuracy of urinary cytology is good if essential methodological prerequisites are fulfilled. Therefore, urinary cytology appears to be an appropriate method for screening programmes in high risk patients such as phenacetin abusers. The estimated costs of a screening programme in Basel are 50 000-150 000 Swiss francs. However, a preliminary study to verify the value of such a screening programme is suggested.

[Phanacetin abuse III. Malignant urinary tract tumors in phenacetin abuse in Basle 1963-1977]

In 442 inhabitants of Basel 451 malignant tumors of the lower urinary tract were found at autopsy or biopsy from 1963 to 1977. 69/442 patients were abusers of phenacetin containing analgesics. Carcinomas and sarcomas of the lower urinary tract were nearly 13 times as frequent in abusers as in non-abusers. Carcinomas of the renal pelvis were 77 times, carcinomas of the ureter 89 times and those of the urinary bladder 7 times as frequent among abusers. The differences in incidence of malignant tumors are statistically highly significant for all localizations and for multiple carcinomas as well, even if smokers are excluded. "Phenacetin tumors" occurred in younger patients and were more common in women than in non-abusers. They were ofen, though not always, accompanied by analgesic nephropathy. Comparison with other etiological factors such as aromatic amines or thorotrast demonstrated that phenacetin abuse is of greatest importance. The significance of smoking cannot be established unequivocally. Because of the occurrence of a large number of malignant tumors in phenacetin abusers it is very important to prohibit by legislation the use of phenacetin or paracetamol containing analgesics without medical prescription. In addition, these drugs should be replaced by other analgesic compounds.