Mucormycosis in a Severe Trauma Patient Treated with a Combination of Systemic Posaconazole and Topical Amphotericin B-Case Report

Mucormycosis is an opportunistic infection affecting mainly immunocompromised hosts. Infection in immunocompetent patients is rare, but may occur typically in trauma or burn victims. We report on a previously healthy young man suffering devastating trauma from an agricultural accident with the subsequent development of a multifocal mucormycosis. Diagnosis was achieved by cultures obtained from non-healing wounds, some of them even covered by a macroscopic mold formation. Specific treatment was initiated soon after the preliminary results indicated mucormycosis. Aggressive surgical therapy, with concomitant use of systemic posaconazole and topical amphotericin B in a combination treatment, led to the elimination of the fungal infection. The remaining deep tissue defects were consequently reconstructed by a muscle flap and skin graft autotransplantation with a good overall outcome, which would not have been possible without the complete remission of mucormycosis. This case study presents the successful use of a combination treatment with systemic posaconazole and topical amphotericin B and underlines the importance of timely and aggressive surgical therapy.

Effects of goal-directed fluid management guided by a non-invasive device on the incidence of postoperative complications in neurosurgery: a pilot and feasibility randomized controlled trial

BACKGROUND

The positive effects of goal-directed hemodynamic therapy (GDHT) on patient-orientated outcomes have been demonstrated in various clinical scenarios; however, the effects of fluid management in neurosurgery remain unclear. Therefore, this study was aimed at assessing the safety and feasibility of GDHT using non-invasive hemodynamic monitoring in elective neurosurgery. The incidence of postoperative complications was compared between GDHT and control groups.

METHODS

We conducted a single-center randomized pilot study with an enrollment target of 34 adult patients scheduled for elective neurosurgery. We randomly assigned the patients equally into control and GDHT groups. The control group received standard therapy during surgery and postoperatively, whereas the GDHT group received therapy guided by an algorithm based on non-invasive hemodynamic monitoring. In the GDHT group, we aimed to achieve and sustain an optimal cardiac index by using non-invasive hemodynamic monitoring and bolus administration of colloids and vasoactive drugs. The number of patients with adverse events, feasibility criteria, perioperative parameters, and incidence of postoperative complications was compared between groups.

RESULTS

We successfully achieved all feasibility criteria. The GDHT protocol was safe, because no patients in either group had unsatisfactory brain tissue relaxation after surgery or brain edema requiring therapy during surgery or 24 h after surgery. Major complications occurred in two (11.8%) patients in the GDHT group and six (35.3%) patients in the control group (p = 0.105).

CONCLUSIONS

Our results suggested that a large randomized trial evaluating the effects of GDHT on the incidence of postoperative complications in elective neurosurgery should be safe and feasible. The rate of postoperative complications was comparable between groups.

TRIAL REGISTRATION

Trial registration: ClininalTrials.gov, registration number: NCT04754295, date of registration: February 15, 2021.

Effect of Prophylactic Fibrinogen Concentrate In Scoliosis Surgery (EFISS): a study protocol of two-arm, randomised trial

INTRODUCTION

Fibrinogen is one of the essential coagulation factors. Preoperative lower plasma fibrinogen level has been associated with higher blood loss. Scoliosis surgery presents a challenge for the anaesthetic team, one of the reasons being blood loss and transfusion management. Recently, the prophylactic fibrinogen administration has been a debated topic in various indications. It has been described for example, in urological or cardiovascular surgery, as well as in paediatrics. This pilot study is focused on verifying the feasibility of potential large randomised trial and verifying the safety of prophylactic fibrinogen administration in paediatric scoliosis surgery.

METHODS AND ANALYSIS

A total of 32 paediatric patients indicated for scoliosis surgery will be recruited. Participants will be randomised into study groups in a 1:1 allocation ratio. Patients in the intervention group will receive prophylactic single dose of fibrinogen, in addition to standard of care. Patients in the control group will receive standard of care without study medication prior to skin incision. The primary aim is to assess the safety of prophylactic fibrinogen administration during scoliosis surgery in children, the incidence of any adverse events (AEs) and reactions will be monitored during participation in the study. The secondary objective is to investigate the additional safety information, feasibility and efficacy of a prophylactic fibrinogen administration. The incidence of AEs and reactions according to selected adverse events of special interest will be monitored. All collected data will be subjected to statistical analysis according to a separate statistical analysis plan.

ETHICS AND DISSEMINATION

This trial follows the applicable legislation and requirements for good clinical practice according to the International Conference on Harmonisation E6(R2). All essential trial documents were approved by the relevant ethics committee and national regulatory authority (State Institute for Drug Control) and their potential amendments will be submitted for approval.

TRIAL REGISTRATION NUMBER

NCT05391412.

Stereotactic Body radiotherapy and pedicLE screw fixatioN During one hospital visit for patients with symptomatic unstable spinal metastases: a randomized trial (BLEND RCT) using the Trials within Cohorts (TwiCs) design

BACKGROUND

Spinal metastases can lead to unremitting pain and neurological deficits, which substantially impair daily functioning and quality of life. Patients with unstable spinal metastases receive surgical stabilization followed by palliative radiotherapy as soon as wound healing allows. The time between surgery and radiotherapy delays improvement of mobility, radiotherapy-induced pain relief, local tumor control, and restart of systemic oncological therapy. Stereotactic body radiotherapy (SBRT) enables delivery of preoperative high-dose radiotherapy while dose-sparing the surgical field, allowing stabilizing surgery within only hours. Patients may experience earlier recovery of mobility, regression of pain, and return to systemic oncological therapy. The BLEND RCT evaluates the effectiveness of SBRT followed by surgery within 24 h for the treatment of symptomatic, unstable spinal metastases.

METHODS

This phase III randomized controlled trial is embedded within the PRospective Evaluation of interventional StudiEs on boNe meTastases (PRESENT) cohort. Patients with symptomatic, unstable spinal metastases requiring stabilizing surgery and radiotherapy will be randomized (1:1). The intervention group (n = 50) will be offered same-day SBRT and surgery, which they can accept or refuse. According to the Trial within Cohorts (TwiCs) design, the control group (n = 50) will not be informed and receive standard treatment (surgery followed by conventional radiotherapy after 1-2 weeks when wound healing allows). Baseline characteristics and outcome measures will be captured within PRESENT. The primary outcome is physical functioning (EORTC-QLQ-C15-PAL) 4 weeks after start of treatment. Secondary endpoints include pain response, time until return to systemic oncological therapy, quality of life, local tumor control, and adverse events up to 3 months post-treatment.

DISCUSSION

The BLEND RCT evaluates the effect of same-day SBRT and stabilizing surgery for the treatment of symptomatic, unstable spinal metastases compared with standard of care. We expect better functional outcomes, faster pain relief, and continuation of systemic oncological therapy. The TwiCs design enables efficient recruitment within an ongoing cohort, as well as prevention of disappointment bias and drop-out as control patients will not be informed about the trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05575323. Registered on October 11, 2022.

Kinetics of Biomarkers of Oxidative Stress in Septic Shock: A Pilot Study

Septic shock is a major cause of mortality in ICU patients, its pathophysiology is complex and not properly understood. Oxidative stress seems to be one of the most important mechanisms of shock progression to multiple organ failure. In the present pilot study, we have analysed eight oxidative-stress-related biomarkers in seven consecutive time points (i.e., the first seven days) in 21 septic shock patients admitted to the ICU. Our objective was to describe the kinetics of four biomarkers related to pro-oxidative processes (nitrite/nitrate, malondialdehyde, 8-oxo-2′-deoxyguanosine, soluble endoglin) compared to four biomarkers of antioxidant processes (the ferric reducing ability of plasma, superoxide dismutase, asymmetric dimethylarginine, mid-regional pro-adrenomedullin) and four inflammatory biomarkers (CRP, IL-6, IL-10 and neopterin). Furthermore, we analysed each biomarker’s ability to predict mortality at the time of admission and 12 h after admission. Although a small number of study subjects were recruited, we have identified four promising molecules for further investigation: soluble endoglin, superoxide dismutase, asymmetric dimethylarginine and neopterin.

Delivery of a Healthy Baby from a Brain-Dead Woman After 117 Days of Somatic Support: A Case Report

Patient: Female, 27-year-old

Final Diagnosis: Brain death

Symptoms: Loss of consciousness

Medication:—

Clinical Procedure: —

Specialty: Critical Care Medicine • Obstetrics and Gynecology

Impact of the COVID-19 pandemic on quality of life and emotional wellbeing in patients with bone metastases treated with radiotherapy: a prospective cohort study

Implementation of COVID-19 measures may have induced concerns about access and quality of health care for cancer patients with bone metastases, and it may have affected their quality of life. In this study, we evaluated the effect of the first COVID-19 lockdown on quality of life and emotional functioning of patients with stage IV cancer treated for painful bone metastases in the UMC Utrecht, the Netherlands. A COVID-19 specific questionnaire was sent to active participants in the Prospective Evaluation of interventional StudiEs on boNe meTastases (PRESENT) cohort, consisting of patients irradiated for metastatic bone disease. Patient reported outcomes (PROs) were compared with the last two PROs collected within the PRESENT cohort before the COVID-19 lockdown in the Netherlands on the 16th of March. For the 169 (53%) responders, median age at start of lockdown was 68 years (range 38–92) and 62% were male. Patients reported a statistically significant decrease in emotional functioning (83.6 to 79.2, P = 0.004) and in general quality of life score during the COVID-19 lockdown (72.4 to 68.7, P = 0.007). A steep increase in feeling isolated was reported (18% before and 67% during lockdown). This study has shown a strong increase in the experience of isolation and a decrease of emotional functioning and general quality of life during the COVID-19 lockdown in cancer patients with bone metastases. Due to the nature of the treatment of this patient population, efforts should be made to minimize these changes during future lockdowns.

Pre-treatment expectations of patients with spinal metastases: what do we know and what can we learn from other disciplines? A systematic review of qualitative studies

Background

Little is known about treatment expectations of patients with spinal metastases undergoing radiotherapy and/or surgery. Assuming that patients with spinal metastases share characteristics with patients who had spinal surgery for non-cancer related conditions and with advanced cancer patients, we performed a systematic review to summarize the literature on patient expectations regarding treatment outcomes of spinal surgery and advanced cancer care.

Methods

A comprehensive search was performed in MEDLINE, EMBASE and PsycINFO for studies between 2000 and sep-2019. Studies including adult patients (> 18 years), undergoing spinal surgery or receiving advanced cancer care, investigating patients’ pre-treatment expectations regarding treatment outcomes were included. Two independent reviewers screened titles, abstracts and full-texts, extracted data and assessed methodological quality.

Results

The search identified 7343 articles, of which 92 were selected for full-text review. For this review, 31 articles were included. Patients undergoing spinal surgery had overly optimistic expectations regarding pain and symptom relief, they underestimated the probability of functional disability, and overestimated the probability of (complete) recovery and return to work. Studies highlighted that patients feel not adequately prepared for surgery in terms of post-treatment expectations. Similarly, advanced cancer patients receiving palliative treatment often had overly optimistic expectations regarding their survival probability and cure rates.

Conclusions

Patients tend to have overly optimistic expectations regarding pain and symptom relief, recovery and prognosis following spinal surgery or advanced cancer care. Pretreatment consultation about the expected pain and symptom relief, recovery and prognosis may improve understanding of prognosis, and promote and manage expectations, which, in turn, may lead to better perceived outcomes.

Trial registration

PROSPERO registration number: CRD42020145151.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07683-7.

Comparison of continuous versus intermittent enteral nutrition in critically ill patients (COINN): study protocol for a randomized comparative effectiveness trial

Background

Enteral nutrition is part of the treatment of critically ill patients. Administration of enteral nutrition may be associated with signs of intolerance, such as high gastric residual volumes, diarrhea, and vomiting. Clinical trials regarding the effects of the mode of administration of enteral nutrition on the occurrence of these complications have yielded conflicting results. This trial aims to investigate whether the mode of administration of enteral nutrition affects the time to reach nutritional targets, intolerance, and complications.

Methods

COINN is a randomized, monocentric study for critically ill adult patients receiving enteral nutrition. Patients will be randomly assigned to two groups receiving (1) continuous or (2) intermittent administration of enteral nutrition. Enhancement of enteral nutrition will depend on signs of tolerance, mainly the gastric residual volume. The primary outcome will be the time to reach the energetic target. Secondary outcomes will be the time to reach the protein target, tolerance, complications, hospital and ICU lengths of stay, and 28-day mortality.

Discussion

This trial aims to evaluate whether the mode of application of enteral nutrition affects the time to reach nutritional targets, signs of intolerance, and complications.

Trial registration

ClinicalTrials.gov NCT03573453. Registered on 29 June 2018

P781Resveratrol improves cardiac function and exerts an anti-inflammatory effect in systolic heart failure patients

Introduction

The positive effects of resveratrol on heart failure have already been evaluated in several experimental animal models, however, in a human clinical trial it was not yet confirmed. The aim of our study was to assess the effect of resveratrol supplementation on left ventricular structure and function in patients with heart failure with reduced ejection fraction (HFrEF).

Methods and materials

60 HFrEF patients (age: 66.7±11.04 years, 17 women and 43 men) were enrolled into our study. They were randomized into two groups, in the first group (n=30) daily 2x50 mg resveratrol was administered orally and placebo was given in the other group (n=30). 56% of the enrolled patients had ischemic HFrEF. During the whole study period, patients were taken the optimal medical therapy of HFrEF (ACEI/ARB, BB, MRA) in the same dose as before the randomization. On the day of randomization and 3 months later echocardiography, six minutes walking test (6MWT) and quality of life questionnaire (QoL) test were performed. Besides the routine lab tests, the levels of biomarkers (NT-proBNP, galectin-3) and inflammatory cytokines (IL-1, IL-6) were also measured.

Results

After the 3-month-long follow-up period left ventricular ejection fraction improved significantly in the resveratrol group comparing to the placebo group (p<0.001). The function of the right ventricle (RV) improved (p<0.05), moreover the RV dimensions, as well as atrial volumes decreased significantly in the resveratrol group (p<0.05). In the case of 6MWT (p<0.05) and QoL test (p<0.05) a significant improvement could be observed in the resveratrol group versus the placebo group (p<0.05). Lab test analysis showed that resveratrol supplementation reduced significantly the total cholesterol level (p<0,05) and LDL-C level (p<0,05) and had no overt effect on other metabolic parameters. NT-proBNP level increased significantly in the placebo group (p<0.05) by the end of the trial, however, in the resveratrol group we could see a slight improving tendency (NS). In the case of Galectin-3, no significant changes could be seen.

Conclusions

Our results revealed that resveratrol supplementation in systolic heart failure patients adding to the standard medical therapy resulted in an improvement of echocardiographic parameters, functional status and decreased the level of inflammatory cytokines.

Acknowledgement/Funding

GINOP-2.3.2-15-2016-00048

Physical activity levels of women with breast cancer during and after treatment, a comparison with the Dutch female population

Background: Physical activity has been shown to reduce side-effects of breast cancer and its treatment. As physical activity levels of patients with breast cancer are largely unknown, we investigated these levels and compared them to women from the general population. Methods: In this prospective cohort study, physical activity levels of women with breast cancer participating in the UMBRELLA cohort were assessed at radiotherapy intake and thereafter every 6 months up to 3 years with the SQUASH questionnaire, which was also used in a random sample of the Dutch population. We compared physical activity levels (no activity, low, moderate or high levels of sports, leisure time or total activity) between patients and the Dutch female population using multinomial logistic regression. Standardized Prevalence Ratios (SPR) were calculated to compare adherence to Dutch physical activity guidelines. Results: Women with breast cancer (n_baseline = 1655, n_{6 months} = 1414, n_{12 months} = 1186, n_{18 months} = 957, n_{24 months} = 744, n_{30 months} = 555, and n_{36 months} = 377) were less likely to spend time in physical activity compared to the general population (n = 11,710) until 3 years post-diagnosis, especially after 6 months (OR_{high-vs.-no activity} = 0.34, 95% CI: 0.28-0.41). From 12 months onwards, patients were more likely to perform sports compared to the general population, especially patients who underwent systemic therapy. Guideline adherence was significantly lower in patients at baseline and 6 months (SPR_baseline = 89, 95% CI: 82-97; SPR_{6 months} = 88, 95% CI: 81-96), and comparable to the general population at 12-36 months, especially in older women. Conclusions: Physical activity levels in women with breast cancer during and after treatment were lower compared to the Dutch female population. Three years post-treatment, they were still less physically active, although they spend more time in sport activities. As about half of the patients did not perform any sports, physical activity needs to be stimulated during and after treatment.

An Ancillary Tool for the Diagnosis of Amyloid A Amyloidosis in a Variety of Domestic and Wild Animals

Immunohistochemistry, the standard method for diagnosing amyloid A (AA) amyloidosis, is limited in animals because it requires a large array of animal-specific anti-AA antibodies, not commercially available. The Shtrasburg method (SH method) is a highly specific and sensitive technique, helping in the diagnosis and determination of AA amyloidosis in humans. The aim of this study is to determine whether the SH method is applicable in the diagnosis of AA amyloidosis in a variety of animals. Tissue samples were obtained from animals suffering from spontaneous or experimentally induced AA amyloidosis (mice, hamsters, guinea pigs, cheetahs, cats, cows, ducks, a dog, a goose, a chicken, and a turaco). Detection of the amyloid and quantitative evaluation were performed using Congo red staining, and specific AA typing was performed by the potassium permanganate technique. The studied tissues were subjected to the SH method, which confirmed the AA nature of the amyloid deposit, by displaying in polyacrylamide gel electrophoresis protein bands consistent with the molecular weight of the species-specific AA, in all the animals examined, except mice, hamsters, and guinea pigs. N-terminal analysis of these bands corroborated their AA origin. We conclude that the SH method may be used as an ancillary simple tool for the diagnosis of AA amyloidosis in a large number of domestic and wild animals. Moreover, our findings further increase the feasibility of applying this method in humans.

Soluble ST2 levels in patients with cardiogenic and septic shock are not predictors of mortality

BACKGROUND

Soluble ST2 (sST2) is an interleukin-33 receptor. sST2 was found to be an independent prognostic factor in patients with myocardial infarction, sepsis and heart failure.

OBJECTIVES

To assess sST2 levels in patients with cardiogenic shock (CS) and septic shock (SS), and to evaluate the prognostic value of sST2 for short-term mortality.

METHODS

The present prospective observational study evaluated 32 patients with CS, 17 patients with SS and 61 patients with ST segment elevation myocardial infarction (STEMI )(control group). Samples of serum were collected eight times and the follow-up time was three months.

RESULTS

sST2 levels were elevated from admission in SS patients relative to patients with CS and STEMI, who exhibited peak sST2 levels 24 h after admission. On admission, CS patients had a median (5th percentile; 95th percentile) sST2 level of 62.5 pg/mL (8.3 pg/mL; 315.8 pg/mL) and SS patients had a median sST2 level of 216.4 pg/mL (46.8 pg/mL; 364.4 pg/mL). ROC analysis found sST2 to be a biomarker that could distinguish between CS and SS at admission (area under the curve [AUC] 0.813; P<0.01) with a cut-off value of 210.4 pg/mL. Patients with STEMI had significantly lower sST2 levels at admission (20.3 pg/mL (4.2 pg/mL; 339.8 pg/mL) compared with CS patients. The AUC of the ROC analysis was 0.671 (P=0.007) for the detection of CS in patients with STEMI. Only a weak correlation was observed between sST2 and B-type natriuretic peptide (r=0.376, P=0.05) and sST2 and N-terminal pro-B-type natriuretic peptide (r=0.496, P=0.019). No statistically significant differences were observed in sST2 levels in patients with CS and SS relative to three-month mortality.

CONCLUSION

Levels of sST2 at admission are significantly higher in patients with SS compared with CS. sST2 could be a diagnostic marker to distinguish SS and CS as well as CS and STEMI at the time of admission. Levels of sST2 are related to levels of natriuretic peptides in CS but not in SS. sST2 levels are not a suitable prognostic marker for patients with CS and SS.

Thrombelastography during an acute normovolemic hemodilution in patient undergoing radical retropubic prostatectomy

The aim of our study was to monitor a patient undergoing radical prostatectomy (RP) with an extraordinary large blood loss of 3600 ml. The perioperative bleeding was minimalized through an acute normovolemic hemodilution (ANH). During the procedure we monitored the patient's hemocoagulation profile. ANH is one of the possibilities for practical and pragmatic hemotherapy. It is a safe and effective method when facing massive blood loss or when it is necessary to temporarily replace or substitute the blood with a fluid during the operation (through a transfusion of allogeneic blood); and the patient benefits from the procedure. We argue that during ANH, the hypercoagulatory state appears in the patient--and even during the introduction of a combined solution of both crystalloids and colloids. In fact, during ANH it should not be recommended to provide a substitute for the patient's blood using only a single crystalloid solution alone (Tab. 2, Ref. 16).

Therapeutic hypothermia after out-of-hospital cardiac arrest with the target temperature 34-35 degrees C

BACKGROUND

The objective of this study was to evaluate the impact of mild hypothermia (34-35 degrees C) on the final neurological outcome in patients after resuscitation from out-of-hospital cardiac arrest.

METHODS

Forty three patients, admitted at University Hospital Brno after the out-of-hospital cardiac arrest, were included in the cohort study. The inclusion criteria were out-of-hospital cardiac arrest resulting from ventricular fibrillation or non-perfusing ventricular tachycardia as well as recovery of spontaneous circulation within 60 minutes after first symptoms. Blanketrol II (Cinncinnatti Sub Zero, USA) water mattresses were used for cooling the patients. The temperature was maintained at 34-35 degrees C for 24 hours. Favorable neurological outcome was defined as a Pittsburgh cerebral-performance category 1 (good recovery) or 2 (moderate disability) on five-category scale.

RESULTS

The required temperature was reached in all patients; the cooling rate was 0.8 +/- 0.3 degrees C/hour. The time between the restoration of circulation and reaching the temperature of 35 degrees C was 119 +/- 32 minutes. The time induce the hypothermia (with the core body temperature below 35 degrees C) was 26 +/- 2 hours. Good outcome at hospital discharge was achieved in 21 out of 43 (49%) patients. Ten patients died in the hospital and two patients died after the discharge from the hospital, with the overall 6 months mortality being 28%.

CONCLUSION

The study confirmed feasibility, safety and possible efficacy of the mild hypothermia (34-35 degrees C) patients after the cardiac arrest. To evaluate whether the target temperature 34-35 degrees C is as beneficial as 32-34 degrees C; a randomised controlled trial design should be used (Tab. 4, Fig. 2, Ref. 17). Full Text (Free, PDF) www.bmj.sk.

Mild hypothermia for intracranial aneurysm surgery

BACKGROUND

Eighty nine patients with established intracranial aneurysm (Hunt-Hess score 1 to 3), who were operated at The Department of Neurosurgery, University Hospital Brno in 2003-2006, were enrolled in to the study group.

METHODS

After introduction of anesthesia, we started cooling with two circulating-water mattresses (Blanketrol III, Cincinnatti Sub Zero). Body temperature was maintained at 34 degrees C during preparation of cerebral vessels. Active rewarming was started after clip putting. Cooling rate was 0.9 +/- 0.3 degree C per hour and rewarming rate was 0.7 +/- 0.3 degrees C per hour. The required core body temperature was achieved in all patients, i.e. in 100% of cases. Measured values of both esophageal and bladder temperature were not significantly different (p = 0.4475). No significant difference was found when preoperative coagulation parameters and values measured during managed hypothermia were compared. Neurological condition was evaluated as good in 82 patients (92%). Two patients died and one patient was in vegetative status.

CONCLUSION

When compared with similar group of patients, who underwent surgery in 1998 to 2002, where good treatment results were achieved in 80%, final good neurological treatment results increased statistically significantly by 12% due to managed hypothermia as well (p = 0.0086) (Tab. 4, Ref. 11).

Acute normovolemic haemodilution for management of blood loss during radical prostatectomy

INTRODUCTION

The reduction of the risks of anemia and allogeneic transfusion is one the basic parts of the anaesthesia management in large urological procedures. We used acute normovolemic haemodilution (ANH) as a technique of autologous blood procurement in patients scheduled for radical prostatectomy.

METHODS

15 patients undergoing radical prostatectomy were enrolled in our study. After starting general anaesthesia the left radial artery line was placed for invasive blood pressure monitoring and withdrawing blood for ANH. The restoration of circulated volume was instituted by infusion of crystalloids and colloids. Reinfusion of gained blood was started after transfusion trigger was reached (Hct 0.25).

RESULTS

The average total blood loss was in amount of 2393 +/- 238 (ml), autologous blood was infused in amount of 1919 +/- 220 (ml). The preoperative haematocrit was 41 +/- 3, after ANH 29 +/-2 and 31 +/- 3 (%) postoperatively. One unit of allogeneic blood was transfused in 2 patients only. All patients were hemodynamically stable during the entire surgery, with minimal systolic blood pressure of 100 mmHg and were extubated in the operation room with no complications.

CONCLUSIONS

This study demonstrated the effectiveness and safety of ANH as a method for avoiding the allogeneic blood transfusion in patients undergoing radical prostatectomy (Tab. 1, Ref. 10). Full Text (Free, PDF) www.bmj.sk.

A retrospective analysis of medical or surgical therapy in young patients with diverticulitis

BACKGROUND

Acute diverticulitis is increasingly being recognized in younger patients, but its management remains controversial.

AIM

To compare long-term outcomes of young patients treated with surgery vs. medical therapy for their first episode of diverticulitis.

METHODS

A retrospective chart analysis at a university and an affiliated community hospital between 1991 and 2002 revealed 149 patients < or = 40 years of age with confirmed diverticulitis. Forty-nine patients (38 males, 11 females) were contacted at least 1 year after their first episode of diverticulitis. Outcomes were compared based on initial therapy--antibiotics or surgical resection. The groups were compared by outcomes, gender, age, white blood cell count, temperature and diet.

RESULTS

Three (15%) of 20 surgical patients (mean follow-up 6.89 years), and 16 (55%) of 29 medical patients had a recurrence of diverticulitis (mean follow-up 5.72 years; P = 0.01). The treatment groups did not differ in age, white blood cell count, or temperature.

CONCLUSIONS

(i) Surgical treatment is effective initial therapy but disease may recur in a minority of patients; (ii) medical treatment is less effective initial therapy, with recurrence in half of the patients; (iii) initial presentation is not a strong predictor of disease recurrence.

Increased propensity for amyloidogenesis in male mice

BACKGROUND

The male sex is a risk factor for reactive amyloidogenesis in several disease entities. Environmental, socioeconomic or genetic factors may underlie this male preponderance. This study was aimed at discovering whether male sex predisposes to reactive amyloidosis also in mice and to elucidate some of the hormonal associations of this risk.

METHODS

Male and female Swiss mice were subjected to an established amyloid induction protocol and the amount of their splenic amyloid was determined and compared. The effect of estrogen, progesterone, testosterone and adrenalin on amyloidogenesis was studied in both sexes by administering these hormnones during amyloid induction and comparing the amount of splenic amyloid of the study mice with the control mice which received the amyloid induction protocol alone.

RESULTS

Amyloid deposition appeared to be more abundant in male mice. This gender difference was not associated with any of the 3 sex hormones tested. Despite an expected increment, adrenalin caused an attenuation of amyloid deposition.

CONCLUSIONS

The preferential expression of reactive amyloidosis in male mice seems to be unrelated to the common sex hormones. Increased production of other hormones such as adrenalin, or perhaps an augmented susceptibility to their effect, may cause gender differences by suppressing female amyloidogenesis. Our study favors the hypothesis of genetic predisposition as the mechanism leading to sex differences in amyloidogenesis. Further validation of our findings in gonadal ablated models and other amyloid induction protocols is warranted.

DCC protein expression in clear cell renal cell carcinoma

OBJECTIVES

To investigate whether the expression of protein from the "deleted in colorectal cancer" (DCC) gene, which predicts a poor outcome for patients with colorectal carcinoma, can also serve as a prognostic factor in renal cell carcinoma (RCC).

PATIENTS AND METHODS

The expression of DCC was evaluated immunohistochemically in 94 paraffin-embedded tumour samples from patients with stage T1, T2, and T3 clear cell RCC. The mean follow-up was 52.3 months. The endpoints of the study were recurrence of disease and death from disease.

RESULTS

The under-expression of DCC protein was detected in 63% of patients who died from the disease and in 36% with no evidence of disease. DCC protein under-expression was detected in all patients with T1 tumours who died from the disease, in half the T2 tumours and in two-thirds of T3 tumours.

CONCLUSION

DCC protein under-expression correlated with more aggressive tumour behaviour and a greater risk of death from RCC. However, a larger cohort of patients should be assessed before drawing definitive conclusions.

Human DNA topoisomerase-IIalpha expression as a prognostic factor for transitional cell carcinoma of the urinary bladder

OBJECTIVE

To investigate the immunohistochemical expression of topoisomerase II-alpha (TII-alpha, a nuclear enzyme, the expression of which increases rapidly at the end of the S to G2/M phase and declines when mitosis ends) in bladder urothelial neoplasms (transitional cell carcinoma), and its correlation with grade, stage and survival.

PATIENTS AND METHODS

Histological sections from 57 urothelial neoplasms were stained immunohistochemically for TII-alpha expression; the percentage of positive cells in the area of greatest staining was recorded as the TII-alpha index.

RESULTS

TII-alpha nuclear staining was positive in all the samples except one. The mean (sd) TII-alpha index was 10.7 (5.9) in urothelial neoplasms of low malignant potential (grade 1), 15.5 (5.0) in low-grade (grade 2) and 42.1 (13.4) in high-grade urothelial carcinoma (grade 3). The mean TII-alpha index was 10.7 (5.9), 26.3 (14.8) and 44 (19) in stages pTa, pT1 and pT2, respectively. The TII-alpha index was significant for predicting death from cancer, independently of the stage or grade of the disease (P = 0.019, hazard ratio 1.1).

CONCLUSIONS

A higher TII-alpha index indicates a greater probability of recurrence of disease and lower overall survival. Therefore TII-alpha expression has prognostic value in bladder carcinoma.

"No-reflow" phenomenon as a cause of hypoperfusion after severe head injury?

INTRODUCTION

Severe head injuries are known to cause secondary ischaemic brain damage. Ischaemia may develop due to transtentorial herniation or due to increased intracranial pressure leading to decreased perfusion. Compression of the brain due to extracerebral haematoma may cause hypoperfusion as well.

METHODS

29 patients with postraumatic transtentorial herniation were studied. Haematoma was urgently removed in these patients and CT and SPECT was performed on the 1st and 5th postoperative day. 26 patients had hypoperfusion on SPECT in the vicinity of the previous haematoma. Only 9 of them, however, had ischaemia on CT. There were 11 patients in whom the previous ischaemia seen on SPECT improved on the follow up SPECT examination. 10 of them had a good treatment result.

CONCLUSION

A possible mechanism of hypoperfusion caused by compression of the brain may be a kind of "no-reflow" phenomenon which is known from pathophysiology of classical brain ischaemia. Patients in whom the collateral blood flow overcomes the decreased perfusion in the microcirculation should have a better outcome. (Tab. 1, Fig. 1, Ref. 13).

Anaesthesia management of major hepatic resections without application of allogeneic blood

BACKGROUND

In a prospective study we used acute normovolemic haemodilution (ANH) together with low CVP anaesthesia in order to avoid allogeneic blood transfusion during major liver surgery.

MATERIAL AND METHODS

With institutional approval, 20 patients, ASA classification I-III, undergoing hepatic lobe resection consecutively (18 for metastatic cancer, 2 for hepatocellular cancer) in 2002, were enrolled into the prospective study. A epidural catheter was inserted before surgery in the thoracic region. General anaesthesia was induced and maintained with sevoflurane and fentanyl. Invasive haemodynamic monitoring was instituted. Blood was removed for ANH and circulation volume was replaced by infusion of colloids and crystalloid. The CVP was maintained less than 5 mm Hg during hepatic parenchymal transection. After procedure the ventilated patients were transported to ICU.

RESULTS

The preoperative haematocrit value (Hct) allowed performance of ANH with a blood removal (1025 +/- 357 g) in all patients. The estimated blood loss was 825 +/- 515 ml. None of the subject received allogeneic blood during surgery. One patient had transfusion of 2 units of allogeneic blood the fifth day after the right hepatectomy during a second look for perihepatic hematoma. The CVP was 3.8 +/- 0.4 mmHg during liver resection. Postoperative Hct was 0.31 +/- 0.02 and haemoglobin 108 +/- 11 g/L. All patients were extubated the first day after surgery. There was no hospital mortality.

CONCLUSIONS

We have shown that the routine use of new surgical techniques and low CVP anaesthesia in combination with ANH enabled avoidance of allogeneic blood transfusion in all patients during surgery. (Tab. 3, Ref. 22).

Acute normovolemic haemodilution for management of 4200 ml blood loss during radical prostatectomy

BACKGROUND

We refer a case report of patient with 4200 ml large blood during urological surgery, in which was used acute normovolemic haemodilution as a solely method for avoiding of allogeneic blood transfusions.

METHODS

A 65 years old patient was scheduled for radical prostatectomy. After starting general anaesthesia was removed 2360 g (target haematocrit 0.30 in patients with calculated total body blood volume 5460 ml) of whole blood from patient and circulation volume was replaced by 1500 ml of colloids and 2000 ml of crystalloid solution. Retransfusion was started after 1800 ml blood loss (transfusion trigger--Hct 0.20).

RESULTS

The total blood loss was 4200 ml during 4 hour and 40 minutes of surgery. The patient was the whole operation time haemodynamic stable, with minimal systolic blood pressure 100 mmHg and haematocrit value was 0.32 after the procedure.

CONCLUSIONS

To reduce the risk of anaemia and also the risk of allogeneic blood transfusion is the one of the basic part of the anaesthesia management of large urological procedures. This case demonstrated the effectiveness and safety of acute normovolemic haemodilution as a method for avoiding allogeneic blood transfusion in a patient with 77% loss of total body blood volume.

Intraoperative mild hypothermia therapy in patients scheduled for neurosurgical procedures

BACKGROUND

Deliberate mild hypothermia has been proposed as a means of providing cerebral protection during neurosurgicals procedures complicated by cerebral ischaemia. Our prospective study was designed to examine the safety of deliberate mild hypothermia and to evaluate our techniques for cooling and rewarming.

MATERIALS AND METHODS

With institutional approval, 20 patients scheduled for elective neurosurgery were enrolled into our prospective study. After the induction of anaesthesia, the core temperature was measured by urinary catheters with probes (Kendall). The patients were cooled (temperature of blankets set at 15 degrees C) and rewarmed (temperature set at 40 degrees C) by two circulating water blankets (Blanketrol III, Cincinnati Sub-Zero, Cincinnati). The variables are expressed as a mean +/- standard deviation.

RESULTS

The time of anaesthesia was 316+/-53 min. The core temperature was 36.5+/-0.4 degrees C at the start of anaesthesia. The minimal temperature reached 34.4+/-0.4 degrees C. The patients were cooled at a rate of 1.1+/-0.3 degrees C/h and rewarmed at a rate of 0.9+/-0.4 degrees C/h. The temperature was 35.8+/-0.5 degrees C after the neurosurgical procedure. Deliberate mild hypothermia with rewarming did not cause delays in emerging from anaesthesia. On the control CT scan, no ischaemic changes were observed after surgery.

CONCLUSIONS

Our findings indicate that patients can be cooled and rewarmed by two circulating water blankets, and core temperatures about 34 degrees C were easily achieved. The deliberate mild hypothermia is together with careful anaesthesia management a safe technique of cerebral protection from ischaemic insult during elective neurosurgical procedures. (Tab. 1, Ref. 11.).

Mild hypothermia therapy for patients with severe brain injury

The authors present a group of patients with severe head injuries in which deliberate mild hypothermia was carried out together with the standard treatment protocol according to the European Brain Injury Consortium. Thirty patients with severe head injuries with Glasgow Coma Scale (GCS) score of 3-8 were enrolled into the study. The subjects were divided into two groups. The average age in the hypothermic group of 15 patients was 35 years. The average GCS was 4.5 at the site of accident. Eight patients (53%) sustained associated severe injuries of other organs. The average age of the 15 patients in the normothermic control group was 39 years with an average GCS of 4.3. All the patients in the normothermic group and 11 patients in the hypothermic group underwent neurosurgery, five of them also decompressive craniotomy. Artificial ventilation with continuous monitoring of intracranial pressure (ICP), cerebral perfusion pressure (CPP), arterial blood pressure, jugular bulb oximetry and urinary bladder temperature were instituted in the ICU. Cooling to a core temperature of 34 degrees C in the hypothermic group was achieved by forced air cooling in combination with circulating-water mattress cooling (Blanketrol II, Cincinnati Sub-Zero) and maintained for 72 h. The difference in the Glasgow Outcome Scale (GOS) between the hypothermic and normothermic groups of patients after 6 months was not statistically significant (P value 0.0843). In the hypothermic group, however, good neurological outcome (GOS 4 and 5) was reached in 13 patients (87%), which represents a 40% increase compared with the normothermic control group in which good neurological outcome was reached in 7 patients (47%). Mean normothermia ICP value of 18+/-2 mmHg was significantly (P value 0.0007) reduced during mild hypothermia therapy to 12+/-2 mmHg. Mean normothermia CPP value of 72+/-3 mmHg significantly increased (P value 0.0007) during this time to 80+/-4 mmHg with unchanged systolic arterial pressure (P value 0.9013). There were no cardiac or coagulopathy-related complications. Our results showed that mild therapeutic hypothermia could be useful in improving the outcome and neurological recovery in patients with severe head injuries.

Light chain amyloidosis of the urinary bladder. A site restricted deposition of an externally produced immunoglobulin

AIMS

To identify the amyloid protein in a patient with amyloidosis localised to the urinary bladder, and to see whether subtyping of the protein by sequence analysis increases the understanding of the selection of the urinary bladder as the site of amyloid deposition.

METHODS

A patient with gross haematuria and a congophilic mass in his urinary bladder was evaluated further. Characterisation of the amyloid protein was performed using conventional histological and immunohistochemical methods. Determination of the N-terminal amino acid sequence of the amyloid protein was performed using protein sequencers.

RESULTS

The patient's history, physical examination, and laboratory evaluation excluded the involvement of other organs, justifying a diagnosis of amyloidosis localised to the urinary bladder. Histological and immunological studies showed that the amyloid protein deposited in the urinary bladder of the patient was probably of the amyloid light chain type. No plasma cells or lymphocytes were seen in sections of the urinary bladder and lower ureter adjacent to the amyloid deposits. Molecular analysis showed the sequence NFMLTQPHSISGSPG, which assigned the amyloid protein to either the Vlambda(I) or the Vlambda(VI) immunoglobulin (Ig) light chain families.

CONCLUSIONS

The findings suggest that the amyloid protein in this patient originated outside the urinary bladder. The heterogeneity of the Ig proteins in known cases of amyloidosis of the lower urinary tract suggests that the amino acid residues, which determine the Vlambda subtyping, have no major role in restricting the deposited protein to the urinary bladder.

Translating research findings to PTSD prevention: results of a randomized-controlled pilot study

Based on therapeutic studies revealing positive prognostic factors and on research findings revealing how trauma is processed, we developed the memory structuring intervention (MSI) in attempt to prevent posttraumatic stress disorder (PTSD). The MSI attempts to shift processing of traumatic memory from uncontrollable somatosensory and affective processes to more controlled linguistic and cognitive processes by providing patients organization, labeling, and causality. In a single-blind randomized-controlled pilot study, 17 traffic accident victims at risk for PTSD (heart rate >94 BPM) were assigned to two MSI or two supportive-listening control sessions. Three months later, MSI patients reported significantly less frequent intrusive, arousal, and total PTSD symptoms than controls. A replication study with a larger sample is underway.

Reduced expression of activin A in focal lymphoid agglomerates within nasal polyps

It has been previously reported that activin A, a homodimer of the betaA inhibin subunit, is secreted by stromal cells from mouse bone marrow and causes apoptotic death of mouse plasmacytoma tumor cells. Recent in vitro studies have also implicated this cytokine in the suppression of normal B-cell lymphopoiesis. In this study we examined the occurrence of activin A in nasal polyp tissues that present a combination of epithelium, mesenchyme, and vascular endothelium, with frequent massive hemopoietic infiltration. Anti-betaA-chain antibodies strongly stained epithelial mucous glands and some endothelial cells, and diffusely stained the polyp stroma. Normal adult conchae were similarly stained, whereas activin A was not detected prenatally by immunostaining of nasal tissues. Staining specificity was substantiated by ligand competition assays. Detailed examination of the inflammatory polyp infiltrate showed that activin A staining was reduced in sites of focal infiltration of B-lymphoid cells. It is therefore implied that local accumulation of a large number of B-cells is associated with relatively low activin A expression.

Patterns of protein kinase C isoenzyme expression in transitional cell carcinoma of bladder. Relation to degree of malignancy

We determined the pattern of protein kinase C (PKC) isoform expression in human cell lines by Western blotting and immunofluorescent staining techniques. In addition, we examined PKC isoform expression in tissue samples of transitional cell carcinoma (TCC) of the bladder. PKC delta, PKC beta II, and PKC eta were found primarily in the RT4 cell line (low-grade tumor), and PKC zeta was expressed most strongly in the SUP cell line (invasive tumor). In tissue samples of urinary bladder cancer, PKC isoenzymes were expressed differentially as a function of tumor stage and grade; expression of PKC beta II and PKC delta was high in normal tissue and in low-grade tumors and decreased with increasing stage and grade of TCC. The opposite pattern was seen with PKC zeta. The differences in expression of specific isoenzymes as related to levels of malignancy of the cell lines and tissue samples suggest that the PKC family has an important role in normal and neoplastic urothelium.

Transplacental effect of a 15% olive-oil diet on functional activity of immune components in the spleen and colon tumors of rat offspring

We studied whether feeding pregnant female rats a 15% olive-oil diet affects the activity of lymph cells in the spleen and tumors in offspring with chemically-induced colon tumors. Rat mothers were fed either a 7% corn-oil or a 15% olive-oil diet. Five-week-old male offspring were divided into 3 groups. A control group was fed the 7% corn-oil diet similar to their mothers. The experimental group I was fed the 7% corn-oil diet whereas their mothers were fed the 15% olive-oil diet. The experimental group II was fed the same 15% olive-oil diet as their mothers. Experimental rats were injected weekly for 8 weeks with the carcinogen, 1,2-dimethylhydrazine (DMH), 20 mg/kg b.w. Results of experiments were studied 6 months later. The area of zones in the spleen responsible for producing B and T lymphocytes were measured and the number of cells counted. The activity of lymphoid elements of the spleen and of tumors were studied using immunohistochemical methods for evaluating the synthesis of CD8(+) lymphocytes and proliferative activity of lymphocytes in spleens and tumors. Feeding pregnant or lactating mothers with the 15% olive-oil diet had no marked tumor-protective effect on chemically-induced colon cancer in offspring. Diet-dependent changes were found at the cellular level. In the spleen of control offspring, the presence of a tumor was accompanied by an increase in the number of Ki-67(+) cells and CD8(+) lymphocytes in the red pulp. In experimental group I, DMH significantly increased the total cell number and the number of CD8(+) lymphocytes in the red pulp of the spleen in both tumor-bearing and tumor-free rats. In experimental group II, the total number of lymph cells and the number of CD8(+) lymphocytes increased compared to offspring fed a control diet. Tumor formation activated the proliferative activity of lymph elements. The total number of cells in infiltrates of the colon mucosa decreased in tumor-bearing rats compared to tumor-free counterparts, and this was seen in all three dietary groups of rats. In tumors from offspring of experimental group II, only the number of CD8(+) lymphocytes increased compared to those in offspring of experimental group I. The findings indicate that feeding mothers the 15% olive-oil diet had a cancer-inhibiting role in offspring, predominantly changes at the cellular level.

Inhibition of the second phase of amyloidogenesis in a mouse model by a single-dose colchicine regimen

Amyloidogenesis consists of two stages. In the first, amyloid enhancing factor (AEF) is generated, and in the second, deposition of amyloid fibrils occurs. Colchicine is a known inhibitor of amyloidosis of familial Mediterranean fever (FMF) and of mouse experimental amyloidosis, but the timing and mechanism of its effect are still unclear. The aim of this study is to determine whether colchicine inhibits the second phase of amyloidogenesis and to study the time correlate of such an effect. To that end, amyloid was induced in Swiss male mice with AEF and AgNO(3) (an inflammatory stimulus), a method that skips the first phase of amyloidogenesis. Two amyloid induction protocols were used: a standard protocol, in which AEF and AgNO(3) were administered concurrently, and a prolonged protocol, in which the administration of AgNO(3) was delayed by 24 hours or 7 days. To study the inhibitory effect of colchicine on the second phase of amyloidogenesis, a single dose of colchicine (30 microg) was injected intravenously before, during, or after administration of AgNO(3) in both the standard and prolonged amyloid induction protocols. The amount of amyloid deposition in the spleens was determined with the crush-and-smear technique and a 5-grade scale. Colchicine was found to inhibit the second phase of amyloidogenesis. Its best effect was achieved when administered 48 hours after initiation of AgNO(3) injections. The pattern of colchicine-inhibition-in-time in the standard and the prolonged amyloid induction protocols was similar, indicating that colchicine exerts inhibition through its effect on the inflammatory stimulus (AgNO(3)). These findings suggest that (1) colchicine suppresses amyloidogenesis in the late (second) stage and that (2) this suppression is possibly related to the anti-inflammatory effect of colchicine.

Waldenström's macroglobulinemia associated with AA amyloidosis

It is widely accepted that amyloidosis in Waldenström's macroglobulinemia (WM) is exclusively due to amyloid light-chain deposition. However, only a small number of previous reports have actually characterized the type of amyloid in WM. We now report the third patient with WM and amyloid A protein (AA) amyloidosis. This patient developed malabsorption, nephrotic syndrome, and orthostatic hypotension. AA was immunohistochemically demonstrated in the rectal biopsy. In conjunction with previous examples of AA amyloidosis, the present report raises the possibility that AA amyloidosis may also occur in WM patients.

Histological changes in the cervical lymph nodes after radiotherapy

Radiotherapy to the neck is frequently employed in the treatment of malignancies, sometimes alone and sometimes before or after surgery or with or without chemotherapy. We checked the histopathological changes in the neck after radiotherapy, dividing the changes into two groups. One with short-term changes between six months to one year, and the second group with long-term changes after more than six years. We compared these two groups with a control group without radiotherapy. The changes in the long-term group were more pronounced than in the short-term group, with more stromal fibrosis, vascular changes, and specially lymph nodes smaller than one centimeter. Thus, bigger lymph nodes (more then one centimeter) are more radiosensitive and become smaller after six years.

Capsular collagen staining of follicular thyroid neoplasms by picrosirius red: role in differential diagnosis

A key criterion in the diagnosis of thyroid follicular carcinoma is capsular invasion, but invasion cannot always be demonstrated histologically. Since invasion is likely to evoke reactions in the capsular collagen, we examined the effects of invasion on capsular collagen with the picrosirius orange-red (PSR) staining technique for collagen. Under polarized light, the color of PSR-stained collagen varies as a function of the structural and biochemical properties of the collagen fibers. Capsules of widely invasive carcinomas (n = 10), minimally invasive carcinomas (n = 10), and adenomas (n = 28) were stained with the PSR method. Carcinomas were assessed along the thickened capsule for sites of definite invasion, minimal invasion, and no evidence of invasion. In adenomas, sites of thickened capsules (similar to carcinomas) were compared to sites of thin capsules. All foci were evaluated for the color and color intensity of collagen fibers. We found a significantly higher frequency of yellow-green collagen fibers than of orange-red fibers at sites of invasion, whereas orange-red fibers significantly predominated at non-invaded sites. In a minority of cases both colors occurred but the non-dominant color was of lesser intensity in all but 1 case. There were no significant differences in staining between minimally and widely invasive carcinomas. Thick capsules of adenomas consistently stained with an intense orange-red color, although weakly stained yellow-green fibers were also observed in some of these cases. We conclude that PSR staining can provide diagnostically useful information in capsular samples of carcinomas, when both color and color intensity of PSR staining are evaluated at the same site. Specifically, intense yellow-green birefringence of collagen in a thickened capsule is additional evidence for capsular invasion.

99mTc-MIBI scintigraphy of parathyroid adenomas and its relation to tumour size and oxyphil cell abundance

The aim of this study was to assess the correlation between technetium-99m methoxyisobutylisonitrile (MIBI) uptake by parathyroid adenomas, oxyphil cell content and volume of the lesions. Thirty-one patients with parathyroid adenomas were evaluated prospectively. Preoperative double-phase 99mTc-MIBI scintigraphy was performed in all patients and tracer uptake by parathyroid lesions was assessed semi-quantitatively employing region of interest ratios to normal adjacent neck areas. Surgical specimens underwent histological evaluation and oxyphil cell content was determined. The intensity of tracer uptake was compared with oxyphil cell content, volume of the lesions and serum levels of calcium and parathormone. 99mTc-MIBI tracer uptake was correlated with oxyphil cell content, volume of parathyroid lesions and the functional status of the parathyroid adenomas. Tracer accumulation in oxyphil cells might partially explain the preferential 99mTc-MIBI retention in parathyroid lesions.

Increased incidence of diabetes mellitus in the patients with transitional cell carcinoma of urinary bladder

The progression of bladder cancer to invasive disease is highly dependent on its ability to penetrate basement membrane of urothelium. Studies on diabetic nephropathy have shown a reduction in proteoglycan content of the glomerular basement membrane. Based on the well-known fact that proteoglycans are one of the main components of basement membrane and extracellular matrix we assessed the relationship between diabetes mellitus, bladder cancer incidence and its behavior. These studies include 252 patients with microscopically confirmed transitional cell carcinoma of bladder, and 549 patients with other urological disorders who served as controls. The prevalence of diabetes mellitus in each group was assessed. The group of patients suffering from transitional cell carcinoma was divided according to etiological risk factors such as cigarette smoking, diabetes and patients that were non-smokers and did not suffer from diabetes mellitus. We assessed the features of bladder cancer behavior in each group. Logistic regression model estimation for statistical analysis was used, with transitional cell carcinoma as a dependent binary variable and age, sexes smoking and diabetes as independent variables. Statistical significance was considered at two levels: p <or=0.001 and p <or=0.05. Odds ratio (OR) adjusted to age, sex, cigarette smoking, diabetes mellitus and 95% Confidence Interval (CI) were calculated for TCC. In the TCC group 22.2% of the patients suffered from diabetes mellitus. In the control group 10.38% suffered from diabetes mellitus. Logistic regression analysis, OR and 95% CI showed a statistically significant relationship between diabetes and TCC. These data are comparable only with smoking (OR 2.3; 95% CI 1.6 3.5 and OR 1.58; 95% CI 1.08 2.4 correspondingly). Based on these data we suggest that diabetes mellitus may be considered an etiological risk factor for bladder cancer development.

Neck-dissection surgical specimens treated by lymph node revealing solution

The detection of metastatic lymph nodes in cancer patients is essential for determining the cancer stage, and thus, the therapeutic modalities. However, very small lymph nodes can easily be missed during routine examination. We described a "Lymph Node Revealing Solution" (LNRS) that helps to detect tiny lymph nodes in neck dissection specimens. Twenty-one consecutive specimens of neck-dissection were investigated. The entire surgical specimen, fixed at first in formalin, was searched for lymph nodes by the traditional method. These were excised and sent for processing. The remaining tissue was immersed for 24 hours in LNRS. The lymph nodes stood out as white chalky nodules on the background of the yellow fat. They were then excised, and examined. A total of 227 lymph nodes were detected by the traditional method; 38 (17%) were positive for metastasis. Using the LNRS method, an additional 72 nodes were identified, among them 8 (11%) were positive for metastases and 2 cases were upstaged. LNRS is an inexpensive and easy method of detecting tiny lymph nodes; it enhances significantly the yield of normal and metastatic nodes of neck-dissection specimens and helps to establish a more accurate staging.

Pregnancy and amyloidosis: II. Suppression of amyloidogenesis during pregnancy

The observation of a deleterious effect of pregnancy on kidney function in amyloidosis of familial Mediterranean fever suggests that pregnancy may enhance amyloidogenesis. To determine whether pregnancy may indeed affect amyloidogenesis, pregnant mice were made amyloidotic by administration of amyloid-enhancing factor (AEF) and AgNO3 at different points in time from conception, and amyloid- deposition was studied with the crush-and-smear technique. A possible effect of exogenous female sex hormones (beta-estradiol and progesterone) on amyloidogenesis was studied by administration of these hormones during amyloid induction in nonpregnant female mice. Amyloidogenesis was found to be significantly suppressed in mice during pregnancy. The reduction was possibly related to the effect of pregnancy on the inflammatory stimulus (AgNO3) and not on the administered AEF. Exogenous estrogen and progesterone failed to inhibit amyloidogenesis in nonpregnant mice. These findings suggest that pregnancy may suppress amyloidogenesis in mice. The suppression is caused by an anti-inflammatory effect of pregnancy. Estrogen and progesterone are probably unrelated to this finding.