Fluorine-18-fluorodeoxyglucose positron emission tomography is useless for the detection of local recurrence after radical prostatectomy

OBJECTIVE

After radical retropubic prostatectomy a rise of the prostate-specific antigen (PSA) indicates a local recurrent or metastatic disease. If the bone scan shows no apparent bone metastasis, morphological imaging methods like x-ray computed tomography, magnetic resonance imaging or transrectal ultrasound often cannot distinguish between postoperative scar and local recurrence. Therefore we investigated the feasibility of fluorine-18-fluorodeoxyglucose positron emission tomography (F-18 FDG PET) for metabolic characterization of prostatic cancer, especially for differentiation of scar or recurrent prostate cancer after radical prostatectomy.

METHODS

Dynamic PET with 370 MBq F-18 deoxyglucose (F-18 FDG) up to 60 min p.i. was performed in 2 patients with biopsy-proven benign prostatic hyperplasia, in 11 patients with a histologically proven prostate cancer prior to radical retropubic prostatectomy (RRP) and 7 patients with suspected local recurrence (with negative bone scan) after RRP prior to biopsy of anastomosis (3 local recurrence, 4 postoperative scar).

RESULTS

Prostate cancer showed a very low F-18 FDG uptake. The placement of regions of interest was only possible by the use of other imaging methods. There was not difference between the F-18 FDG uptake of benign prostate hyperplasia, prostate carcinoma, postoperative scar or local recurrence after radical prostatectomy.

CONCLUSION

F-18 FDG seems not to be useful to distinguish between postoperative scar and local recurrence after radical prostatectomy.

Limited value of endorectal magnetic resonance imaging and transrectal ultrasonography in the staging of clinically localized prostate cancer

OBJECTIVE

To examine the role of endorectal magnetic resonance imaging (eMRI) and transrectal ultrasonography (TRUS) for clinically localized prostate cancer and to assess interobserver agreement in interpreting MRI studies.

PATIENTS AND METHODS

Fifty-four patients with biopsy-confirmed prostate cancer underwent TRUS and eMRI before radical retropubic prostatectomy. The MR images were prospectively interpreted by two radiologists with special expertise in this field. The criteria evaluated prospectively in each patient were extracapsular extension (ECE) and seminal vesicle invasion (SVI). The results were correlated with the histopathological findings after radical prostatectomy.

RESULTS

At pathology, 27 patients had stage pT2, 15 had stage pT3a and 12 had stage pT3b lesions. The overall accuracy of eMRI in defining local tumour stage was 93% by radiologist A and 56% by radiologist B; the overall accuracy by TRUS was 63%. There was a poor correlation for the MRI studies between observers. The eMRI was more sensitive than TRUS for detecting ECE and SVI in organ-confined prostate cancer. TRUS had a relatively high specificity for ECE and SVI, and was better than eMRI in this regard.

CONCLUSION

Whereas MRI tended to over-stage, TRUS under-staged prostate cancer. This series shows the current limited value of TRUS and eMRI for planning treatment in patients with clinically localized prostate cancer. Treatment decisions should not be altered based on TRUS or eMRI findings alone.

An updated evaluation of the carcinogenic potential of 1,4-dioxane

This paper presents a critical review of the information pertaining to the potential carcinogenicity of 1,4-dioxane. The primary target organs for cancer via the oral route are the liver and the nasal cavity, however, the relevance of nasal cavity tumors to human exposures has been questioned. Liver tumors were accompanied by degenerative changes and appear only to occur at high doses where clearance mechanisms are saturated and liver toxicity is significant. Genetic toxicity data suggests that 1,4-dioxane is a very weak genotoxin. An increase in hepatocyte cell proliferation was reported and 1,4-dioxane was shown to act as a tumor promoter in rat liver and mouse skin carcinogenicity assays. Two reports are available from the literature regarding physiologically based pharmacokinetic (PBPK) modeling approaches to assess the risk of liver cancer for 1,4-dioxane. A comparison of cancer risk estimates from linear and nonlinear models in the presence or absence of PBPK modeling suggests that USEPAs current cancer slope factor significantly overestimates the potential cancer risk from 1,4-dioxane. This critical review of the scientific literature indicates that a formal reevaluation of the carcinogenic potency of 1,4-dioxane is warranted.

Phosphatidylcholine-fatty acid membranes. I. Effects of protonation, salt concentration, temperature and chain-length on the colloidal and phase properties of mixed vesicles, bilayers and nonlamellar structures

The phase and colloidal properties of phosphatidylcholine/fatty acid (PC/FA) mixed vesicles have been investigated by optical methods, acid-base titration, and theoretically as a function of temperature (5-80 degrees C), molar lipid ratio (0-1), lipid chain length (C14-C18), headgroup ionization (1.5 less than or equal to pH less than or equal to 10), vesicle concentration (0.05-32 mumol vesicle.dm-3, and ionic strength (0.005 less than or equal to J less than or equal to 0.25). Increasing the fatty acid concentration in PC bilayers causes the phase transition temperatures (at 4 less than or equal to pH less than or equal to 5) to rise until, for more than 2 FA molecules per PC molecule, the sample turbidity exhibits only two transitions corresponding to the chain-melting of the 1:2 stoichiometric complexes of PC/FA, and pure fatty acid. The former transition is into a nonlamellar phase and is accompanied by extremely rapid vesicle aggregation (with association rates on the order of Ca approximately 10(7) dm3.mol-1.s-1) and massive lipid precipitation. Fluid-phase vesicles with less than 2 FA per PC associate much more slowly (Ca approximately 10(3) dm3.mol-1.s-1), their aggregation being comparable to that of the ordered-phase liposomes. Under no conditions was the relation between the fatty acid concentration and the vesicle association rate for the fluid-phase vesicles linear. In contrast to the X-ray diffraction data, optical measurements reveal a 'pretransitional region' between the chain-melting temperature of the PC component and the temperature at which the gross transformation into a nonlamellar phase sets in. This is seen for all lipid mixtures investigated. On the relative temperature scale, lipids with different chain lengths behave qualitatively similarly; however, the effective association constants determined for samples of constant lipid concentration seem to decrease somewhat with the number of CH2 groups per chain. Fatty acid protonation, which yields electrically neutral bilayers, invariably increases the rate of vesicle association; we have measured, for example, Ca approximately 10(2) at pH approximately 7 and Ca approximately 10(7) dm3.mol-1.s-1 at pH approximately 4). Protonation of the phosphatidylcholine phosphate groups, which causes a net positive charge to accumulate on the lipid vesicles, initially increases (Ca approximately 10(8) dm3.mol-1.s-1) but ultimately decreases (Ca approximately 10(7) dm3.mol-1.s-1) the rate of association between PC/FA (1:2) mixed vesicles.(ABSTRACT TRUNCATED AT 400 WORDS)

Clinical relevance of urokinase plasminogen activator, its receptor, and its inhibitor in patients with renal cell carcinoma

BACKGROUND

Urokinase plasminogen activator (u-PA) plays a key role in the metastatic process by promoting plasmin mediated tissue degradation. Metastatic cell invasion requires localized proteolysis, which may be directed by u-PA receptor. The binding of u-PA and PAI-1 to the u-PA-receptor may cause internalization of the trimeric complex into the cell and activate a tyrosine-kinase. In a prospective study the u-PA, u-PA-R, and PAI-1 content in patients with renal cell carcinoma (RCC) and benign renal tissue were correlated with traditional prognostic factors such as the TNM staging, histologic grading, ploidy, and the clinical outcome of the patients.

METHODS

One hundred fifty-two patients who underwent transperitoneal tumor nephrectomy for RCC were followed up for a mean of 23.9 months. u-PA, u-PA-R, and PAI-1 from the tumor tissue and corresponding benign renal tissue were quantified from detergent extracted tissue samples (1% Trinton-X-100 in triethanolamine-buffered saline) and measured with an enzyme-linked immunoadsorbent assay.

RESULTS

PAI-1 significantly correlated with the prevalence of distant metastasis (M0: 10.04 vs. M1 23.79, P=0.02) and the development of new metastasis postoperatively (M0: 10.85 vs. M1 27.36, P=0.001). A cut-off level of 12 ng/mg protein for PAI-1 selected a group of patients at high risk for relapse. Forty-one patients had PAI-1 > 12 ng/mg with 6 relapses compared with 55 patients with PAI-1 < 12 ng/mg with 1 relapse during the follow-up. Content of mu-PA correlated with the development of distant metastases (log rank 4.32, P=0.037). A cut-off value of 0.84 ng/mg selected 2 groups: a group at high risk for metastasizing (u-PA > 0.84, n=11 with 9 events and a group at low risk (u-PA < 0.84 with 94 patients and 5 events). Applying a cut-off value of 0.85 for u-PA-R 2 groups could be discriminated: 31 patients had no relapse with u-PA-R < 0.85 and 18 had 3 recurrences with u-PA-R > 0.85 g/ml.

CONCLUSIONS

u-PA, u-PA-R, and PAI-1 are strong and independent prognostic factors for predicting early relapse for RCC. Especially with PAI-1, a high and low risk group for disease free survival can be discriminated.

Significance of random bladder biopsies in superficial bladder cancer

OBJECTIVES

We investigated to what extent biopsies of normal-appearing urothelium taken from patients with superficial bladder cancer (Ta, T1, Tis) showed malignant disease and whether those findings had impact on therapeutical decisions.

PATIENTS AND METHODS

1033 consecutive patients presenting with Ta, T1 or Tis (carcinoma in situ) superficial bladder tumors at increased risk for recurrence underwent multiple random biopsies from normal-appearing urothelium during transurethral resection (TUR). Patients with small, primary, singular tumors (smaller or equal to 1cm) were excluded from random biopsies.

RESULTS

No tumor was found in the random biopsies of 905 patients (87.6%). 128 patients (12.4%) showed urothelial bladder cancer in their random biopsies (Tis: 74, Ta: 41, T1: 12, T2: 1). In 14 patients, where transurethral resection of the primary tumor revealed no signs of malignancy, urothelial bladder cancer was detected in the random biopsy material: Ta 8 patients, Tis 5 patients and T1 one patient. 21 patients with Ta tumors and 29 patients with T1 disease showed concomitant Tis. Upstaging of the primary, resected tumor by histological examination of the random biopsy material occurred in 75 patients (7%). Altogether, due to the random biopsy results therapy was altered in 70 patients (6.8%) of our series: It changed intravesical chemotherapy to BCG in 45, provoked a second TUR in 48 and cystectomy in 15 patients.

CONCLUSIONS

While the clinical significance of random biopsies is still controversial, random biopsy results had strong impact on therapeutical decisions in our series. Regarding random bladder biopsies a simple tool for the urologist to identify high risk groups of patients, we recommend them as part of the routine management of superficial bladder cancer.

Dysfunctional voiding in women: which muscles are responsible?

OBJECTIVE

To analyse the striated external urethral sphincter (EUS) and pelvic floor muscles using two different electromyography (EMG) techniques in women with dysfunctional voiding and/or urinary retention.

PATIENTS AND METHODS

Fifteen women (mean age 38.2 years, range 18-61) with dysfunctional voiding and/or unexplained voiding dysfunction associated with urinary retention were examined neurologically and urologically; urodynamics and kinesiological EMG of the bilateral pubococcygeal and external urethral striated sphincter muscles were obtained. In an additional neurophysiological session, concentric-needle EMG of the external urethral sphincter was performed.

RESULTS

Kinesiological EMG recordings revealed inappropriate pelvic floor muscle activation during voiding in 11 and EUS activation in four women. Concentric needle EMG of the EUS revealed complex repetitive discharges in the four women with inappropriate urethral sphincter activation recorded by kinesiological EMG during voiding. Biofeedback training led to improvement in women with inappropriate pubococcygeal activation but not in those with urethral sphincter complex repetitive discharges.

CONCLUSION

Urodynamic examinations in combination with kinesiological EMG examination of the pubococcygeal and external urethral sphincter muscles revealed two groups of women with dysfunctional voiding. Further diagnostic evaluation of such patients with concentric-needle EMG is mandatory. The differentiation of the two groups is therapeutically relevant.

No association of converting enzyme insertion/deletion polymorphism with immunoglobulin A glomerulonephritis

It has been recently reported that in type 1 diabetes the insertion/deletion (I/D) polymorphism of the angiotensin I-converting enzyme gene is associated with the presence of diabetic nephropathy. Tissue angiotensin I-converting enzyme is determined by I/D polymorphism, and it has been speculated that in diabetes differences of local angiotensin II availability determine the risk of renal disease. Since angiotensin II is thought to play an important role in the evolution of renal disease in general, we tested whether genotype distribution of the I/D polymorphism is also different in patients with immunoglobulin A-glomerulonephritis (IgA-GN). Furthermore we compared IgA-GN patients with (1) stable renal function or (2) terminal renal failure to investigate a potential role of the I/D polymorphism in the renal prognosis. We examined 122 patients with biopsy-confirmed IgA-GN who had stable renal function and 82 dialysis-dependent or transplanted patients with biopsy-confirmed IgA-GN. Furthermore, in 134 healthy individuals used as controls we analyzed the DNA for normal distribution of genotypes and allele frequencies. The polymorphic region was amplified using polymerase chain reaction with specific primers. Alleles were detected on 2% agarose gels. Genotype distributions and allele frequencies were not significantly different between controls and patients with IgA-GN and stable renal function. Furthermore, no significant difference in genotype distribution was detected between patients with IgA-GN and stable renal function compared with patients with IgA-GN and end-stage renal failure, although a trend for a higher frequency of DD-homozygotes was noted in the latter group (P = 0.07).(ABSTRACT TRUNCATED AT 250 WORDS)

Improved urinary continence after radical retropubic prostatectomy with preparation of a long, partially intraprostatic portion of the membraneous urethra: an analysis of 1013 consecutive cases

PURPOSE

To improve the rate of full continence in our patients, we performed, since June 1997, a careful preparation of the distally intraprostatic part of the membranous urethra to obtain a long urethral stump for the vesicourethral anastomosis.

PATIENTS AND METHODS

In all, 610 patients without (group 1) and 403 patients with (group 2) a long intraprostatic stump of the urethra were asked by a self-administered questionnaire about their continence status. The rate of positive surgical margins were compared as a marker of local tumour control.

RESULTS

Full continence (no pads) was achieved in 76.02% in group 1 and in 88.84%, of all patients in group 2. Stress incontinence (SIC) I degrees was found in 12.46% and 7.44% respectively, SIC II degrees was noted in 8.69 and 3.72% and complete incontinence was seen in 2.79% in group 1 and in two patients (0.5%) in group 2. Also the time to reach the final continence status was statistically and highly significantly (P<0.001) shortened. The rate of positive margins decreased in group 2, despite intraprostatic preparation.

CONCLUSIONS

The preparation of a long, partially intraprostatic portion of the membranous urethra for vesicourethral anastomosis in radical retropubic prostatectomy leads to a statistically highly significant improvement of full continence and earlier continence in prostate cancer patients without compromising local tumour control.

Diagnosis and monitoring of urological tumors using positron emission tomography

The purpose of this article was to critically review the diagnostic value of positron emission tomography (PET) in urological oncology. Urinary tract tumor assessment is hampered by the renal elimination of (18)F-fluorodeoxyglucose (FDG), the most commonly used PET radiopharmaceutical. PET imaging offers no significant benefits over conventional imaging modalities for renal cell and bladder carcinomas. As a result of the low metabolic activity of prostate cancer, PET does not differentiate adequately between adenoma and carcinoma, nor detect local recurrence after radical prostatectomy with sufficient sensitivity. However, lymph node staging with FDG-PET, specifically in bladder cancer, has been shown to have a potential clinical benefit. Further studies are required to determine the clinical value of retroperitoneal lymph node staging and recurrent disease detection in germ cell tumors. Finally, encouraging early results exist for the use of serial PET measurements to predict and assess therapy response to chemotherapy which may also be valuable in urological oncology.

Novel methods for the estimation of acceptable daily intake

This paper describes two general methods for estimating ADIs that circumvent some of the limitations inherent in current approaches. The first method is based on a graphic presentation of toxicity data and is also shown to be useful for estimating acceptable intakes for durations of toxicant exposure other than the entire lifetime. The second method uses dose-response or dose-effect data to calculate lower CLs on the dose rate associated with specified response or effect levels. These approaches should lead to firmer, better established ADIs through increased use of the entire spectrum of toxicity data.

First clinical experience with a Q-switched neodymium:YAG laser for urinary calculi

Animal studies using a high intensity nanosecond pulsed neodymium:YAG laser did not reveal any serious tissue damage. Following these investigations patient treatment was begun in June 1987. Laser energy of a neodymium:YAG laser with an 8 nsec. pulse duration and a repetition rate of up to 50 Hz. was coupled into a flexible 600 resp. 400 micron. quartz fiber. Laser-induced breakdown was created with 35 to 50 mJ. at the fiber tip, resulting in a shock wave that disintegrated the calculus into tiny fragments. A total of 56 patients with 58 calculi (54 ureteral and 4 kidney stones) was treated from June 1987 to March 1988. Of the calculi 48 could be fragmented completely, while 6 others were reduced to a size small enough to be removed with forceps. Four stones composed of calcium oxalate monohydrate could not be disintegrated. The combination of laser stone disintegration with flexible ureterorenoscopy implies the possibility of an atraumatic, 1-step procedure for fragmentation of ureteral and kidney calculi.

Priming of NADPH oxidase by tumor necrosis factor alpha in patients with inflammatory and autoimmune rheumatic diseases

Oxidative damage caused by oxygen free radicals from activated phagocytes contributes to the pathology of arthritis. The present study evaluates the activity of NADPH oxidase of neutrophils and monocytes from patients suffering from various inflammatory and autoimmune rheumatic disease. Production rates of reactive oxygen species [ROS] of neutrophils and monocytes from rheumatic patients are compared to those of healthy controls and non rheumatic disease controls and correlated with the plasma levels of tumor necrosis factor alpha, C-reactive protein and the sedimentation rates of erythrocytes. There was a two- to eightfold increase in phagocytic superoxide production in rheumatic patients, when compared to healthy subjects or patients with non-rheumatic internal diseases [p < 0.005]. The enhanced NADPH oxidase-dependent superoxide generation correlated well with elevated levels of tumor necrosis factor alpha [TNF-alpha] in plasma [p = 0.005], suggesting a causal relation. There was no correlation with the plasma levels of C-reactive protein and a weak though significant correlation with the sedimentation rates of erythrocytes [p = 0.043]. Removal of circulating TNF-alpha by dialysis of patients blood and inhibition of NADPH oxidase by prednisolone treatment normalized elevated ROS production to the levels of healthy controls and correlated with the clinical improvements. Our data support the hypothesis of a central role for TNF-alpha during the development of arthritis. The chemiluminescence assay described here may be useful as a convenient screen and as a potential follow up procedure for individual patients with rheumatic diseases.

Prostate-specific antigen in urine

We investigated concentrations of prostate-specific antigen (PSA) in mid-stream urine of 213 patients. Among them were 34 females. Diagnoses of the male patients were 42 benign prostatic hypertrophy (BPH), 21 localized prostate cancer prior to radical prostatectomy (RP), 15 post-RP without distant or local recurrence, 5 post-RP with local recurrence and 82 with other urological diseases. PSA levels were determined by the Hybritech Tandem E method. Female urine samples were positive in 38% of the cases. This and the finding of PSA in urine of men after RP is most likely due to extraprostatic production by periurethral glands. Urinary PSA levels do not differ between patients with BPH, organ-confined prostate cancer and other diagnoses. In some cases, however, urine PSA levels can be elevated in men with local tumor recurrence after RP when serum levels are still undetectably low. This indicates that the determination of urinary PSA concentration might be useful in the follow-up of patients after RP.

Schwann cell seeded guidance tubes restore erectile function after ablation of cavernous nerves in rats

PURPOSE

Dissection of the cavernous nerves eliminates spontaneous erections. We evaluated the ability of Schwann cell seeded nerve guidance tubes to restore erections after bilateral cavernous nerve resection in rats.

MATERIALS AND METHODS

Sections (5 mm) of the cavernous nerve were excised bilaterally, followed by immediate bilateral microsurgical reconstruction. In 10 animals per group (20 study nerves) reconstruction was performed by genitofemoral nerve interposition, interposition of silicone tubes or interposition of silicone tubes seeded with homologous Schwann cells. As the control 10 animals (20 study nerves) underwent sham operation (positive control) and bilateral nerve ablation (without reconstruction) was performed in a further 10 (negative control). Erectile function was evaluated 3 months postoperatively by relaparotomy, electrical nerve stimulation and intracavernous pressure recording.

RESULTS

After 3 months neurostimulation resulted in an intact erectile response in 90% (18 of 20) of Schwann cell grafts, while treatment with autologous nerves (30% or 6 of 20) or tubes only (50% or 10 of 20) was less successful (p <0.01). Whereas untreated ablated rats showed no inducible erections (0% or 0 of 20), all sham operated animals had an intact erectile response (100% or 20 of 20). Maximum intracavernous pressure upon electrostimulation was significantly elevated using Schwann cell grafts compared to results in the other treatment groups (p <0.001). Morphological evaluation revealed advanced regeneration within Schwann cell grafts.

CONCLUSIONS

Schwann cell seeded guidance tubes restore erectile function after the ablation of cavernous nerves in rats and they are superior to autologous nerve grafts.

The ability of the American Joint Committee on Cancer Staging system to predict progression-free survival after radical prostatectomy

OBJECTIVE

To examine, in a retrospective analysis of outcome based on prostate-specific antigen (PSA) levels, whether the 1992 and revised 1997 staging criteria for prostate cancer can be used to predict progression-free survival for patients after radical prostatectomy for pT2 and pT3 prostate cancer.

PATIENTS AND METHODS

In all, 291 patients with a PSA determination during a 6-month interval after radical prostatectomy were analysed (mean follow-up 5.2 years). In the absence of a uniform system of pathological staging, the histopathological stage was defined according to the 1992 and 1997 American Joint Cancer Committee/Union Internationale Contre le Cancer (AJCC/UICC) tumour-nodes-metastases (TNM) staging classification. Findings were correlated with the PSA value after surgery. The subgroups of pT2 and pT3 disease were compared for the time to PSA progression, using Kaplan-Meier data analysis and the log-rank test.

RESULTS

The biochemical progression-free 5-year survival rates for stage pT2 were 83% (pT2a), 81% (pT2b) and 62% (pT2c); there were no significant differences in the pT2 subgroups. The recurrence-free rates for pT3 were 79% (pT3a), 65% (pT3b) and 50% (pT3c); the actuarial recurrence-free rate was significantly different for patients with 1997 AJCC pT3a vs pT3b disease (P=0.0132). There was no significant difference in the 1992 AJCC stages pT2a vs pT2b (P=0.1232) and the recurrence-free rate was not significantly different for patients with 1992 AJCC pT3a vs pT3b disease (P=0.9). There was a significant difference in the likelihood of a PSA relapse between patients with positive and negative surgical margins (P=0.131).

CONCLUSION

These results support the current revised 1997 AJCC/UICC staging system for prostate cancer. There is an urgent need to develop a pathological equivalent to the AJCC/UIC TNM clinical staging system. Greater clinical input and evaluation from different institutions are essential to reach consensus on pathological staging categories that maximize the predictability of outcome after definitive therapy. Crucial issues are the definition and quantification of extraprostatic extension and definition of surgical margin categories.

New ultradeformable drug carriers for potential transdermal application of interleukin-2 and interferon-alpha: theoretic and practical aspects

Transfersomes (TFs) are highly deformable hydrophilic lipid vesicles that are able to penetrate the skin barrier spontaneously because of their characteristics. Transfersomes are able to transport noninvasively low- and high-molecular-weight molecules into the body. We describe the formulation and several biologic characteristics of interleukin-2 (IL-2)- and interferon-alpha (IFNalpha )-containing TFs. TFs contain natural phosphatidylcholine and sodium cholate. Recombinant human IL-2 and human hybrid IFNalpha were added to TFs and incubated for 24 hours at 4 degrees C. Immunotransfersomes were isolated from free IL-2 and IFNalpha by filtration (Centrisart, Sartorius). The biologic activity of immunotransfersomes was measured by a cytotoxic lymphoid line assay for IL-2 and by an A549-encephalomyocarditis virus assay for IFN; concentrations of proteins were determined by the enzyme-linked immunosorbent assay (ELISA). It was possible to incorporate a large amount of IL-2 and IFN in TFs (75-80%), and the incorporated IL-2, and IFN were biologically active. The increased lipid/protein ratio (90.9/1.0) led to a growing probability of association. We were thus able to show that IL-2 and IFN are trapped by transfersomes in a biologically active form and in sufficient concentrations for immunotherapy. In upcoming experiments these IL-2- and IFN-containing TFs will be used for a transdermal approach in the murine RENCA cell line model.

Subcutaneous heparin injection in the upper arm as a method of avoiding lymphoceles after lymphadenectomies in the lower part of the body

The authors have measured the concentration of biologically active heparin in the drainage fluid after ilioinguinal, pelvic and retroperitoneal lymphadenectomy. After s.c. heparin administration in the thighs high levels of heparin were found in the drainage fluid of all patients (up to 0.89 IU/ml). After s.c. heparin application in the upper arms, no measurable concentrations of heparin were detected. Lymph loss in these patients was considerably lower. According to this experience, subcutaneous application of heparin into the upper arms is to be recommended in patients who undergo lymphatic surgery of the lower part of the body.

Incidence and outcome of patients with adrenal metastases of renal cell cancer

OBJECTIVES

To evaluate the outcome of patients with adrenal metastasis in renal tumors to establish the oncologic necessity of adrenalectomy in these patients. Radical nephrectomy for renal cell cancer includes simultaneous ipsilateral adrenalectomy. Recent reports suggest that adrenal involvement in renal cell cancer is rare and can be predicted by computed tomography or distinct algorithms.

METHODS

In a retrospective analysis of 866 consecutive patients who underwent nephrectomy and adrenalectomy, we established the rate of adrenal metastasis and obtained follow-up information to evaluate disease outcome.

RESULTS

We calculated an adrenal metastasis rate of 3.1% (n = 27); of these 27 patients, only 6 (0.7% of all patients) presented with a solitary adrenal metastasis. Kaplan-Meier analysis demonstrated that patients with solitary adrenal and multiple metastases have a poor outcome. The median survival of patients with localized renal cancer was 43.9 months compared with 21.3 months for patients with a solitary adrenal metastasis and 11.0 months for patients with multiple metastases.

CONCLUSIONS

Ipsilateral, solitary, and synchronous metastases in renal cell cancer are rare and patients have a poor outcome despite surgical resection. Therefore, simultaneous adrenalectomy can be omitted during radical nephrectomy if the preoperative examinations or algorithms used do not predict adrenal metastasis in the patient with renal cell cancer.

Depression among aging persons with schizophrenia who live in the community

OBJECTIVES

The study used the social antecedent model of depression in later life proposed by Linda K. George to develop a multifactorial model of predictors of depression among aging persons with schizophrenia living in the community.

METHODS

The SHORT-CARE and the Network Analysis Profile, along with supplemental items, were administered to 117 outpatients age 55 and older who received DSM-III-R diagnoses of schizophrenia before age 45. Bivariate and multivariate analyses examined associations between 27 variables derived from George's model and the presence of depression. A cutoff score for the depression scale of the SHORT-CARE was used to detect clinically significant depression.

RESULTS

Forty-four percent of the sample had probable pervasive depression. Bivariate analysis indicated that 16 variables were significantly associated with depression, and logistic regression showed that six variables were strong predictors. Depression was associated with the presence of positive symptoms, physical limitations interfering with activities, younger age, diminished linkage of members of the social network, lower income, and a smaller proportion of social network members who provided sustenance such as food and money. An 11-variable model correctly classified 81 percent of cases.

CONCLUSIONS

The level of depression among older outpatients with schizophrenia is approximately one and a half to three times the level in the general older population. Depression in this patient group is associated with nonclinical variables that are independent of psychoses and that resemble patterns found among general older populations. Several of the variables are potentially alterable and therefore afford opportunities to enhance the well-being of persons with schizophrenia who live in the community.

Laser induced shock wave lithotripsy--biologic effects of nanosecond pulses

Laser energy of a Nd-YAG laser (1064 nm. wave length, 8 nsec pulse duration) was directed against various tissue cultures and the urothelium of the ureter, bladder and kidney parenchyma in pigs. Single pulse energy was 50 to 120 mJ with a repetition rate of 20 Hz. Urothelium and kidney parenchyma were irradiated in seven pigs. Tissue samples were examined histologically and electron microscopically directly, two, four, eight and 12 days after irradiation. No macroscopic lesion could be found. Maximum energy caused a small 'rupture cone' of 40 micron. depth. No thermic effects or necrosis resulted, so that no harm is to be expected with unintentional irradiation during laser stone disintegration.

Angiotensin II enhances insulin sensitivity in healthy volunteers under euglycemic conditions

OBJECTIVE

It has been postulated that vasoconstrictors cause insulin resistance. This effect has been documented for epinephrine but not for angiotensin II (Ang II). The aim of this study was to investigate the effect of the latter on insulin sensitivity.

DESIGN

In order to study the influence of subpressor doses of Ang II on insulin-mediated glucose uptake under euglycemic conditions, eight healthy volunteers were allocated in random order to sham infusion or infusion of Ang II (first 0.75 ng/kg per min and subsequently 1.5 ng/kg per min). In addition, in seven of the subjects Ang II was infused after 3 days of indomethacin pretreatment (150 mg/day).

METHODS

Insulin-mediated glucose uptake (expressed as M value) was measured with the euglycemic clamp technique. Insulin levels were measured enzymatically, plasma renin activity, Ang II, aldosterone and C-peptide levels by radioimmunoassay, blood pressure by Dinamap and muscle blood flow by plethysmography.

RESULTS

The M value after sham infusion was 7.81 +/- 1.52 mg/kg per min and after 1.5 ng/kg Ang II per min was 9.76 +/- 1.26 mg/kg per min (P < 0.001). Indomethacin pretreatment did not abolish the Ang II-induced rise in the M value. Mean arterial blood pressure during the euglycemic clamp was unchanged with sham infusion and the low dose of Ang II. It increased slightly with the higher dose of Ang II. Inferior limb muscle perfusion was higher after infusion of Ang II than after sham infusion; this effect was not obliterated by indomethacin pretreatment.

CONCLUSIONS

Ang II increases insulin-mediated glucose uptake: that is, it enhances insulin sensitivity by mechanisms independent of prostaglandins. The observations are of potential relevance to the changes in insulin sensitivity in some forms of hypertension.