POS0135 REDUCING IMMUNOGENICITY OF PEGLOTICASE (RECIPE) WITH CONCOMITANT USE OF MYCOPHENOLATE MOFETIL IN PATIENTS WITH REFRACTORY GOUT: A PHASE II RANDOMIZED CONTROLLED TRIAL

Background:

Pegloticase is a recombinant, pegylated uricase, used for treatment of gout patients who fail oral urate lowering therapy (ULT). Its use has been limited due to immunogenicity leading to infusion reactions.1

Objectives:

We evaluated if co-administration of an immunomodulatory agent could prolong the efficacy of pegloticase.

Methods:

Participants were recruited in a Phase II, double-blind, placebo-controlled trial over 18 months and randomized in a 3:1 ratio by site. Inclusion criteria were: a) Age ≥ 18 years who met 2015 ACR/EULAR gout classification criteria and b) chronic refractory gout defined as symptoms inadequately controlled with ULT or contraindications. After a 2-week run-in of mycophenolate mofetil (MMF) 1000 mg twice daily or matching placebo (PBO), they received a combination of pegloticase 8 mg biweekly with MMF or PBO for 12 weeks. Subsequent to this MMF or PBO were discontinued but pegloticase was continued for another 12 weeks. The primary endpoint was proportion of patients who sustained a serum urate (SU) level of ≤ 6 mg/dl at 12 weeks. Secondary endpoints included 24-week durability of SU ≤ 6 mg/dl and rate of adverse events (AEs). Fisher’s exact test and Wilcoxon two-sample test were used for analyses along with Kaplan-Meier estimates and log-rank tests to compare survival curves between groups. Hypothesis tests were two-tailed and p-value (p) < 0.05 indicated statistical significance.

Results:

Of 42 subjects screened, 35 were randomized, and 32 who received at least one dose of pegloticase were included in modified intention to treat analyses. Subjects were predominantly men (88%), mean age of 55.2 years (SD=9.7). Mean duration of gout was 13.4 years (SD=9.0), mean baseline sUA was 9.2 mg/dL (SD=1.6). Tophi were present in 88% and majority were on optimized ULT - 59% on allopurinol and 16% on febuxostat, with 63% reporting > 1 flare in the past year. At baseline both arms (MMF vs. PBO) had similar comorbidities – (82% vs 70%), diabetes mellitus/metabolic syndrome (14% vs 20%), coronary artery disease/peripheral vascular disease (41% vs.70%), BMI>30 (86% vs. 90%) and renal insufficiency (defined as eGFR < 90 mL/min; 73% vs. 70%). At 12 weeks, 19 of 22 (86%) in the MMF arm achieved SU ≤ 6 mg/dl compared to 4 of 10 (40%) in PBO arm (p-value = 0.01). At 24 weeks, the SU was ≤ 6 mg/dl in 68% of MMF arm vs. 30% in PBO (p-value = 0.06), and rates of AEs per month were similar between groups with the PBO arm having more infusion reactions (30% vs. 0%). The MMF arm had higher AEs compared to placebo: musculoskeletal (41% vs. 10%), gastrointestinal (18% vs. 10%), and infections (9% vs. 0%). Figure 1 shows that the percentage of subjects maintaining a sUA < 6 mg/dL at 12 weeks was significantly higher (p=0.02) in the MMF arm, and a significant difference (p=0.03) at 24 weeks indicates sustained benefit from MMF.

Conclusion:

To our knowledge this is the first randomized-controlled proof of concept trial to demonstrate the ability of an immunomodulatory agent in prolonging the efficacy of pegloticase. Short-term concomitant use of MMF therapy with pegloticase was well tolerated and showed a clinically meaningful improvement in the targeted SU ≤6 mg/dL at 12 and 24 weeks. This study suggests an innovative approach to utilize pegloticase therapy in patients with chronic gout.

References:

[1]Sundy et al. Efficacy and tolerability of pegloticase for the treatment of chronic gout in patients refractory to conventional treatment: two randomized controlled trials. JAMA. 2011;306(7):711-20.

Figure 1.

Proportion of subjects maintaining serum urate (SU) ≤ 6 mg/dL over 24 week study period in mycophenolate mofetil + pegloticase vs. placebo + pegloticase

Disclosure of Interests:

Puja Khanna Consultant of: Horizon Pharmaceuticals, Swedish Orphan Biovitrum A, Grant/research support from: Selecta, 2)DYVE, Dinesh Khanna Consultant of: Horizon Pharmaceuticals, Gary Cutter: None declared, Jeff Foster: None declared, Josh Melnick: None declared, Sara Jaafar: None declared, Stephanie Biggers: None declared, Fazlur Rahman: None declared, Hui-Chen Kuo: None declared, Michelle Feese: None declared, Kenneth Saag Consultant of: AbbVie, Inc., Bayer, Daiichi Sankyo Company LTD, Gilead Services, Inc., Horizon Pharma plc, Mallinkrodt, Radius Health, Inc., Roche/Genentech, Shanton Pharma Co., LTD, Teijin, Dyve Bioscience, LG Chem, Regeneron Pharmaceuticals., Swedish Orphan Biovitrum AB, Takeda Pharmaceuticals America, Inc.,

Safety and tolerability of transcranial magnetic and direct current stimulation in children: Prospective single center evidence from 3.5 million stimulations

BACKGROUND

Non-invasive brain stimulation is being increasingly used to interrogate neurophysiology and modulate brain function. Despite the high scientific and therapeutic potential of non-invasive brain stimulation, experience in the developing brain has been limited.

OBJECTIVE

To determine the safety and tolerability of non-invasive neurostimulation in children across diverse modalities of stimulation and pediatric populations.

METHODS

A non-invasive brain stimulation program was established in 2008 at our pediatric, academic institution. Multi-disciplinary neurophysiological studies included single- and paired-pulse Transcranial Magnetic Stimulation (TMS) methods. Motor mapping employed robotic TMS. Interventional trials included repetitive TMS (rTMS) and transcranial direct current stimulation (tDCS). Standardized safety and tolerability measures were completed prospectively by all participants.

RESULTS

Over 10 years, 384 children underwent brain stimulation (median 13 years, range 0.8-18.0). Populations included typical development (n = 118), perinatal stroke/cerebral palsy (n = 101), mild traumatic brain injury (n = 121) neuropsychiatric disorders (n = 37), and other (n = 7). No serious adverse events occurred. Drop-outs were rare (<1%). No seizures were reported despite >100 participants having brain injuries and/or epilepsy. Tolerability between single and paired-pulse TMS (542340 stimulations) and rTMS (3.0 million stimulations) was comparable and favourable. TMS-related headache was more common in perinatal stroke (40%) than healthy participants (13%) but was mild and self-limiting. Tolerability improved over time with side-effect frequency decreasing by >50%. Robotic TMS motor mapping was well-tolerated though neck pain was more common than with manual TMS (33% vs 3%). Across 612 tDCS sessions including 92 children, tolerability was favourable with mild itching/tingling reported in 37%.

CONCLUSIONS

Standard non-invasive brain stimulation paradigms are safe and well-tolerated in children and should be considered minimal risk. Advancement of applications in the developing brain are warranted. A new and improved pediatric NIBS safety and tolerability form is included.

Improved carrier injection in GaN-based VCSEL via AlGaN/GaN multiple quantum barrier electron blocking layer

In this report, the improved lasing performance of the III-nitride based vertical-cavity surface-emitting laser (VCSEL) has been demonstrated by replacing the bulk AlGaN electron blocking layer (EBL) in the conventional VCSEL structure with an AlGaN/GaN multiple quantum barrier (MQB) EBL. The output power can be enhanced up to three times from 0.3 mW to 0.9 mW. In addition, the threshold current density of the fabricated device with the MQB-EBL was reduced from 12 kA/cm2 (9.5 mA) to 10.6 kA/cm2 (8.5 mA) compared with the use of the bulk AlGaN EBL. Theoretical calculation results suggest that the improved carrier injection efficiency can be mainly attributed to the partial release of the strain and the effect of quantum interference by using the MQB structure, hence increasing the effective barrier height of the conduction band.

Maternal citrulline supplementation prevents prenatal dexamethasone-induced programmed hypertension

Glucocorticoids are administered to premature infants to accelerate pulmonary maturation. In experimental model, prenatal dexamethasone (DEX) results in reduced nephron number and adulthood hypertension. Asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase (NOS), can cause oxidative stress and is involved in the development of hypertension. L-citrulline can be converted to l-arginine (the substrate for NOS) in the body. Thus we intended to determine if maternal L-citrulline therapy can prevent prenatal DEX-induced programmed hypertension by restoration ADMA/nitric oxide (NO) balance, alterations of renin-angiotensin system (RAS) and sodium transporters, and epigenetic regulation by histone deacetylases (HDACs). Male offspring were assigned to four groups: control, pregnancy rats received intraperitoneal DEX (0.2 mg/kg body weight) daily on gestational days 15 and 16 (DEX), pregnancy rats received 0.25% L-citrulline in drinking water during the entire pregnancy and lactation period (CIT), and DEX + CIT. We found DEX group developed hypertension at 16 weeks of age, which was prevented by maternal L-citrulline therapy. Prenatal DEX exposure increased plasma ADMA concentrations and reduced renal NO production. However, L-citrulline reduced plasma ADMA level and increased renal level of NO in DEX + CIT group. Next, prenatal DEX-induced programmed hypertension is related to increased mRNA expression of angiotensin and angiotensin II type 1 receptor, and class I HDACs in the kidney. Prenatal DEX exposure increased renal protein abundance of Na(+)/Cl(-) cotransporter (NCC), which was prevented by L-citrulline therapy. The beneficial effects of L-citrulline therapy include restoration of ADMA/NO balance and alteration of NCC, to prevent the prenatal DEX-induced programmed hypertension.

Waveguide based energy transfer with gold nanoclusters for detection of hydrogen peroxide

Detection of hydrogen peroxide by using fluorescence resonance energy transfer from InGaN quantum wells to Au nanoclusters via optical waveguiding has been demonstrated. This technique provides a new strategy for the visual detection of H₂O₂ with large-area analysis.

Distance dependence of energy transfer from InGaN quantum wells to graphene oxide

We report the distance-dependent energy transfer from an InGaN quantum well to graphene oxide (GO) by time-resolved photoluminescence (PL). A pronounced shortening of the PL decay time in the InGaN quantum well was observed when interacting with GO. The nature of the energy-transfer process has been analyzed, and we find the energy-transfer efficiency depends on the 1/d² separation distance, which is dominated by the layer-to-layer dipole coupling.

Optical coupling from InGaAs subcell to InGaP subcell in InGaP/InGaAs/Ge multi-junction solar cells

Spatially-resolved electroluminescence (EL) images in the triple-junction InGaP/InGaAs/Ge solar cell have been investigated to demonstrate the subcell coupling effect. Upon irradiating the infrared light with an energy below bandgap of the active layer in the top subcell, but above that in the middle subcell, the EL of the top subcell quenches. By analysis of EL intensity as a function of irradiation level, it is found that the coupled p-n junction structure and the photovoltaic effect are responsible for the observed EL quenching. With optical coupling and photoswitching effects in the multi-junction diode, a concept of infrared image sensors is proposed.

Acute disseminated encephalomyelitis that meets modified McDonald criteria for dissemination in space is associated with a high probability of conversion to multiple sclerosis in Taiwanese patients

BACKGROUND

Patients with acute disseminated encephalomyelitis (ADEM) may relapse and some may ultimately convert to multiple sclerosis (MS); however, no criteria that can predict MS conversion are available to date. Our aim was to describe the clinical and magnetic resonance imaging (MRI) features of patients with an initial ADEM attack and evaluate which MRI criteria can predict conversion to MS.

METHODS

We retrospectively reviewed the records of 36 patients diagnosed with ADEM. We determined clinical signs/symptoms, examined the cerebrospinal fluid (CSF), and performed brain MRI scans and compared the findings between patients who did and did not convert to MS.

RESULTS

Clinical signs/symptoms, and CSF analysis show no significant difference between the two groups. The rate of conversion to MS from ADEM in Taiwanese patients is low (11%) after a mean follow-up period of 28.36 months. Modified McDonald criteria were fulfilled in 19/36 patients: 21% (4/19) of those patients developed MS according to Poser criteria subsequently. Of the other patients (17/36) who did not fulfill these criteria, none converted to MS. (log rank test; P=0.027).

CONCLUSIONS

It is difficult to predict from initial clinical presentations to address which patients with ADEM will convert to MS. Patients with ADEM whose brain MRI findings met the modified McDonald criteria may have clinically isolated syndrome because they have a significantly higher probability of conversion to MS. In contrast, patients whose brain MRI findings did not meeting these criteria may be considered as having classic ADEM because they have a lower probability of conversion to MS.

Energy transfer from InGaN quantum wells to Au nanoclusters via optical waveguiding

We present the first observation of resonance energy transfer from InGaN quantum wells to Au nanoclusters via optical waveguiding. Steady-state and time-resolved photoluminescence measurements provide conclusive evidence of resonance energy transfer and obtain an optimum transfer efficiency of ~72%. A set of rate equations is successfully used to model the kinetics of resonance energy transfer.

Light extraction efficiency enhancement of GaN-based light emitting diodes on n-GaN layer using a SiO2 photonic quasi-crystal overgrowth

In this paper, GaN-based LEDs with a SiO2 photonic quasi-crystal (PQC) pattern on an n-GaN layer by nano-imprint lithography (NIL) are fabricated and investigated. At a driving current of 20 mA on Transistor Outline (TO)-can package, the better light output power of LED III (d = 1.2 microm) was enhanced by a factor of 1.20. After 1000 h life test (55 degrees C/50 mA) condition, Normalized output power of LED with a SiO2 PQC pattern (LED III (d = 1.2 microm)) on an n-GaN layer only decreased by 5%. This results offer promising potential to enhance the light output power of commercial light-emitting devices using the technique of nano-imprint lithography.

Oblique electron-beam evaporation of distinctive indium-tin-oxide nanorods for enhanced light extraction from InGaN/GaN light emitting diodes

This paper presents a novel and mass-producible technique to fabricate indium-tin-oxide (ITO) nanorods which serve as an omnidirectional transparent conductive layer (TCL) for InGaN/GaN light emitting diodes (LEDs). The characteristic nanorods, prepared by oblique electron-beam evaporation in a nitrogen ambient, demonstrate high optical transmittance (T>90%) for the wavelength range of 450nm to 900nm. The light output power of a packaged InGaN/GaN LED with the incorporated nanorod layer is increased by 35.1% at an injection current of 350mA, compared to that of a conventional LED. Calculations based on a finite difference time domain (FDTD) method suggest that the extraction enhancement factor can be further improved by increasing the thickness of the nanorod layer, indicating great potential to enhance the luminous intensity of solid-state lighting devices using ITO nanorod structures.

Broadband and omnidirectional antireflection employing disordered GaN nanopillars

Disordered GaN nanopillars of three different heights: 300, 550, and 720 nm are fabricated, and demonstrate broad angular and spectral antireflective characteristics, up to an incident angle of 60? and for the wavelength range of lambda=300-1800 nm. An algorithm based on a rigorous coupled-wave analysis (RCWA) method is developed to investigate the correlations between the reflective characteristics and the structural properties of the nanopillars. The broadband and omnidirectional antireflection arises mainly from the refractive-index gradient provided by nanopillars. Calculations show excellent agreement with the measured reflectivities for both s- and p- polarizations.

Enhanced light output from a nitride-based power chip of green light-emitting diodes with nano-rough surface using nanoimprint lithography

Enhanced light extraction from a GaN-based power chip (PC) of green light-emitting diodes (LEDs) with a rough p-GaN surface using nanoimprint lithography is presented. At a driving current of 350 mA and with a chip size of 1 mm × 1 mm packaged on transistor outline (TO)-cans, the light output power of the green PC LEDs with nano-rough p-GaN surface is enhanced by 48% when compared with the same device without a rough p-GaN surface. In addition, by examining the radiation patterns, the green PC LED with nano-rough p-GaN surface shows stronger light extraction with a wider view angle. These results offer promising potential to enhance the light output powers of commercial light-emitting devices by using the technique of nanoimprint lithography under suitable nanopattern design.

Optically modulated internal strain in InGaN quantum dots grown on SiN(x) nano masks

Optically modulated internal strain has been observed in InGaN quantum dots (QDs) deposited on SiN(x) nano masks. The modulated internal strain can induce a number of intriguing effects, including the change of refractive index and the redshift of InGaN A(1)(LO) phonon. The underlying mechanism can be well accounted for in terms of the variation of internal strain through the converse piezoelectric effect arising from the screening of the internal electric field due to spatial separation of photoexcited electrons and holes. Our results point out a convenient way for the fine tuning of physical properties in nitride-based semiconductor nanostructures, which is very important for high quality optoelectronic devices.

Tunable slow light device using quantum dot semiconductor laser

This investigation experimentally demonstrates a tunable slow light device using a quantum dot (QD) semiconductor laser. The QD semiconductor laser at 1.3 mum fabricated on a GaAs substrate is grown by molecular beam epitaxy. Tunable slow light can be achieved by adjusting the bias current and wavelength detuning. The slow light device operated under probe signal from 5 to 10 GHz is presented. Moreover, we also demonstrate that the tunable slow light device can be used in a subcarrier multiplexed system.

Dynamic characteristics of long-wavelength quantum dot vertical-cavity surface-emitting lasers with light injection

This investigation experimentally demonstrates the dynamic characteristics of quantum dot vertical-cavity surface-emitting lasers (QD VCSEL) without and with light injection. The QD VCSEL is fully doped structure on GaAs substrate and operates in the 1.3 mum optical communication wavelength. The eye diagram, frequency response, and intermodulation distortion are presented. We also demonstrate that the frequency response enhancement by light injection technique allows us to improve the performance of subcarrier multiplexed system.

InGaN self-assembled quantum dots grown by metal-organic chemical vapour deposition with growth interruption

Self-assembled InGaN quantum dots (QDs) were grown by metal-organic chemical vapour deposition with growth interruption at low V/III ratio and low growth temperature on sapphire substrates. The effects of the interruption time on the morphological and optical properties of InGaN QDs were studied. The results show that the growth interruption can modify the dimension and distribution of InGaN QDs, and cause the QD emission wavelength to blue shift with increasing interruption time. A density of InGaN QDs of about 4.5 × 10(10) cm(-2) with an average lateral size of 11.5 nm and an average height of 1.6 nm can be obtained by using a growth interruption time of 60 s.

Computer-identified nuclear localization signal in exon 1A of the transporter DMT1 is essentially ineffective in nuclear targeting

Divalent metal transporter 1 (DMT1; also called DCT1, Nramp2, or SLC11A2) has multiple isoforms that localize differently in many cell types. DMT1 +IRE species (encoded by mRNA with an iron-responsive element) are limited to the plasma membrane and cytosolic vesicles. In neural cells, -IRE isoforms of DMT1 (encoded by mRNA lacking an IRE) localize to the nucleus, plasma membrane, and cytosolic vesicles. In considering nuclear compartmentalization of -IRE isoforms, we hypothesized that the newly identified exon 1A in the N-terminus of this transporter might contain a nuclear localization signal. DNA constructs starting with exon 1A and ending with exons encoding alternative isoforms were made and transiently transfected into HEK293T and PC12 cells as well as rat sympathetic neurons. None of the constructs appeared in the nucleus despite the presence of exon 1A. Antibody specific for exon 1A was also used in both immunostaining and Western blots to investigate localization of exon 1A expressed both endogenously and ectopically in cells. Again, nuclear localization of DMT1 containing exon 1A was not observed. Our data suggest that exon 1A is neither sufficient nor necessary for DMT1 to appear in the nucleus.

Epidemiological and genetic studies of myotonic dystrophy type 1 in Taiwan

To investigate the prevalence and genetic characteristics of myotonic dystrophy type 1 (DM1) in Taiwan, DM-suspected patients and their families identified during the period of 1990-2001 had their clinical records reevaluated and the CTG repeat sizes at the DM1 locus examined. A total of 96 subjects belonging to 26 families were identified as DM1 patients, which gave a minimal disease prevalence of 0.46/100,000 inhabitants. Clinical anticipation was frequently observed in affected families, even in some parent-child pairs with transmission contraction of the CTG repeat size. The inverse correlation between age at onset and CTG repeat length was significant only in patients with small expansions. In addition, a DM1 carrier with a childhood-onset son was found to have CTG length heterogeneity in the range of 40-50, indicating that premutation alleles could be unstable during gametogenesis as well as in somatic tissues. Our data demonstrated that DM1 is a rare disease in Taiwan and showed that transmission contraction of repeat size is more likely to occur in alleles with large repeats.

A defect in the Kv channel-interacting protein 2 (KChIP2) gene leads to a complete loss of I(to) and confers susceptibility to ventricular tachycardia

KChIP2, a gene encoding three auxiliary subunits of Kv4.2 and Kv4.3, is preferentially expressed in the adult heart, and its expression is downregulated in cardiac hypertrophy. Mice deficient for KChIP2 exhibit normal cardiac structure and function but display a prolonged elevation in the ST segment on the electrocardiogram. The KChIP2(-/-) mice are highly susceptible to the induction of cardiac arrhythmias. Single-cell analysis revealed a substrate for arrhythmogenesis, including a complete absence of transient outward potassium current, I(to), and a marked increase in action potential duration. These studies demonstrate that a defect in KChIP2 is sufficient to confer a marked genetic susceptibility to arrhythmias, establishing a novel genetic pathway for ventricular tachycardia via a loss of the transmural gradient of I(to).

The surgical results of the pubovaginal sling procedure using polypropylene mesh for stress urinary incontinence

OBJECTIVE

To investigate the surgical results after a pubovaginal sling procedure using polypropylene mesh in women with stress urinary incontinence (SUI).

PATIENTS AND METHODS

Sixty-four women with different types of SUI underwent a pubovaginal sling procedure, using polypropylene mesh. The sling was placed at the level of the proximal half of the urethra and tied with adequate tension, but not obstructing the bladder outlet. A video-urodynamic study and transrectal ultrasonography were undertaken before and after surgery. The surgical results were assessed and the urodynamic changes compared at different stages.

RESULTS

At a median follow-up of 24 months, 52 patients (81%) were completely continent, 10 (16%) had an improvement but with mild SUI, and two had persistent SUI requiring a second sling procedure. The treatment result was considered satisfactory by 55 patients (86%). The video-urodynamic study showed no significant change in voiding pressure, cystometric capacity and residual urine volume after surgery. The bladder neck opening time was increased at 7 days and the maximum flow rate increased at 3 months after surgery. Transrectal ultrasonography showed that all the polypropylene mesh slings were located beneath the bladder neck and proximal urethra, with no notable granuloma formation around the sling.

CONCLUSION

The pubovaginal sling procedure is effective in treating female SUI, using polypropylene mesh as the sling material. The video-urodynamic results showed that a pubovaginal sling of polypropylene mesh causes no bladder outlet obstruction when the correct surgical technique is used.

Myasthenia gravis and Waldenström's macroglobulinemia: a case report and review of the literature

An elderly man with ocular type myasthenia gravis (MG) was found to have monoclonal gammopathy (IgM). Waldenström's macroglobulinemia (WM) was proven later. This is the second case report of MG associated with WM. However, this case is unique due to the presence of anti-acetylcholine receptor (anti-AChR) antibody (IgG). MG is considered to be an autoimmune disease and WM an immunoproliferative disorder. The association of MG and WM is not clear.

Sonographic evaluation of anatomic results after the pubovaginal sling procedure for stress urinary incontinence

OBJECTIVE

To investigate the anatomic changes after the pubovaginal sling procedure in women with stress urinary incontinence by transrectal sonography

METHODS

This study enrolled 56 women with varying types of stress urinary incontinence who were treated with the pubovaginal sling procedure using self-fashioned polypropylene mesh. The suburethral sling was fixed without tension and was placed at the position between the bladder neck and the proximal urethra. The patients were investigated preoperatively and postoperatively by transrectal sonography of the bladder and urethra.

RESULTS

At a median follow-up of 24 months (range, 6-39 months), 48 patients (85.7%) were cured, 6 (10.7%) had improved, and 2 (3.6%) had treatment failures. Transrectal sonography revealed a well-suspended bladder neck and proximal urethra in all patients who were cured. As measured by changes of the axis of the pubovesical ligament, the position of the bladder neck was elevated by a mean of 29.6 +/- 21.5 degrees in the resting condition and 47.4 +/- 27.7 degrees in the straining condition. An incompetent bladder neck and proximal urethra were noted in 8 patients who had stress urinary incontinence after surgery. The incidence of opening of the bladder neck was 84.6% in 13 patients with de novo urgency or urge incontinence, whereas only 2 (4.7%) of 43 patients who did not have postoperative urgency had opening of the neck (P = .000).

CONCLUSION

Transrectal sonography provides useful information about anatomic changes after the pubovaginal sling procedure. Bladder neck incompetence after surgery was closely related to postoperative urgency or urge incontinence.

Anatomical and functional results of pubovaginal sling procedure using polypropylene mesh for the treatment of stress urinary incontinence

PURPOSE

The anatomical and functional results of pubovaginal sling procedure using polypropylene mesh were investigated.

MATERIALS AND METHODS

A total of 50 women with stress urinary incontinence, including 26 with type 2, 7 with mixed type 2/3 and 17 with type 3 disease, underwent the pubovaginal sling procedure using polypropylene mesh. A self-fashioned 2 cm. polypropylene mesh sling was used in all cases. The slings were fixed without tension at each side of the bladder neck. The sling was further suspended to elevate the bladder neck in patients with type 2 disease and those with a hypermobile bladder base, while it was placed without further tension in those with type 3 disease and those with a nonmobile bladder base. After the operation video urodynamics and transrectal sonography were done to evaluate functional and anatomical results.

RESULTS

At a median followup of 24 months 42 women were cured, 6 had improvement and treatment had failed in 2. Although the maximum flow rate increased, no changes were noted in detrusor pressure, post-void residual urine or cystometric capacity at month 3. Transrectal sonography revealed that mean sling width plus or minus standard deviation had decreased to 13.5 +/- 3.3 mm. at 3 months. The endopelvic fascia was thicker in women with type 2 than in those with types 2/3 or 3 disease (mean 5.3 +/- 1.5 versus 3.5 +/- 1.3 mm., p = 0.001). The position of bladder neck on video urodynamics was elevated a mean of 2.01 +/- 2.01 and 3.07 +/- 2.07 cm. compared to baseline elevation during resting and straining, respectively (p = 0). No hypermobility was noted while the patients coughed and no kinking of the urethra was observed while they performed the Valsalva maneuver. Detrusor instability resolved in 6 of 8 women (75%) and new onset detrusor instability was noted in 7 (14%). In 2 women with persistent stress urinary incontinence a repeat sling procedure was necessary to treat type 3 disease and cure incontinence. The overall success rate was 96%. One patient with sling erosion into the vaginal wall was treated with simple revision.

CONCLUSIONS

Fixation of a polypropylene mesh sling at the bladder neck and adequate suspension may effectively achieve a hammock effect without creating bladder outlet obstruction in patients with types 2 and 2/3 stress urinary incontinence. The anatomical and functional results of this study show that a well suspended bladder neck did not create bladder outlet obstruction after a pubovaginal sling procedure using polypropylene mesh.

Urodynamic results of intravesical heparin therapy for women with frequency urgency syndrome and interstitial cystitis

BACKGROUND AND PURPOSE

Although intravesical heparin instillation is effective in relieving symptoms in patients with frequency urgency syndrome and interstitial cystitis (IC), its efficacy has not been evaluated by urodynamic study. We used urodynamic studies to evaluate the efficacy of heparin instillation in patients with frequency urgency syndrome and IC.

METHODS

Forty women (mean age, 59.6 yr) with severe frequency, urgency, and suprapubic pain at full bladder were enrolled in this study. Patients underwent videourodynamic study with the potassium chloride (KCl) test. All patients had a positive KCl test and were treated with intravesical heparin 25,000 units twice a week for 3 months. Results of urodynamic study and voiding symptom changes assessed by the International Prostate Symptom Score at the end of treatment were compared with baseline data.

RESULTS

Twenty-nine patients had symptom score improvement of more than 50%, and eight had symptom score improvement of less than 50% but improved nocturia. Significant improvement in symptom score (9.0 +/- 4.0 vs 19.5 +/- 4.6, p < 0.001) and nocturia (2.3 +/- 1.1 vs 5.7 +/- 2.0, p < 0.001) were noted after treatment. Urodynamic study at the end of treatment revealed significant improvements in the first sensation of filling (146 +/- 55.4 vs 96 +/- 46.4 mL, p = 0.001) and cystometric capacity (304 +/- 84.8 vs 262 +/- 89.8 mL, p = 0.002). Posttreatment KCl test was negative in 20 patients, improved in 13, and unchanged in seven. Among the 10 patients with cystoscopically proven IC, eight had symptomatic improvement and four had a negative KCl test after treatment.

CONCLUSIONS

IC and frequency urgency syndrome may be caused by increased urothelial permeability. The results of this study show that intravesical heparin can relieve bladder symptoms in a significant proportion of patients, and this may be associated with the restoration of mucosal integrity.

Long-term results of surgical treatment for female stress urinary incontinence

OBJECTIVE

To compare the long-term success rates of bladder neck suspension (BNS) and pubovaginal sling procedure in different types of female stress urinary incontinence (SUI) in order to identify appropriate treatment strategies for SUI.

METHODS

A total of 157 women who received anti-incontinence surgery were followed-up for a mean period of 58.1 +/- 33.9 months. The surgical outcome was analyzed and was compared among the different types of SUI and among BNS and pubovaginal sling procedures.

RESULTS

SUI was classified as type I in 16 patients, type II in 111 patients, and type III in 34 patients. Surgical procedures included Gittes BNS (n = 62), Raz BNS (n = 53), and pubovaginal sling procedure (n = 42). The total success rate was 77.1%, including a 38.2% cure rate and a 38.9% significantly improved rate. Analysis of the results revealed that type III SUI had the lowest success rate (67.6%), while the pubovaginal sling procedure had the best success (93.9%) and cure rates (54.8%). The success rates of BNS were significantly lower than that of pubovaginal sling in type III SUI, less favorable in type II SUI, but remained high in type I SUI. 75% of patients with treatment failure had recurrence within the fist postoperative year.

CONCLUSIONS

In this series of patients, the long-term cure rates of anti-incontinence surgeries are not satisfactory. BNS procedures had satisfactory results only in type I SUI while the pubovaginal sling procedure had better results in both types II and III SUI. The pubovaginal sling procedure might have better long-term results in the treatment of all types of SUI.

Comparison of video urodynamic results after the pubovaginal sling procedure using rectus fascia and polypropylene mesh for stress urinary incontinence

PURPOSE

Video urodynamic changes were compared after the pubovaginal sling procedure using rectus fascia or polypropylene mesh in women with stress urinary incontinence.

MATERIALS AND METHODS

A total of 50 women with various types of stress urinary incontinence were treated with the pubovaginal sling procedure using randomly abdominal rectus fascia in 24 or polypropylene mesh in 26. The sling was placed at the level of the bladder neck and tied with sufficient tension to prevent urinary leakage without obstructing the bladder outlet. Video urodynamics were performed preoperatively, and 7 to 14 days and 3 to 6 months postoperatively in all cases. Surgical results and urodynamic changes after the pubovaginal sling procedure were compared in the 2 groups. Long-term results were evaluated at a mean followup of 2 years.

RESULTS

Complete continence was achieved in 23 patients (95.8%) in the rectus fascia group and 26 (100%) in the polypropylene mesh group, including 1 initial failure with reoperation, at a median followup of 24 and 23 months, respectively. The subjective success rate was 91.6% for rectus fascia and 92.3% for polypropylene mesh. The main cause of dissatisfaction was persistent urge incontinence and dysuria in 2 cases each. In each group video urodynamics revealed a mild but nonsignificant decrease in maximum urinary flow and a significant increase in bladder neck opening time at 7 to 14 days versus baseline. However, these parameters returned to baseline within 3 to 6 months postoperatively. Voiding pressure, cystometric capacity and post-void residual urine also showed no significant change in either group after the pubovaginal sling procedure. Patients treated with a polypropylene mesh sling had a shorter operative time and hospital stay, a higher spontaneous voiding rate after catheter removal and a lower incidence of wound pain after surgery. One patient treated with polypropylene mesh had sling margin extrusion. The incidence of new onset detrusor instability and persistent dysuria was similar in the 2 groups. Transrectal sonography of the sling showed that it was located beneath the bladder neck and proximal urethra in all patients in each group.

CONCLUSIONS

The results of this study show that the pubovaginal sling procedure using rectus fascia or polypropylene mesh as the sling material had similar effectiveness for treating female stress incontinence but the polypropylene group had more rapid recovery. Postoperatively video urodynamics demonstrated that the pubovaginal sling using either sling material did not cause bladder outlet obstruction with proper surgical technique.

A pregnancy following PGD for X-linked dominant [correction of X-linked autosomal dominant] incontinentia pigmenti (Bloch-Sulzberger syndrome): case report

Incontinentia Pigmenti (Bloch-Sulzberger syndrome) is a rare multisystem, ectodermal disorder associated with dermatological, dental and ocular features, and in <10% of cases, severe neurological deficit. Pedigree review suggests X-linked dominance with lethality in affected males. Presentation in female carriers is variable. Following genetic counselling, a mildly affected female carrier diagnosed in infancy with a de novo mutation was referred for preimplantation sexing, unusually selecting for male gender, with an acceptance of either normality or early miscarriage in an affected male. Following standard in-vitro fertilization and embryo biopsy, fluorescence in situ hybridization (FISH) unambiguously identified two male and two female embryos. A single 8-cell, grade 4 male embryo was replaced. A positive pregnancy test was reported 2 weeks after embryo transfer, although ultrasonography failed to demonstrate a viable pregnancy. Post abortive fetal tissue karyotyping diagnosed a male fetus with trisomy 16. This is an unusual report of preimplantation genetic diagnosis (PGD) being used for selection of males in an X-linked autosomal dominant disorder and demonstrates the value of PGD where amniocentesis or chorion villus sampling followed by abortion is not acceptable to the patient. This case also demonstrates the importance of follow-up prenatal diagnosis.

Pathophysiology of lower urinary tract symptoms in aged men without bladder outlet obstruction

OBJECTIVE

To assess the pathophysiology of lower urinary tract symptoms (LUTS) in aged men without bladder outlet obstruction in a videourodynamic study.

METHODS

In a videourodynamic study of 324 consecutive men with moderate to severe LUTS suggestive for bladder outlet obstruction, 112 were found to be urodynamically nonobstructed. International prostatic symptom score (IPSS), uroflowmetry and transrectal sonography of the prostate were assessed before videourodynamic study. The pressure flow expression and the obstructive parameters were compared between the 212 obstructed and 112 nonobstructed men.

RESULTS

Of the 112 nonobstructed men investigated, 25 had a normal bladder and urethral trace (22.3%), 5 had detrusor instability (4.5%), 17 had a hypersensitive bladder and a normal urethra (15.2%), 3 had detrusor underactivity and a normal urethra (2.7%), while 61 were found to have a poorly relaxed external sphincter and low detrusor contractility (54.5%). Most of the patients in the normal and hypersensitive groups had normal voiding pressure and high flow (NPHF) tracings, whereas men with detrusor underactivity or a poorly relaxed external sphincter had normal voiding pressure and low flow (NPLF) tracings. Only the maximal flow rate and voided volume were significantly higher in patients with NPHF than in patients with NPLF tracings. However, both groups showed a significantly lower IPSS, less residual urine, and a smaller transition zone index than the obstructive group. After medical treatment, 78 patients (69.6%) had satisfactorily improved, 31 patients (27.6%) remained stationary, while 3 (2.7%) worsened.

CONCLUSION

Nonobstructed men with LUTS have various pathophysiologies other than benign prostatic obstruction. In this study 54.5% of these patients had poorly relaxed external sphincter on videourodynamic study. Identification of the underlying pathology can not only prevent unnecessary prostate surgery but can also enable proper medical treatment to be selected.

Comparative study of therapeutic effect of dibenyline, finasteride, and combination drugs for symptomatic benign prostatic hyperplasia

OBJECTIVES

A prospective study was conducted in a community hospital in order to evaluate the therapeutic effect of dibenyline, finasteride, and a combination of the two drugs for symptomatic benign prostatic hyperplasia (BPH).

METHODS

190 men suffering from severe prostatism entered this study. They were assessed by IPSS symptom score, digital rectal examination, transrectal sonography of the prostate, uroflowmetry and residual urine. The patients were randomly selected for medical treatment with dibenyline 10 mg b.i.d. (n = 71), finasteride 5 mg q.d. (n = 54), and a combination (n = 65). Clinical assessments were carried out before treatment and 3 and 6 months after starting treatment. Patients who could not complete the treatment and those with prostatic cancer were excluded from the final statistics. The quality of life after 6 months of treatment and side effects were also assessed.

RESULTS

A total of 172 patients completed the treatment course and 153 patients completed the periodic clinical assessments. Improvement in IPSS was noted in all 3 groups of patients both at 3 and 6 months. The prostatic volume was found to decrease in the finasteride group and the combination group at 6 months by 24.3 and 10.5%, respectively. Maximal flow rate (Qmax) was significantly improved in the dibenyline and combination groups but not in the finasteride group at 3 months. At 6 months a significant increase in Qmax was noted in all groups with a mean increase of 1.4-1.8 ml/s. The quality of life after treatment was satisfactory in 71.9% of the dibenyline group, 70.4% of the finasteride group and 83.1% of the combination group. Side effects were higher in the dibenyline than the finasteride or combination group. The dropout rate was higher in the dibenyline group (15.5%) than in the finasteride (7.5%) and combination (4.6%) groups. After 6 months of treatment, some of the patients discontinued medication and symptom relapse was noted in 92.6% of the dibenyline group, 57.6% of the finasteride group, and 71% of the combination group.

CONCLUSIONS

Medical treatment is effective in treating symptomatic BPH. Combination dibenyline and finasteride provides a weak synergistic clinical effect without additive side effects.

Quality of life after active urological management of chronic spinal cord injury in eastern Taiwan

OBJECTIVE

Motor cycle accidents are the major cause of head injury and spinal cord injury (SCI) in Taiwan. The incidence of SCI in Hualien county is the highest in the world. In a community hospital in Hualien, active urological management was carried out for SCI patients with voiding dysfunctions and urological complications. This study was conducted to assess the success of active urological management.

METHODS

From 1988 to 1996, in the urological department, 251 SCI patients with varying voiding dysfunctions or urological complications were managed with various surgical or nonsurgical procedures according to their underlying pathologies. The satisfaction rate and quality of life index were assessed before and after active urological treatment.

RESULTS

There were 118 patients with cervical SCIs, 93 patients with thoracic or lumbar SCIs, and 40 patients with sacral SCIs or infrasacral neuropathy. After initial managements, 174 patients were able to pass urine by themselves, by clean intermittent self-catheterization (CISC) or with an indwelling Foley catheter. The remaining 77 patients suffering from severe dysuria, urinary incontinence, hydronephrosis and frequent urinary tract infections were managed with various surgical procedures. The procedures included external sphincterotomy (n = 30), enterocystoplasty (n = 28), autoaugmentation (n = 6), continent urinary diversion (n = 7), periurethral Teflon injection (n = 3), and transurethral resection of the prostate (n = 3). After treatment, hydronephrosis resolved in 100% of the kidney units; frequent symptomatic urinary tract infection improved in 83.3% after external sphincterotomy and 75% after enterocystoplasty and continent diversion; while urinary incontinence disappeared or improved in 93% after enterocystoplasty and autoaugmentation. The total satisfaction rate was 84.4% after the surgical procedures. The mean quality of life index improved from -1.27 +/- 0.39 to +1.54 +/- 0.38 after management. However, some complications such as mucus secretion (76.5%), abdominal pain (20.6%), loose stool (23.5%) and frequent stone formation (11.8%) still bothered the patients undergoing enterocystoplasty and continent diversion. Repeat sphincterotomy was necessary in 16.7% of patients, and 50% were not satisfied with total incontinence after external sphincterotomy. During the follow-up period, 87% of all patients had > or = 1 yearly episode of urinary tract infection after spinal injury and 11 patients died of urosepsis.

CONCLUSIONS

Active urological management to improve quality of life and to treat urological complications in SCI patients is mandatory. After long-term follow-up, SCI patients can be free of indwelling catheters, hydronephrosis usually resolves and urinary tract infections are infrequent.

Lack of cell cycle checkpoints in human cleavage stage embryos revealed by a clonal pattern of chromosomal mosaicism analysed by sequential multicolour FISH

Multicolour fluorescence in situ hybridisation (FISH) analysis of interphase nuclei in cleavage stage human embryos has highlighted a high incidence of postzygotic chromosomal mosaicism, including both aneuploid and ploidy mosaicism. Indeed, some embryos appear to have a chaotic chromosomal complement in a majority of nuclei, suggesting that cell cycle checkpoints may not operate in early cleavage. Most of these studies, however, have only analysed a limited number of chromosomes (3-5), making it difficult to distinguish FISH artefacts from true aneuploidy. We now report analysis of 11 chromosomes in five sequential hybridisations with standard combinations of two or three probes and minimal loss of hybridisation efficiency. Analysis of a series of arrested human embryos revealed a generally consistent pattern of hybridisation on which was superimposed frequent deletion of one or both chromosomes of a specific pair in two or more nuclei indicating a clonal origin and continued cleavage following chromosome loss. With a binucleate cell in a predominantly triploid XXX embryo, the two nuclei remained attached during preparation and the chaotic diploid/triphoid status of every chromosome analysed was the same for each nucleus. Furthermore, in each hybridisation the signals were distributed as a mirror-image about the plane of attachment, indicating premature decondensation during anaphase consistent with a lack of checkpoint control.

Videourodynamic study for diagnosis of bladder outlet obstruction in women

BACKGROUND AND PURPOSE

In order to characterize the etiology of bladder outlet obstruction (BOO) in Taiwanese women, the results of videourodynamic studies performed in women with lower urinary tract symptoms (LUTS) were analyzed. The treatment results were compared with the underlying pathophysiology among the three etiologies of urethral stricture, spastic urethral sphincter, and cystocele.

METHODS

From October 1997 through February 1999, 364 female patients underwent videourodynamic study to investigate the underlying etiology of LUTS. BOO was defined as a voiding detrusor pressure of 50 cm H2O or greater and a narrow urethra on the voiding cystourethrography. Cystoscopy, urethral sounding, and external sphincter electromyography were used in conjunction with the pressure/flow findings for differential diagnosis of the etiology of BOO.

RESULTS

Among the 364 patients with LUTS who underwent videourodynamic study, 35 (9.6%) had BOO. Detailed investigation revealed that 15 of these women had urethral stricture (43%), 14 had spastic urethral sphincter (40%), and six had cystocele (17%). No significant difference was found in the urodynamic parameters among these three groups of patients. The incidence of bladder trabeculation and urge incontinence was significantly higher in patients with urethral stricture. Improvement of urine flow and voiding symptoms was achieved in 87% of the patients with urethral stricture, 50% female patients with spastic urethral sphincter, and 100% of those with cystocele.

CONCLUSIONS

The results suggest that BOO is not uncommon in women with LUTS, and that a correct diagnosis of BOO should be based on comprehensive urodynamic study.

Videourodynamic results after pubovaginal sling procedure for stress urinary incontinence

OBJECTIVES

To determine the influence of surgery on bladder and urethral function by performing a videourodynamic study in female patients with stress urinary incontinence (SUI) before and after a pubovaginal sling procedure.

METHODS

A total of 14 women with type II SUI, 7 with type III SUI, and 3 with mixed type II/III SUI were included in the study. The pubovaginal sling procedure was carried out using a modified method that minimized interference with the endopelvic fascia. Videourodynamic study was performed before the procedure, within 7 to 14 days postoperatively, and at 3 to 6 months postoperatively.

RESULTS

Videourodynamic study within 7 to 14 days postoperatively revealed no change in the mean voiding detrusor pressure (Pdet), cystometric capacity, or maximal flow rate (Qmax) compared with the preoperative data. The bladder neck opening time and residual urine amount were significantly increased. Within 3 to 6 months after surgery, Pdet, Qmax, bladder neck opening time, and residual urine amount returned to preoperative levels. An elevation of the bladder neck was noted during coughing in 7 patients. After surgery, de novo detrusor instability was noted in 2 patients (8.3%). No infection or sling failure was noted at a mean follow-up time of 12 months. The success rate was 96%.

CONCLUSIONS

The pubovaginal sling procedure is an effective method for the treatment of type II or type III SUI. The postoperative videourodynamic results show that this procedure can re-establish a "hammock effect" on the proximal urethra during abdominal straining without compromising urethral resistance.

Analysis of anthropometric growth trends and prevalence of abnormal body status in Tainan elementary-school children

Objectives of this study were to examine the prevalence of over/underweight or obesity in Chinese children and investigate the trend of anthropometric change through the years. Cross-sectional measurements on randomly selected 6,373 Tainan elementary-school children were conducted in 1997. Anthropometric parameters such as height, weight, body mass index (BMI), triceps skinfold thickness (TSF), mid-arm circumference (MAC) and body-fat percentage (%FAT) were measured. Girls and boys had an average of 4.8 cm and 5.1 cm, or 3.7% and 3.9% increase in height, and 5.5 kg, 6.2 kg, or 19.9% and 22.2% increase in weight when compared to data of nationwide survey in 1986-88. If the height and weight were compared to the data of nationwide survey in 1993-1996, Tainan girls and boys would have similar height but have averaged 3.4% and 4.7% heavier weight. Mean BMI reached 19.4 kg/m2 for girls and 19.6 kg/m2 for boys of age 12 to 13. Mean %FAT of girls was 24.3% and of boys was 23.7%. When using weight-for-length index (WLI) larger than 1.2, mean weight exceeding 120% of age-and-sex specific mean weight, %FAT exceeding 30% to evaluate prevalence of obesity, results would be 42.1%, 17% and 22.0% respectively. In conclusion, both sexes had faster growth in weight than in height in recent 10 years. Boys had significantly higher weight, WLI, BMI, MAC than girls, while girls had significantly higher TSF and %FAT than boys. Prevalence of obesity is highly method-dependent. Appropriate index and cutoff values need to be developed.

Clinical prostate score for diagnosis of bladder outlet obstruction by prostate measurements and uroflowmetry

OBJECTIVES

To establish a clinical prostate score based on the parameters of uroflowmetry and prostate measurements to provide a better prediction of benign prostatic obstruction (BPO) in men with lower urinary tract symptoms (LUTS) and small prostate volume.

METHODS

From October 1997 to September 1998, a prospective study of 324 consecutive men with LUTS was conducted in a community hospital in Taiwan. All patients were first evaluated by uroflowmetry and transrectal sonography of the prostate, and a videourodynamic study (VUDS) was performed before any medication was given. Patients were grouped as obstructed or unobstructed according to the results of the VUDS. Parameters from uroflowmetry and prostate measurements were evaluated for their sensitivity in predicting BPO. A clinical prostate score was established by summing scores on seven prostatic and uroflowmetric items: maximal flow rate (Qmax), flow pattern, voided volume, residual urine amount, total prostate volume (TPV), transition zone index (TZI), and prostatic configuration. Each of these items had a score representing the grade of sensitivity of BPO.

RESULTS

Among the 324 men examined, only 65.4% were found to have obstruction by VUDS. A value of Qmax 10 mL/s or less had a sensitivity of only 75.4% and specificity of only 63.7% for BPO. A constrictive flow pattern had 87.2% sensitivity, residual urine 100 mL or greater had 86.1%, TPV 40 mL or greater had 94.6%, TZI 0.5 or greater had 87.8%, and the presence of a median lobe had 87.1% sensitivity; the presence of any of these factors added 2 points to the score. The other parameters were scored as 1, 0, and -1, representing their sensitivity as slightly superior or inferior to that of LUTS. A prostate score of 3 or greater had a sensitivity of 87.2% and a specificity of 60.8% for BPO. On the basis of this prostate score, 148 patients (46%) would have been treated for BPO without the need for further investigation, of whom 19 (5.9%) would have been misdiagnosed. The remaining 176 patients (54%) would have undergone a VUDS and 93 of these patients (28.7%) were unobstructed.

CONCLUSIONS

By combining uroflowmetry and transrectal sonography of the prostate, patients with LUTS can be diagnosed with a good sensitivity and specificity. Using the parameters in the uroflow and prostate measurements, a prostate score could be established and used as an indicator of BPO for selecting patients with LUTS who require further treatment or invasive VUDS.

Position of poly(methyl methacrylate) and silicone intraocular lenses after phacoemulsification

PURPOSE

To compare the positional change of poly(methyl methacrylate) (PMMA) and silicone intraocular lenses (IOLs) in vivo after phacoemulsification.

SETTING

Taipei Municipal Yang-Ming Hospital, Taipei, Taiwan.

METHODS

A prospective study of 70 cataractous eyes treated by phacoemulsification with IOL implantation was carried out. The eyes were randomized into 2 groups based on IOL type: 1-piece PMMA IOL; 3-piece silicone IOL. The amount of IOL tilt and decentration was measured and anterior chamber depth (ACD) determined by Scheimpflug photography using an anterior eye segment analysis system (EAS-1000, Nidek). All eyes were examined 1 week and 1 to 6 months after surgery.

RESULTS

No statistically significantly differences were found in the amount of tilt and decentration between 2 IOL types throughout the study. The ACDs were relatively constant in both groups through the early postoperative periods.

CONCLUSION

The stability of PMMA and silicone IOLs were the same after phacoemulsification.

Transrectal sonographic investigation of urethral and paraurethral structures in women with stress urinary incontinence

Transrectal sonography of the urethra was used in 14 asymptomatic volunteers, 37 women with frequency-urgency syndrome, 42 patients with mild stress urinary incontinence, and 18 with severe stress urinary incontinence. Transverse scanning over the midurethra was performed and cross-sectional images of the urethral and paraurethral structures were compared among the four groups, with P < 0.05 being considered statistically significant. The total cross-sectional area of the midurethra was significantly smaller in patients with stress urinary incontinence than in those without this disorder (86.7+/-29.9 versus 104+/-35.6 mm2, P = 0.005); this difference resulted from a significantly smaller peripheral striated muscle component in patients with stress urinary incontinence (42.8+/-20.7 versus 58.3+/-27.3 mm2, P = 0.001). The thickness of the urethropelvic ligaments was significantly thinner in patients with stress urinary incontinence than in those without (5.9+/-1.7 versus 8.9+/-2.1 mm, P < 0.001). The distribution of the peripheral striated muscle around the urethra was variable: complete surrounding the urethra was noted in 35.7% of the control women and in 48.6% of frequency-urgency patients, but only in 16.7% of patients with mild stress urinary incontinence and 5.3% of patients with severe disease. Bladder neck incompetence was seen in 42 patients with stress urinary incontinence but in none of the control women. The length of the pubourethral ligaments was similar in the four groups. Our finding showed that stress urinary patients had a smaller striated muscle component in the midurethra and thinner urethropelvic ligaments. These defects in the continence mechanisms might have great implications in the pathophysiology of stress urinary incontinence. Transrectal sonography of the urethra is a valuable investigative tool in assessing urethral and paraurethral conditions in patients with stress urinary incontinence before deciding treatment modality.

Chromosomal mosaicism in cleavage-stage human embryos and the accuracy of single-cell genetic analysis

PURPOSE

Our purpose was to assess the effect of chromosomal mosaicism in cleavage-stage human embryos on the accuracy of single-cell analysis for preimplantation genetic diagnosis.

METHODS

Multicolor fluorescence in situ hybridization with X, Y, and 7 or X, Y, 7, and 18 chromosome-specific probes was used to detect aneuploidy in cleavage-stage human embryos.

RESULTS

Most nuclei were diploid for the chromosomes tested but there was extensive mosaicism including monosomic, double-monosomic, nullisomic, chaotic, and haploid nuclei.

CONCLUSIONS

Identification of sex by analysis of a single cleavage-stage nucleus is accurate but 7% of females are not identified. One or both parental chromosomes 7 were absent in at least 6.5% of the nuclei. With autosomal recessive conditions such as cystic fibrosis, carriers would be misdiagnosed as normal or affected. With autosomal dominant conditions, failure to analyze the affected parents allele (1.6-2.5%) would cause a serious misdiagnosis and analysis of at least two nuclei is necessary to reduce errors.

Inhibitory effect of capsaicin on detrusor contractility: further study in the presence of ganglionic blocker and neurokinin receptor antagonist in the rat urinary bladder

In order to understand the mechanisms by which capsaicin at high concentrations affects the micturition reflex and detrusor contractility, in vivo and in vitro whole bladder studies were conducted using ganglionic blockers and a neurokinin receptor antagonist. Thirty-eight adult rats were divided into control (normal saline cystometry) and experimental (1,000 microM capsaicin cystometry) groups. Both groups were subdivided to receive pretreatment with intravesical hexamethonium, perivesical hexamethonium, or intravesical spantide ([D-Arg1, D-Trp7,9, Leu11]-substance P). After in vivo cystometry, the bladders were removed and in vitro whole bladder contractility studies using electrical field stimulation as well as bethanechol and KCl stimulations were performed. In the bladders pretreated with perivesical hexamethonium, the amplitudes of contractions and in vitro detrusor contractility under electrical stimulation were decreased. Other bladder preparations showed no significant differences from the controls. However, when 1,000 microM capsaicin was infused into the bladders, both control and experimental bladders showed an initial excitation and a final inhibition with an elevated basal intravesical pressure and retention. Capsaicin at 100 microM did not have this effect. The results of this study conclude that blockage of perivesical ganglia or neurokinin receptors in the submucosa did not influence the depressant effects of 1,000 microM capsaicin on the micturition reflex and detrusor contractility in rats. Nonspecific toxic effects on detrusor muscle or nerves is likely when intravesical high-concentration capsaicin is administered.

Protective effect of tetrandrine on normal human mononuclear cells against ionizing irradiation

Tetrandrine, an alkaloid isolated from the plant Stephania tetrandra, at low concentration (2 micrograms/ml) was shown to protect normal human mononuclear cells in vitro against damage due to a single high-dose of ionizing irradiation (10 Gy). The cell survival rate increased from 58.3 +/- 2.2% in the irradiated group to 78.0 +/- 2.6% in the tetrandrine-pretreated group, and similarly, the percentage of necrotic cells declined from 20.7 +/- 2.5% to 10.7 +/- 1.9%, respectively. This protective effect of tetrandrine for cell surviving fraction increased in a dose-dependent manner. Tetrandrine was also found to inhibit inflammatory responses induced by irradiation including the release of superoxide (NBT [nitroblue tetrazolium] reduction decreased from 21.3 +/- 2.3% to 10.2 +/- 2.5%) and phagocytic activity (decreased from 80.7 +/- 3.8% to 50.7 +/- 2.3%, the same range level as that of the control group). However, the alkaloid demonstrated no effect on the production of nitric oxide. In terms of cell morphology, only two types were observed-normal or necrotic cells, and there were no characteristics of programmed cell death. These results indicate that tetrandrine possesses radioprotective activity against 10 Gy of ionizing irradiation and could suppress irradiation-induced inflammatory processes.

Reversibility of the inhibitory effect of intravesical capsaicin on the micturition reflex in rats

The reversibility of the inhibitory effect of capsaicin on the micturition reflex was investigated in adult rats. The experimental group (n = 38) were given 0.5 mL of 1 mmol/L intravesical capsaicin. After 30 minutes the bladder was evacuated, then the rats were allowed to recover for various times from 0 to 24 hours before cystometrography. Control rats (n = 6) were injected with saline. Immediately after capsaicin treatment, the bladders showed detrusor hyperactivity and high intravesical pressure during cystometrography. All capsaicin-treated bladders showed final urinary retention and hematuria developed in 32 of 38. At 6 hours after intravesical instillation of capsaicin, detrusor hyperactivity was reduced and the micturition reflex gradually reappeared. By 12 hours, micturition reflexes were noted in seven of eight bladders with a volume threshold equal to that of the control group. At 24 hours, the volume threshold for the micturition reflex was significantly greater in the capsaicin-treated group than in the control group. The amplitude of detrusor contractions at 6, 12, and 24 hours showed no significant difference from that in the controls. In vitro whole bladder contractility in response to electrical field stimulation, bethanechol, and KCl also showed no significant difference between the control and the experimental groups. The bladder weight increased as the recovery period increased, indicating the presence of neurogenic inflammation. From this study we conclude that capsaicin-induced micturition reflex inhibition in rats is reversible at 12 hours and the volume threshold for eliciting the micturition reflex continues to increase up to 24 hours after capsaicin treatment. These results may provide insight into the clinical application of capsaicin in the treatment of various voiding disorders in humans.

Capsaicin inhibits detrusor contractility but not the micturition reflex in capsaicin-desensitized rats

Intravesical capsaicin at high concentration (1 mmol/L) inhibits the micturition reflex and detrusor contractility. To investigate the mechanism, we compared rats that had been desensitized by capsaicin at birth with control rats. In vivo cystometrography was performed with normal saline (n = 5) or 1 mmol/L capsaicin (n = 5), then an isolated whole bladder contractility study with electrical field stimulation, bethanechol, and KCl was carried out. In the bladders with normal saline cystometrography and after isolated bladder study, 0.5 mL of 1 mmol/L capsaicin was instilled into the bladders and another set of stimulations by electrodes, bethanechol, and KCl was given. The bladders of capsaicin-desensitized rats showed the presence of detrusor reflexes but diminished amplitudes of detrusor contractions. There was no urinary retention or increased intravesical pressure in these desensitized bladders after capsaicin cystometrography. The detrusor contractility in the isolated whole bladder study showed no significant difference between the control and experimental bladders. After 1 mmol/L capsaicin cystometrography the bladders had little contractility compared with bladders after saline cystometrography. The bladders of the desensitized rats increased in weight compared to the controls. Intravesical administration of 1 mmol/L capsaicin induced an initial excitatory effect on the micturition reflex and final urinary retention in control rats. After capsaicin treatment at birth, these effects no longer existed but the depressant effect of capsaicin on detrusor contractility persisted. We conclude that a high concentration of intravesical capsaicin acutely inhibits the micturition reflex and detrusor contractility. Neonatal desensitization by capsaicin can depress the detrusor contractility in rats but the micturition reflex is not affected.

Aspirin improves uterine blood flow in the peri-implantation period

A prospective clinical study at the Infertility Clinic of National Cheng Kung University Hospital investigated the effect of aspirin on infertile women with impaired uterine perfusion. A total of 127 women with unexplained infertility or repeated failure with various assisted-conception techniques were enrolled. Uterine perfusion was assessed by Doppler ultrasound and classified as normal or impaired (pulsatility index < 3.0 or > or = 3.0, respectively). One-third (43/127) of the women were found to have impaired uterine perfusion during their menstrual cycles. Those with impaired uterine blood flow were given aspirin (100 mg/day) starting on day 3 of the next ovulatory cycle. Only 36 women completed both the screening and the aspirin-treated cycles. The pulsatility index was measured in the natural and aspirin-treated cycles in the same group of women and compared using repeated measures analyses of variance. A significant improvement in the uterine blood perfusion (p < 0.05) was detected on the day leutinizing hormone peaked and in the midluteal phase (peri-implantation period) of aspirin-treated cycles. Thus, the use of low-dose aspirin may improve uterine perfusion in women with unexplained infertility and impaired uterine blood flow.

CARP, a cardiac ankyrin repeat protein, is downstream in the Nkx2-5 homeobox gene pathway

To identify the molecular pathways that guide cardiac ventricular chamber specification, maturation and morphogenesis, we have sought to characterize factors that regulate the expression of the ventricular myosin light chain-2 gene, one of the earliest markers of ventricular regionalization during mammalian cardiogenesis. Previously, our laboratory identified a 28 bp HF-la/MEF-2 element in the MLC-2v promoter region, which confers cardiac ventricular chamber-specific gene expression during murine cardiogenesis, and showed that the ubiquitous transcription factor YB-1 binds to the HF-la site in conjunction with a co-factor. In a search for interacting co-factors, a nuclear ankyrin-like repeat protein CARP (cardiac ankyrin repeat protein) was isolated from a rat neonatal heart cDNA library by yeast two-hybrid screening, using YB-1 as the bait. Co-immunoprecipitation and GST-CARP pulldown studies reveal that CARP forms a physical complex with YB-1 in cardiac myocytes and immunostaining shows that endogenous CARP is localized in the cardiac myocyte nucleus. Co-transfection assays indicate that CARP can negatively regulate an HF-1-TK minimal promoter in an HF-1 sequence-dependent manner in cardiac myocytes, and CARP displays a transcriptional inhibitory activity when fused to a GAL4 DNA-binding domain in both cardiac and noncardiac cell context. Northern analysis revealed that carp mRNA is highly enriched in the adult heart, with only trace levels in skeletal muscle. During murine embryogenesis, endogenous carp expression was first clearly detected as early as E8.5 specifically in heart and is regulated temporally and spatially in the myocardium. Nkx2-5, the murine homologue of Drosophila gene tinman was previously shown to be required for heart tube looping morphogenesis and ventricular chamber-specific myosin light chain-2 expression during mammalian heart development. In Nkx2-5(−/−)embryos, carp expression was found to be significantly and selectively reduced as assessed by both whole-mount in situ hybridizations and RNase protection assays, suggesting that carp is downstream of the homeobox gene Nkx2-5 in the cardiac regulatory network. Co-transfection assays using a dominant negative mutant Nkx2-5 construct with CARP promoter-luciferase reporter constructs in cardiac myocytes confirms that Nkx2-5 either directly or indirectly regulates carp at the transcriptional level. Finally, a carp promoter-lacZ transgene, which displays cardiac-specific expression in wild-type and Nkx2-5(+/−) background, was also significantly reduced in Nkx2-5(−/−) embryos, indicating that Nkx2-5 either directly or indirectly regulates carp promoter activity during in vivo cardiogenesis as well as in cultured cardiac myocytes. Thus, CARP is a YB-1 associated factor and represents the first identified cardiac-restricted downstream regulatory gene in the homeobox gene Nkx2-5 pathway and may serve as a negative regulator of HF-1-dependent pathways for ventricular muscle gene expression.

Comparative study of the effects of capsaicin on the contractility of normal and spinal cord injured human bladders

In order to investigate the effects of capsaicin on human detrusor contractility in both normal and spinal cord injury (SCI) bladders, a detrusor contractility study was performed in 10 normal and 8 SCI patients using isolated muscle strips. Eight bladder muscle strips were harvested from each patient undergoing surgery. Four strips were treated with capsaicin of 1-1000 microM, and electrical field stimulation and bethanechol were applied to the strips before and after capsaicin administration. The other four strips were pretreated with 40 nmole [D-Arg1, D-Trp7,9,Leu11]-Substance P (spantide) and then were underwent the same procedure. The results showed that capsaicin induced a dose-dependent increase in muscle tension on the human detrusor in both normal and SCI bladders. After treatment with varying concentrations of capsaicin for 10 minutes, low doses of capsaicin partially depressed detrusor contractility under both electrical and bethanechol stimulation while high doses of up to 1000 microM almost totally blocked detrusor contractility. The initial contractile effect of capsaicin was higher in normal bladders but the final depressant effect did not show any difference between normal and SCI bladders. With addition of spantide, the initial contractile effect and the final depressant effect of capsaicin remained the same, indicating that the contractile effects of capsaicin were not mainly through NK receptors but directly on muscle cells. Consecutive application of capsaicin to the same strip could not reproduce the contractile response. After washing free of capsaicin, the detrusor contractility under electrical stimulation and bethanechol was not reversible. A direct neurotoxic or cytotoxic effect could be found after high concentration capsaicin administration. In treating patients suffering from detrusor hyperreflexia using intravesical capsaicin instillation, this effect should be considered to prevent irreversible damage to the urinary bladder.