Surgical technique of laparoscopic ureterocalicostomy using the VIO soft-coagulation system

One of the most crucial issues while performing ureterocalicostomy (UC) in patients with well-functioning thick renal parenchyma is controlling bleeding from the anastomotic site. In general, renorrhaphy is necessary for hemostasis because conventional coagulation remains unreliable in cases of an incised thick renal parenchyma. Instead of the parenchymal renorrhaphy, the VIO soft-coagulation system is used for hemostasis. Sutureless hemostasis using soft coagulation is a safe, feasible, and minimally invasive technique for laparoscopic UC.

Improved detection of donor-specific HLA-class II antibody in kidney transplant recipients by modified immunocomplex capture fluorescence analysis

Immunocomplex capture fluorescence analysis (ICFA) which basic principle is same as Luminex crossmatch (LXM), could detect donor-specific HLA antibody (DSA). The advantages of ICFA are (i) detection of DSA and (ii) no requirement of viable cells over the flow cytometry crossmatch (FCXM). However, FCXM has been widely used because of its higher sensitivity than ICFA, in particular HLA-class II antibody detection. In this study the accuracy of DSA detection against HLA-class II was investigated by modifying the original method of ICFA. Increment of the sensitivity was found when purified peripheral blood mononuclear cells (PBMCs) were used instead of whole blood. An ICFA-PBMC in addition to FCXM-T/B was conducted for 118 patients before kidney transplantation and 13 patients with de novo DSA against HLA-class II after transplantation. Significantly positive correlation was observed between the values of ICFA-PBMC and DSA mean fluorescence intensity (MFI) targeting class II (p < 0.0001). When the cutoff level of 1.4 was determined by receiver operating characteristic curve analysis, the average DSA MFI was found to be significantly higher in the ICFA-PBMC (class II) positive group comparing to that in the negative group (12,217 vs 3885, p = 0.0027). ICFA-PBMC and optimized cutoff level could provide valid information in cases of suspected DSA.

[Nurse questionnaire survey about the urethral catheterization and clinical analysis of iatrogenic urethral injury]

OBJECTIVE

This study was aimed at determining the status of iatrogenic urethral injury associated with insertion of urethral catheters at our hospital.

SUBJECTS AND METHODS

We studied the data of 32 patients with iatrogenic urethral injury at our hospital. We also carried out a questionnaire survey of 150 nurses who could be in charge of urethral catheter insertions, and conducted an analysis based on the answers obtained from 133 of the 150 nurses (response rate 88.7%).

RESULTS

The 32 patients included 14 patients with reduced activity of daily living (ADL) who required assistance in daily life (44%), 4 patients with spinal cord injury (13%), and 4 patients under anesthesia or sedation (13%). Acute complications included sepsis in 5 patients (16%) and septic shock in 3 patients (9%). Long-term urethral catheterization was indicated in all the patients with sepsis. Examination of the responses to the questionnaire showed that while 86% of the nurses said "I inject water to fix the balloon after confirming urine outflow," 7% answered "I inject water into the balloon even if there is no urine outflow"; 46% said "I compress the lower abdomen when there is no urine outflow," 6% said "I perform urinary bladder irrigation," and 48% said "I neither compress the lower abdomen when there is no urinary flow nor perform urinary bladder irrigation".

CONCLUSION

Nearly half of the patients with iatrogenic urethral injury at our hospital had reduced ADL. In the patients in whom long-term catheterization was indicated, urethral injury at the time of regular replacement of a catheter was associated with a high likelihood of sepsis occurring as a complication. Based on the results of the questionnaire, more than 80% of the nurses complied with the rule that water to fix the balloon must be injected only after confirming urinary outflow at the time of inserting a urethral catheter. However, when there was no urine outflow after insertion of the catheter, there were variations in the procedure to handle the situation. In the education of nurses, training on the appropriate actions that must be taken in this situation appears to be important.

Activation of the rostral pontine reticular formation increases the spinal glycine level and inhibits bladder contraction in rats

PURPOSE

We examined the mechanism involved in the inhibition of bladder activity in rats by stimulating the rostral pontine reticular formation (RPRF) using carbachol, flavoxate and propiverine, and by analysis of amino acid levels in the lumbosacral cord.

MATERIALS AND METHODS

A total of 82 female rats were anesthetized with urethane. Under isovolumetric conditions physiological saline, carbachol, flavoxate or propiverine was injected into the RPRF or intravenously. Changes in bladder activity and amino acid levels in the lumbosacral cord were examined.

RESULTS

Injection of carbachol or flavoxate (0.3 microM each) into the RPRF abolished bladder contraction but there was no change after injection of physiological saline or propiverine. Intravenous injection of flavoxate or propiverine (0.1 to 10 mg/kg each) inhibited bladder contraction. Amino acid analysis revealed that injection of carbachol into the RPRF increased glutamate and glycine levels in the lumbosacral cord, while injection of flavoxate into the RPRF or intravenously caused an increase in glycine the lumbosacral cord. Injection of propiverine into the RPRF or intravenously did not influence lumbosacral cord amino acid levels.

CONCLUSIONS

These results suggest that the RPRF has an important role in the inhibition of bladder contraction and carbachol or flavoxate can activate descending RPRF neurons and inhibit bladder contraction via spinal glycinergic neurons.

[Risk factors for duration of urinary incontinence after radical prostatectomy]

PURPOSE

In this study, we examined risk factors for duration of incontinence after radical prostatectomy at our hospital.

MATERIALS AND METHODS

From April 1988 to March 2000, 45 patients with prostate cancer underwent retropubic radical prostatectomy at our hospital. Thirty-eight of 45 patients could be followed up. The patients' age, height, weight, body mass index (BMI), preoperative prostatic specific antigen level, clinical stage, nerve-sparing surgery or none, operation time, bleeding volume, resected prostate weight, cancer positive or negative at surgical margins, postoperative stage, radiation therapy or none, anti-androgen therapy or none, duration of postoperative incontinence, and follow-up period were examined.

RESULTS

All patients had postoperative stress incontinence, and no one had urge incontinence. Medians of duration of postoperative incontinence and follow-up period were 5.5 and 12 months, respectively. When the patients were divided into 2 groups by the value of each parameter, postoperative anti-androgen therapy (chi 2 test, p = 0.0429) and high BMI (> or = 25.0 kg/m2, p = 0.0206) were related to the long duration (> or = 5.5 months) of postoperative incontinence.

CONCLUSION

These results suggest that common factors are involved in the etiology of prolonged incontinence after radical prostatectomy and genuine stress incontinence in women. Therefore, both body weight control and pelvic floor muscle exercise might be also important for the treatment of incontinence after radical prostatectomy.

[Cranioplasty for isolated trigonocephaly with developmental disorder]

We reported 50 cases of mild to moderate trigonocephaly (most isolated type) treated by cranioplasty. All of them had clinical symptoms such as severe hyperactivity, speech delay, inability to communicate with others, self-mutilation (head banging), irritability, temper tantrum and mental retardation. Pre-operative CT scan and MRI showed no abnormal findings in the brain except for constricted frontal lobes. The 3 D-CT scan showed the most important diagnostic findings: a ridge of the metopic suture and narrow anterior fossa. TcECD SPECT was performed on 43 patients, and demonstrated in 31 cases some degree of decreased cerebral blood flow (CBF), mainly in the bilateral frontal lobes. Post-operatively, most patients improved to some degrees. The results were compared to those of trigonocephaly patients without cranioplasty. The operated group showed better improvement in the above clinical symptoms, especially, hyperactivity, indifference to others, understanding of verbal communication, self-mutilation, irritability and temper tantrum. The post-operative SPECT represented the increased CBF in 30 out of the 31 cases. MRI and CT scan revealed expanded frontal lobes. Thus, cranioplasty may alleviate the symptoms of patients with mild to moderate trigonocephaly and developmental disorders.

Relation among left ventricular mass, insulin resistance, and blood pressure in nonobese subjects

Because left ventricular (LV) mass (LVM) is a powerful predictor of future cardiovascular events, it is important to identify hemodynamic and nonhemodynamic factors that increase LVM. We studied the separate contribution to LVM of daily arterial blood pressure (BP) and insulin resistance in a consecutive series of 29 (mean+/-SD age, 43+/-13 yr) nonobese (body mass index, 24+/-1.8 kg/m2), nondiabetic, glucose-tolerant subjects with untreated borderline or mild hypertension. The insulin sensitivity index (SI) was quantitatively determined from the frequently sampled iv glucose tolerance test. BP was characterized by ambulatory 24-h BP monitoring, and LVM index (LVMI) was determined by two-dimensional directed M-mode echocardiography. LVMI was directly related to 24-h mean BP (r=0.47; P=0.01). LMVI was also significantly related to Si (r=-0.43; P=0.02). In this nonobese group, neither LVMI nor Si was related to body mass index or age. After adjustment for the influence of BP on LVMI, a significant relation remained between LVMI and Si (P < 0.05). We conclude that in nonobese subjects with high normal BP, insulin sensitivity is related to LVM independently of BP and may be an important modulator of LV growth. In addition to a reduction of arterial BP, optimal prevention of LV hypertrophy in hypertensives may require improved insulin sensitivity.

Motor function of infants with athetoid cerebral palsy

The motor function of 35 children with athetoid cerebral palsy was examined retrospectively using videotape recordings made at five to eight months of age. Many infants showed asymmetric tonic neck, Moro and Galant reflexes. Movements shown to be difficult included: keeping a symmetric supine posture, isolated movements of the hips and knees, forward extension of the upper extremity, extension of neck and trunk in the prone position and in ventral suspension, flexion of the neck in the traction response, and weight support by the upper extremities. Asymmetric or excessive opening of the mouth was present in all infants. The grade of difficulty for each posture and movement might reflect subsequent motor disability at three years of age.

Transport of Na+ and HCO3- out of red blood cells is simultaneous with a chloride shift in canine and human whole blood exposed to CO2-rich gas

To study the release of Na+ from erythrocytes, arterial whole blood obtained from anesthetized and heparinized dogs (n = 8), or human (n = 9) venous blood was aerated with a CO2-rich gas mixture (15% CO2, 25% O2, 60% N2) at a rate of 1 l/min. To examine possible mechanisms involved in the release of sodium ions into plasma, CO2-rich gas was also passed through whole blood in the presence of acetazolamide (n = 8), SITS (n = 8), or furosemide (n = 8). The changes in blood gas parameters, plasma protein concentration, hematocrit, and plasma sodium, chloride, and bicarbonate ion concentrations were examined. When CO2-rich gas was passed through treated and untreated canine or human whole blood, PCO2 and plasma sodium and bicarbonate contents per ml of blood increased, while pH and plasma chloride content per ml of whole blood decreased. After 0 to 5 min of CO2-rich gassing, the mean rates of change in plasma ion contents per ml of whole blood per min were related by the following equations: (1) delta MCI- = a (delta MNa+), (2) delta MHCO3- = b(delta MNa+), (3) delta MHCO3- approximately equal to delta MNa+ + delta MCl-, (4) b approximately equal to 1 + a. These results suggest that the release of Na+ and HCO3- from erythrocytes into plasma in canine and human whole blood occurred in a one-to-one ratio simultaneously with, and probably independently of, the well-known chloride shift during a period of 0 to 5 min after the start of CO2-rich gassing.

Effects of nifedipine-GITS on left ventricular mass and left ventricular filling

Sixteen patients with initial diastolic blood pressure greater than or equal to 120 mm Hg were treated for 1 year with extended-release nifedipine [nifedipine-GITS (gastrointestinal therapeutic system)]. Serial changes in left ventricular mass index and associated alterations in left ventricular systolic function, left ventricular filling, plasma renin activity, atrial natriuretic peptide, and catecholamines were evaluated. Blood pressure was significantly reduced from 200 +/- 8/122 +/- 3 mm Hg (mean +/- SEM) to 144 +/- 5/89 +/- 2 mm Hg (p less than 0.0001) at 1 year. Eleven patients (69%) required only nifedipine-GITS for blood pressure control and 5 (31%) required the addition of chlorthalidone. After 6 months, the left ventricular mass index was significantly reduced by 19% from 121 +/- 8 to 96 +/- 7 g/m2 and this reduction was sustained at 1 year. Septal and posterior wall thicknesses were reduced from 13.4 +/- 0.1 to 11.2 +/- 0.04 mm and from 12.8 +/- 0.1 to 10.0 +/- 0.03 mm (p less than 0.001), respectively. Prevalence of left ventricular hypertrophy decreased from 63 to 25%. Left ventricular fractional shortening increased from 34 to 42% (p less than 0.05) and the relationship between fractional shortening and end-systolic stress did not change. Over the year of sustained blood pressure reduction, the peak velocity of early filling increased from 58 to 63 cm/s (p = 0.07), the peak velocity of late filling did not change, and the ratio of late to early peak velocity of left ventricular filling significantly decreased (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Leg movements in the supine position of infants with spastic diplegia

Leg movements in the supine position of 49 infants with spastic diplegia (three to 11 months corrected age) were examined. Only simultaneous flexion and extension of the hips and knees were seen, with exceptional isolated hip movements; the simultaneous movements had synergic features. When the knees were flexed, the hips were flexed, abducted and externally rotated, and the ankles were dorsiflexed. When the knees were extended, the hips were extended, adducted and internally rotated and the ankles were plantar-flexed. Hip flexion combined with knee extension (leg elevation) and isolated knee movements were not seen in diplegic infants, but were seen in all control preterm infants with a good prognosis, after five and six months corrected age, respectively. The absence of these movements is a useful diagnostic item for spastic diplegia.

Normalization of left ventricular mass and associated changes in neurohormones and atrial natriuretic peptide after 1 year of sustained nifedipine therapy for severe hypertension

Sixteen patients with severe hypertension were treated for 1 year with extended release nifedipine, during which time serial changes in left ventricular mass index and associated alterations in left ventricular systolic function, left ventricular filling, plasma renin activity, atrial natriuretic peptide and catecholamines were evaluated. Mean seated blood pressure (+/- SE) was significantly reduced from 200 +/- 8/122 +/- 3 to 144 +/- 5/89 +/- 2 mm Hg (p less than 0.0001) at 1 year. After 6 months, left ventricular mass index was significantly reduced by 19% from 121 +/- 8 to 96 +/- 7 g/m2 and this reduction was sustained at 1 year. Septal and posterior wall thickness were reduced from 13.4 +/- 0.1 to 11.2 +/- 0.04 mm and from 12.8 +/- 0.1 to 10.0 +/- 0.03 mm (p less than 0.001), respectively. The prevalence of left ventricular hypertrophy decreased from 63% to 25%. Left ventricular fractional shortening increased from 34 +/- 2% to 41 +/- 3% (p less than 0.05) and the relation between fractional shortening and end-systolic stress did not change. Over the year of sustained blood pressure reduction, the peak velocity of early filling increased from 57 +/- 3 to 63 +/- 4 cm/s (p = 0.07), peak velocity of late filling did not change and the ratio of late to early peak left ventricular filling velocity significantly decreased (p less than 0.05). Plasma atrial natriuretic peptide levels, markedly elevated at entry, decreased from 70 +/- 15 to 41 +/- 8 pg/ml at 1 year (p less than 0.05). Plasma renin activity and catecholamine levels were not altered.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolated T-wave abnormalities and evaluation of left ventricular wall motion after nifedipine for severe hypertension

Rapid reduction of blood pressure by vasodilators in severe hypertensives has been associated with T-wave inversion. The significance of these changes in the absence of chest pain or other manifestations of ischemia is not known. To determine if these T-wave inversions are due to myocardial ischemia, we obtained electrocardiograms and left ventricular wall motion studies (2-D echocardiography) before and 1 h after rapid blood pressure reduction with nifedipine in 23 severe hypertensives. One hour after 10 mg nifedipine blood pressure was markedly reduced from 189 +/- 6/117 +/- 3 (mean +/- SE) to 151 +/- 5/91 +/- 3 mm Hg (P less than .001). New T-wave inversions developed in 6 of 23 (26%) subjects, but blinded evaluation of 2-D echocardiograms revealed no new wall motion abnormalities. Wall motion score, which at pretreatment was abnormal in 11 of 23 patients, improved significantly after nifedipine from 1.4 +/- 0.1 to 1.2 +/- 0.1 (P less than .05). Therefore, rapid and marked reduction of blood pressure with nifedipine is accompanied by a high incidence of asymptomatic T-wave inversions which are not accompanied by left ventricular wall motion abnormalities, suggesting that significant myocardial ischemia did not occur.

Effect of nifedipine GITS on left ventricular mass and diastolic function in severe hypertension

Treatment of severe hypertension is beneficial, but reversibility of target-organ damage has not been characterized. Serial studies were performed in 15 patients with severe essential hypertension (age of 56 +/- 3 years, mean +/- SEM) treated for 1 year with 60 to 150 mg/day of continuous-release nifedipine; 3 patients required 50 mg of chlorthalidone/day to lower diastolic blood pressure (BP) to less than 95 mm Hg. Left ventricular (LV) structure and function was evaluated with two-dimensional-directed M-mode echocardiography, digitized from videotape and analyzed blindly. BP was markedly reduced from 194 +/- 8/115 +/- 4 to 146 +/- 4/88 +/- 14 mm Hg (p less than 0.0001) and maintained at this level for 1 year. Posterior wall and septal LV thickness, elevated at entry (12.9 +/- 0.1 and 13.4 +/- 0.1 mm), dropped steadily over 1 year into the normal range (10.0 +/- 0.03 and 11.2 +/- 0.1 mm, p less than 0.001). LV mass index, above 95% for normals at entry, decreased by 19% at 6 months (129 +/- 10 to 104 +/- 7 g/m2, p less than 0.01), and remained at this level at 1 year. LV fractional shortening rose steadily over 1 year from 34 to 42% (p less than 0.02). Atrial natriuretic peptide, which reflects LV filling pressures, was markedly elevated at entry, but was significantly reduced by 6 months (76 +/- 22 vs. 45 +/- 14 pg/ml, p less than 0.05). Sustained reduction of arterial BP with continuous-release nifedipine for 1 year normalizes LV mass, improves LV systolic function, and reduces circulating levels of atrial natriuretic peptide.

Gross motor patterns in children with cerebral palsy and spastic diplegia

Rolling, sitting, and crawling patterns were motoscopically analyzed in 72 children with cerebral palsy and spastic diplegia; the relation between these patterns and the severity of the locomotive disability was studied. In rolling, trunk rotation and elbow support were difficult for the most severely diplegic children. When sitting, most patients had a between-heel sitting pattern in which the thighs were adducted and the knees were flexed. When crawling, the reciprocal thigh movements were insufficient and accompanied by lateral bending of the trunk in many patients. In the more impaired patients, the thighs supported the weight in flexion and did not move reciprocally. Creeping on the elbows without reciprocal leg movements was demonstrated in the most severely affected children after 2 years of age.

Dominant use of the left hand by athetotic cerebral palsied children

Hand preference was studied in 57 children with athetotic cerebral palsy. A left-sided preference was seen in 61% of the subjects. In more severely affected children for whom the possible cause was asphyxia, the left-sided preference was especially common. The perinatal brain damage causing athetosis may affect a motor system controlling movement on the right side more severely.

Motoscopic analysis of gross motor patterns in athetotic cerebral palsied children

Rolling, sitting, and crawling patterns were motoscopically analyzed in 51 athetotic cerebral palsied children. In rolling, rotation of the trunk and support on the elbows were difficult in some subjects. When sitting, most of the subjects had a "W" sitting pattern in which the hips were adducted and the knees were flexed. As for crawling, reciprocal movements of the four extremities were disturbed. The reciprocal hip movements were insufficient and accompanied the lateral bending of the trunk in many of the children. The hips supported the weight in flexion, and the synchronized extension of the hips, with or without lateral bending of the trunk, propelled the body in some. Creeping on the elbows was shown only in the younger children.

Computed tomographic findings in children with spastic diplegia: correlation with the severity of their motor abnormality

Computed tomographic findings of 46 children with spastic diplegia examined at nine months to three years of age corrected for preterm births were analyzed. Both the size of the lateral ventricles measured by the width of the anterior horns, and the volume of the extracerebral low-density areas were enlarged in some patients. Both enlargements did not, however, correlate to the severity of the motor abnormality in the patients. The low-density areas of the periventricular white matter, especially adjacent to the trigone, were reduced in many children, probably due to the atrophy of the cerebral white matter having periventricular leukomalacia. The anterior expansion of the white matter reduction from the trigone corresponded to the severe motor abnormality in the children with spastic diplegia.

Angiographic difference in coronary artery of man, dog, pig, and monkey

Comparative morphological studies on the coronary arteries of the left ventricular free wall were carried out on human, dog, pig, and monkey hearts by using postmortem coronary arteriography, soft X-ray photograms, and the clearing method. The results showed that the types of coronary arteries (types I, II, and III) and connecting portion of anastomotic vessels in the pig and monkey hearts closely resembled those in man. Whereas the dog hearts showed the following characteristics: numerous Type III vessels and anastomoses in the epicardial layer, the existence of only the left predominant type of coronary artery, and the supply of blood to the papillary muscles of the left ventricle mostly through a single branch of the coronary artery. Therefore, it is necessary to take into consideration the basic difference in the structure of the coronary arteries of human and dog hearts, when dogs are used experimentally for research of human ischemic heart disease. The fact that only the papillary muscles of the human heart-compared to animal hearts-are supplied blood from two sources may be advantageous to rescue the papillary muscles from ischemic necrosis.

Compensatory response to hemorrhage in conscious dogs on normal and low salt intake

The compensatory response to moderately severe hemorrhage (30 ml/kg) was studied in chronically catheterized conscious dogs maintained on normal and low salt intake. Although the fall in blood pressure and the increase in heart rate were similar in the two salt states, the salt-restricted animals had significantly greater rises in plasma renin activity and plasma catecholamines following hemorrhage than did the normal salt dogs. To compare further the relative roles of the alpha-adrenergic system and the renin-angiotensin system in the maintenance of blood pressure following hemorrhage, pharmacologic blockade with either phentolamine or converting enzyme inhibitor was performed 20 min after the completion of the hemorrhage. These latter experiments demonstrated that salt restriction resulted in a significantly greater role for the renin-angiotensin system. Moreover, interruption of the renin-angiotensin system blunted the anticipated rise in catecholamines and heart rate during the additional hypotension induced by converting enzyme blockade after hemorrhage.

Origin of sodium ions appearing in the venous blood plasma during acute venous congestion and hemorrhagic hypotension: a study on kidneys and skeletal muscle of dogs

We studied the origin of sodium ions which appeared in a higher concentration in the venous blood plasma obtained from the renal or femoral vein, than in the arterial blood plasma during acute renal venous congestion, acute venous congestion of hindlimbs and acute hemorrhagic hypotension. We measured the sodium concentration in the blood plasma as well as in hemolyzed blood obtained with sonication. In addition, sodium contents of the kidneys and skeletal muscle were determined. All experiments were performed on anesthetized mongrel dogs. Sodium contents of the kidneys and skeletal muscle of hindlimbs, in terms of milliequivalent per gram dry tissue weight, was decreased significantly 30-40 min after exposure of the kidneys and hindlimbs to acute venous congestion, or after exposure of hindlimbs to hemorrhagic hypotension, indicating a release of sodium ion into the blood stream. The sodium ion concentration became slightly higher in the venous blood than in the arterial blood, in terms of both blood plasma and hemolyzed blood, during 15-30 min of exposure of hindlimbs to local venous congestion or hemorrhagic hypotension, again indicating a release of sodium ion into the blood stream. However, acute renal vein congestion caused the sodium ion concentration to become slightly higher in the venous blood than in the arterial blood, only in terms of blood plasma, and not in terms of hemolyzed blood, indicating that red blood cell sodium is the origin of sodium ions which appeared in the renal venous plasma during acute renal vein congestion.