Impaired hospitalized patient mobility is associated with nurse injuries

BACKGROUND

Staff injuries adversely affect the health of staff members as well the ability of health care teams to effectively care for patients. Identifying patients who pose an increased risk of injury may allow for the planning of risk mitigation strategies, but few studies have examined patient factors associated with staff injury risk.

AIMS

Examine the relationship between staff injury and patient mobility, which has been linked to other key hospital outcomes.

METHODS

Linking occupational health and electronic medical record data, we examined documented patient mobility levels, based on the Activity Measure for Post-Acute Care (AM-PAC) and the Johns Hopkins Highest Level of Mobility (JH-HLM) Scale, on the day prior to injury. In addition, we created a matched cohort of control patients not associated with staff injury to examine the influence of patient mobility on the odds of staff injury.

RESULTS

We identified 199 staff injuries associated with 181 patients with 1063 matched controls. Patients had median scores of 11 and 3 on the AM-PAC and JH-HLM, respectively, indicating moderate-severe mobility impairments. In addition, scores in the lowest AM-PAC tertile (6-15) and lowest JH-HLM tertile (1-4) were associated with a 4.46-fold and 2.90-fold increase in the odds of nurse injury, respectively.

CONCLUSIONS

These results indicate that moderate-severe mobility impairments are associated with increased risk of nurse injury. Hospitals and clinical care teams should consider documenting mobility routinely and utilizing these values to identify patients who pose an increased risk of nurse injury.

Cediranib with mFOLFOX6 vs bevacizumab with mFOLFOX6 in previously treated metastatic colorectal cancer

Background:

Cediranib is a highly potent inhibitor of vascular endothelial growth factor (VEGF) signalling with activity against all three VEGF receptors. Bevacizumab is an anti-VEGF-A monoclonal antibody with clinical benefit in previously treated metastatic colorectal cancer (mCRC).

Methods:

Patients with mCRC who had progressed following first-line therapy were randomised 1 : 1 : 1 to modified (m)FOLFOX6 plus cediranib (20 or 30 mg day⁻¹) or bevacizumab (10 mg kg⁻¹ every 2 weeks). The primary objective was to compare progression-free survival (PFS) between treatment arms.

Results:

A total of 210 patients were included in the intent-to-treat (ITT) analysis (cediranib 20 mg, n=71; cediranib 30 mg, n=73; bevacizumab, n=66). Median PFS in the cediranib 20 mg, cediranib 30 mg and bevacizumab groups was 5.8, 7.2 and 7.8 months, respectively. There were no statistically significant differences between treatment arms for PFS (cediranib 20 mg vs bevacizumab: HR=1.28 (95% CI, 0.85–1.95; P=0.29); cediranib 30 mg vs bevacizumab: HR=1.17 (95% CI, 0.77–1.76; P=0.79)) or overall survival (OS). Grade ⩾3 adverse events were more common with cediranib 30 mg (91.8%) vs cediranib 20 mg (81.4%) or bevacizumab (84.8%).

Conclusion:

There were no statistically significant differences between treatment arms for PFS or OS. When combined with mFOLFOX6, the 20 mg day⁻¹ dose of cediranib was better tolerated than the 30 mg day⁻¹ dose.

Myths in the assessment of progression: How frequently should we assess patients in clinical trials?

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Background: It is often believed that within a clinical trial a patient’s progression status should be assessed as frequently as practically possible if the primary objective is to compare progression-free survival (PFS). However, the statistical analysis of PFS data compares rates of progression rather than a specific percentile such as a median, and results in an estimate of the hazard ratio (HR)—the ratio of event rates. Methods: We provide results of simulations assessing the power and bias of an analysis of PFS in controlled trials according to visit frequency, rate of progression and analysis method. The simulations assume a true HR of 0.8 and that data are analyzed after 630 patients have an event to provide a nominal power of 80%. All simulations assume patients are assessed according a symmetric visit schedule as otherwise, if data are analyzed asymmetrically, bias will follow (Proc Am Assoc Cancer Res 2002; abst 975). Results: If patients are assessed at a time interval equal to the median divided by two, there is a negligible (=2%) loss of power for the analysis of PFS data. Data presented in the table show that in a disease with a comparator median of 4 and 8 months when 1,000 patients are randomized, there is little increase in power if patients are assessed more often than every 2 and 4 months, respectively, using a standard log- rank test. The simulations presented assume there is some variability (SD=1 week) of the actual assessment date around the protocolled date. If PFS data are analyzed by moving PFS times to the scheduled assessment time, alternative methods of analysis (grouped survival techniques) preserve power and avoid bias by appropriately handling the excessively tied PFS times. Conclusions: Within the context of a clinical trial, a fully powered analysis of PFS is possible if patients are assessed at a frequency which is one-half of the median of the disease under study, and therefore patients need not be assessed more frequently unless clinical practice outside of a clinical trial would dictate otherwise.

[Table: see text] [Table: see text]

Metastatic dissemination of human malignant oral keratinocyte cell lines following orthotopic transplantation reflects response to TGF-beta 1

This study examined the behaviour of nine human malignant oral keratinocyte cell lines following orthotopic transplantation to the floor of the mouth of athymic mice. Tumourigenesis, local spread, and metastatic dissemination were correlated with known cellular responses to transforming growth factor-beta 1 (TGF-beta 1). Six of nine cell lines were tumourigenic; four of these cell lines showed local spread which was characterized by vascular and bone invasion. Metastatic spread was uncommon, with only 9% of animals with primary tumours developing metastases and these were almost exclusively found in the regional lymph nodes; there was one pulmonary metastasis and no liver deposits. Tumour cell behaviour did not reflect the clinical stage of the original tumours. Cell lines that were resistant to TGF-beta 1-induced growth inhibition were more likely to form primary tumours, exhibit local spread, and metastasize than cells that were growth-inhibited by the ligand. The data demonstrate that tumourigenicity and tumour behaviour in this orthotopic mouse model varied between cell lines and that the pattern of local invasion and metastasis was similar to that seen in human oral cancer. Furthermore, cell lines that were refractory to the growth inhibitory effects of TGF-beta 1 behaved more aggressively than cells that underwent ligand-induced cell-cycle arrest.

Functional significance of MMP-2 and MMP-9 expression by human malignant oral keratinocyte cell lines

This study examined the expression of MMP-2 and MMP-9 in normal and human malignant oral keratinocytes. The expression of pro-MMP-2 and pro-MMP-9 was heterogeneous in the malignant cell lines. Normal oral keratinocytes expressed less pro-MMP-2 and more pro-MMP-9 than their malignant counterparts. Cells that expressed high levels of both MMP-2 and MMP-9 showed the greatest degree of invasion through Matrigel in vitro compared to cells with either low or variable levels of these enzymes; normal keratinocytes were non-invasive in these conditions. The degree to which the cells invaded through Matrigel was similar to their motility in the absence of Matrigel and was not influenced by the activation of the pro-enzymes or the inhibition of enzyme activity using a chemical inhibitor of gelatinases. Cells were transplanted orthotopically to athymic mice and demonstrated a variable capacity not only to form tumours at the site of inoculation but, also, to metastasise; normal oral keratinocytes were non-tumorigenic. There was no correlation between the expression of either MMP-2 or MMP-9 and the tumorigenic/metastatic phenotype. The results emphasise the limitations of correlating in vitro and in vivo assays of tumour cell behaviour and suggest that invasion/motility in vitro may be a distinct phenotype from tumorigenicity/metastasis in vivo.

Overexpression of JunB in undifferentiated malignant rat oral keratinocytes enhances the malignant phenotype in vitro without altering cellular differentiation

Our study examined the expression of AP-1 family members in keratinocytes derived from the rat-4NQO model of oral carcinogenesis in which extremes of epithelial differentiation and tumour cell aggressiveness are evident. The constitutive expression of JunB was diminished in the undifferentiated, more aggressive tumour phenotype compared with the well-differentiated, less aggressive keratinocytes, whereas the expression of other AP-1 family members (c-jun, junD, c-fos, fra1, fra2 and fosB) was either very weak or variable. After transfection of the undifferentiated keratinocytes with junB cDNA, clonal populations were isolated that expressed similar levels of JunB protein as the well-differentiated cells. Both untransfected and transfected cell lines were keratin negative and vimentin positive. Increased expression of JunB in the transfected cells resulted in up-regulation of c-Jun and Fra1 and an enhanced AP-1 activity as demonstrated by transcriptional activation of the prototypic AP-1 dependent promoter, MMP-1. JunB transfected cells grew more quickly than vector-only controls and were refractory to the growth inhibitory effects of TGF-beta1. Over-expression of JunB resulted in the elevated expression of the AP-1 dependent proteinase, MMP-9, whereas the expression of the AP-1 independent enzyme, MMP-2, was unaffected. JunB transfected keratinocytes were highly invasive in an in vitro assay of tumour cell invasion compared with vector controls. The results indicate that increased expression of JunB above baseline levels in undifferentiated rat keratinocytes does not alter epithelial differentiation but enhances the malignant phenotype in vitro, possibly by altering the dynamics of the AP-1 complex.

Stratified care vs step care strategies for migraine: the Disability in Strategies of Care (DISC) Study: A randomized trial

CONTEXT

Various guidelines recommend different strategies for selecting and sequencing acute treatments for migraine. In step care, treatment is escalated after first-line medications fail. In stratified care, initial treatment is based on measurement of the severity of illness or other factors. These strategies for migraine have not been rigorously evaluated.

OBJECTIVE

To compare the clinical benefits of 3 strategies: stratified care, step care within attacks, and step care across attacks, among patients with migraine.

DESIGN AND SETTING

Randomized, controlled, parallel-group clinical trial conducted by the Disability in Strategies Study group from December 1997 to March 1999 in 88 clinical centers in 13 countries.

PATIENTS

A total of 835 adult migraine patients with a Migraine Disability Assessment Scale (MIDAS) grade of II, III, or IV were analyzed as the efficacy population; the safety analysis included 930 patients.

INTERVENTIONS

Patients were randomly assigned to receive (1) stratified care (n = 279), in which patients with MIDAS grade II treated up to 6 attacks with aspirin, 800 to 1000 mg, plus metoclopramide, 10 mg, and patients with MIDAS grade III and IV treated up to 6 attacks with zolmitriptan, 2.5 mg; (2) step care across attacks (n = 271), in which initial treatment was with aspirin, 800 to 1000 mg, plus metoclopramide, 10 mg. Patients not responding in at least 2 of the first 3 attacks switched to zolmitriptan, 2.5 mg, to treat the remaining 3 attacks; and (3) step care within attacks (n = 285), in which initial treatment for all attacks was with aspirin, 800 to 1000 mg, plus metoclopramide, 20 mg. Patients not responding to treatment after 2 hours in each attack escalated treatment to zolmitriptan, 2.5 mg.

MAIN OUTCOME MEASURES

Headache response, achieved if pain intensity was reduced from severe or moderate at baseline to mild or no pain at 2 hours; and disability time per treated attack at 4 hours for all 6 attacks, compared among the 3 groups.

RESULTS

Headache response at 2 hours was significantly greater across 6 attacks in the stratified care treatment group (52.7%) than in either the step care across attacks group (40.6%; P<.001) or the step care within attacks group (36.4%; P<.001). Disability time (6 attacks) was significantly lower in the stratified care group (mean area under the curve [AUC], 185.0 mm. h) than in the step care across attacks group (mean AUC, 209.4 mm. h; P<.001) or the step care within attacks group (mean AUC, 199.7 mm. h; P<.001). The incidence of adverse events was higher in the stratified care group (321 events) vs both step care groups (159 events in across-attack group; 217 in within-attack group), although most events were of mild-to-moderate intensity.

CONCLUSION

Our results indicate that as a treatment strategy, stratified care provides significantly better clinical outcomes than step care strategies within or across attacks as measured by headache response and disability time. JAMA. 2000;284:2599-2605.

Endogenous TGF-beta1 inhibits the growth and metastatic dissemination of rat oral carcinoma cell lines but enhances local bone resorption

This study examined the effect of stable transfection of latent transforming growth factor-beta1 (TGF-beta1) cDNA into a predominantly polygonal, 4 nitroquinoline N-oxide (4NQO)-induced rat oral keratinocyte cell line. Seven polygonal and five spindle clonal populations were isolated that overexpressed TGF-beta1 protein by approximately two- to four-fold compared to vector-only transfected controls. Neutralisation experiments indicated that the majority of protein was in the latent form. There was no change in the proportion of polygonal and spindle cells in vitro after transfection with TGF-beta1 cDNA. Polygonal and spindle cells that overexpressed TGF-beta1 produced similar amounts of protein and grew more slowly in vitro than controls. The parent cell line and all transfected cells were growth inhibited (60-75%) by exogenous TGF-beta1. Orthotopic transplantation of the parent and the vector-only control cell lines resulted in primary tumours in the floor of the mouth in almost 100% (20/21) of athymic mice, with no evidence of bone resorption at the site of the primary tumour and pulmonary metastatic tumour deposits in some 40% (7/20) of these animals. The polygonal and spindle cells that overexpressed TGF-beta1 behaved similarly following orthotopic transplantation. A 96% (23/24) primary tumour take was evident following transplantation of cells that overexpressed TGF-beta1, with a significantly (P<0.02) higher number of animals showing bone resorption at the site of the primary tumour (35%; 8/23) compared to controls. By contrast, there was a significant (P<0.03) decrease in the number of animals with pulmonary metastases (4%; 1/23) following transplantation of TGF-beta1 overexpressing cells compared to controls. Overexpression of TGF-beta1 did not alter tumour cell differentiation in vivo. The results demonstrate that endogenous TGF-beta1 functions as a tumour suppressor in the rat-4NQO model of oral carcinogenesis without altering tumour cell morphology or differentiation but can also act to promote local bone resorption.

Overexpression of autocrine TGF-beta 1 suppresses the growth of spindle epithelial cells in vitro and in vivo in the rat 4NQO model of oral carcinogenesis

We examined the effect of the stable transfection of latent TGF-beta 1 cDNA, under the control of a cytomegalovirus promoter in the expression vector pcDNA3, into a 4NQO-induced clonal rat oral keratinocyte cell line that formed undifferentiated spindle cell tumours following subcutaneous transplantation to athymic mice. Test cells containing latent TGF-beta 1 cDNA produced a 2.3-fold increase in TGF-beta 1 protein compared to pcDNA3 controls as demonstrated by ELISA. Neutralisation experiments indicated that the majority of the protein was in the latent form. Untransfected and transfected (containing either TGF-beta 1 cDNA or pcDNA3) cell lines were keratin negative and vimentin positive. Cells transfected with TGF-beta 1 were inhibited more than pcDNA3 controls when cultured in an anchorage dependent or independent environment. Subcutaneous transplantation of cells overproducing TGF-beta 1 resulted in tumours of significantly smaller volume than vector-only controls. Further, orthotopic transplantation of cells containing TGF-beta 1 cDNA to the floor of the mouth in athymic mice markedly inhibited the development of pulmonary metastases compared to vector-only controls. Both test and control cell lines in athymic mice formed undifferentiated tumours with a complete absence of keratin elaboration. Subcutaneous xenografts were recultured and cells containing the TGF-beta 1 cDNA produced a similar amount of TGF-beta 1 peptide as the cells containing pcDNA3 only. The production of TGF-beta 1 by both of the xenograft-derived cell lines was significantly less than the parent, pre-transplanted cell lines and the untransfected cell line. All of the cell lines were inhibited by exogenous TGF-beta 1. Our results demonstrate that autocrine TGF-beta 1 functions as a tumour suppressor in vitro and in vivo in 4NQO-induced spindle tumour cells that are growth inhibited by the ligand. Furthermore, tumour formation in athymic mice is associated with selection for a cell phenotype with diminished autocrine TGF-beta 1 production.

Evaluation of the chimpanzee breeding program at the Southwest Foundation for Biomedical Research

The history of the chimpanzee (Pan troglodytes) breeding colony of the Southwest Foundation for Biomedical Research was evaluated over a 24-year period to determine age at conception, breeder rearing history, maternal competence, and infant rearing history. The records of 107 breeders and 268 live births were reviewed. Of the breeders with known rearing histories, 40 were wild-born (12 male and 28 female), 16 were reared by their mothers for at least 1 month (8 male and 8 female), and 13 were removed from their mothers immediately after birth (2 males and 11 females). The age of successful mating for males ranged from 7 to 32 years and for females from 7 to 41 years, although the upper limit indicates the age of the population and not reproductive senescence. The mother's rearing history was related to her maternal competence, defined as caring for an infant for at least 1 month. Of the wild-born females, 82% (18/22) were competent mothers. For females that had been reared in captivity with their mothers for 1 to 12 months, 71% (5/7) were competent. For females that had been removed from their mothers immediately and reared in a nursery by humans, only 14% (1/7) were competent. The rearing strategies have changed during the period under consideration. The number of infants reared by their mothers increased in the 1980s, while the number of infants removed from their mothers immediately for experimental reasons decreased and dropped to zero in the 1990s. Information on the history of the breeding colony has been used to make management decisions and to determine the expectations of the Southwest Foundation chimpanzee breeding program.

Tumor necrosis factor alpha (rhTNF) fails to stimulate angiogenesis in the rabbit cornea

BACKGROUND

The objective of this study was to thoroughly examine the in vivo angiogenesis activity of human recombinant tumor necrosis factor alpha (rhTNF).

METHODS

rhTNF (0.5 ng to 1.0 microgram) was incorporated into the slow release polymers Hydron or HYPAN and implanted into the rabbit cornea. Release of biologically active rhTNF from the polymers was determined with the L929 cytotoxicity assay.

RESULTS

All concentrations tested failed to elicit capillary formation beyond that observed for controls. Less than 2% of the rhTNF was released from the Hydron over 7 days. HYPAN released five times the amount of rhTNF in vitro, but even at doses of 500 ng (104.3 ng suggested release) no angiogenesis was stimulated.

CONCLUSIONS

Under the circumstances tested, rhTNF is not angiogenic in vivo.

Long-term use of televisions, balls, and mirrors as enrichment for paired and singly caged chimpanzees

The evaluation of environmental enrichment techniques for nonhuman primates over long periods of time has had mixed results. Some studies report rapid habituation to new enrichment items, while others note continued use. We have investigated the use of three different enrichments that had been available to paired and singly caged chimpanzees for several years. Twenty subjects were observed during 200 hr of scan sampling while singly caged and while pair housed. Each subject had a variety of enrichments available and their use of a television, ball, and mirror were recorded. The chimpanzees had previous exposure to all of the items: televisions had been available for a mean of 22.75 months, balls had been available for 55.9 months, and mirrors had been available for 25.9 months. The results indicated that the chimpanzees continued to use the enrichments for small amounts of time (0.27%-1.53% of the observations) even after such prolonged exposure. Television and ball use were significantly higher than mirror use. Housing condition was not a significant factor in the analyses, contrary to expectations. We concluded that several simple enrichment items may be effective in offering variety and choices to the nonhuman primate and can be one element in a comprehensive environmental enhancement plan. © 1996 Wiley-Liss, Inc.

Age-related alterations in the morphology of femoral artery vasa vasorum in the rat

The objective of this study was to explore any age-related morphological changes in the vasa vasorum of the rat femoral artery. Vascular corrosion casts were prepared from 2, 12 and 24-month-old rats. Examination of the casts with the scanning electron microscope revealed dramatic differences in the appearance of the vessels of young and aged rats. The vasa vasorum of 2-month-old rats consisted of a dense network of capillaries. These vessels were dramatically reduced in number by 12 months, and even fewer capillaries were present at 24 months. This reduction in capillary density is consistent with the observed age-related decreases in oxygen tension and may explain why the aged are more prone to atherosclerosis.

Laparoscopic repair of vesicoureteral reflux utilizing the Lich-Gregoir technique in the pig model

To date, laparoscopic urological surgery has largely been limited to diagnostic or ablative procedures. Herein we report our experience with laparoscopic reconstructive surgery to perform an extravesical ureteral reimplantation. Seven anesthetized pigs with iatrogenic ureteral reflux underwent a laparoscopic extravesical ureteral reimplantation. The newly created ureteral tunnel varied from 2 to 4 cm. In 3 pigs, the tunnel was created with tacking staples, while in the other 4 pigs, the tunnel was created with intracorporeal suturing techniques using a 3-zero polyglyconate running suture. The procedure required an average of 132 minutes. There was one anesthetic death. There were no urinary tract infections. At 3 to 8 weeks after reimplantation, the cystograms were repeated on 5 pigs. One of 2 stapled reimplant pigs still had reflux; 1 of 3 sewn reimplant pigs had reflux. At 6 months following the reimplantation, only 1 pig had residual grade I reflux and this was a sutured reimplantation. None of the stapled reimplantations exhibited any residual reflux on the surgical side; however, in 1 animal a submucosal staple was noted at the time of harvest.

Proliferation of wound derived capillary endothelial cells: young versus aged

The objective of this study was to compare the proliferative potential of wound derived capillary endothelial cells (WCEC) from aged and young rats. Endothelial cells were isolated from subcutaneously implanted sponges in 2- and 24-month-old rats. The identity of the cells as endothelial was confirmed by staining for Ac-LDL uptake. Aged and young WCEC (20,000/well) were stimulated with increasing concentrations of fetal calf serum (0, 2.5, 5, 10 and 15%). The increase in cell number was determined with a Coulter counter. At all serum concentrations, the proliferative capacity of WCEC from aged rats was significantly higher than that of WCEC from young rats.

Vascular endothelial growth factor (rhVEGF165) stimulates direct angiogenesis in the rabbit cornea

The object of this study was to test vascular endothelial growth factor (VEGF) for angiogenic activity in the rabbit corneal assay. VEGF doses ranging from 20 ng to 1000 ng were incorporated into a slow release polymer and implanted into the avascular rabbit cornea. Capillary formation in the cornea was visually analyzed on a daily basis and examined with histology, transmission electron microscopy and scanning electron microscopy of vascular corrosion casts on days 2 and 7 post-implantation. VEGF implants (200ng to 1000ng) consistently stimulated angiogenesis. This neovascularization occurred in the absence of inflammation. We conclude that VEGF acts directly on endothelial cells, initiating and mediating the formation of capillaries.

PDGF-BB induced chemotaxis is impaired in aged capillary endothelial cells

The object of this study was to determine if the decreased angiogenesis in the healing wounds of the aged is due to the failure of endothelial cells to respond to locally produced growth factors. Endothelial cells isolated from wound sponges implanted in aged (24-month-old) and young (2-month-old) rats were tested for their chemotactic response to the BB isoform of platelet-derived growth factor (PDGF-BB). A similar number of cells isolated from both old and young rats stained positive (75-90%) for acetylated-LDL uptake, and the same number of viable cells was used in the chemotaxis assay. Endothelial cells from both old and young rats migrated in a dose-dependent (0.1-3.0 ng/ml) manner in response to PDGF-BB. At all concentrations tested, PDGF-BB elicited the migration of more endothelial cells from the young rats. The difference between the number of young and old cells that responded to PDGF-BB was statistically significant at the 1.0 ng/ml and 3.0 ng/ml concentrations. These results suggest that the impaired angiogenic response in the healing of wounds of the aged is due to altered endothelial cell reaction to the growth factors in the wound microenvironment.

Platelet derived wound healing factors (PDWHF) accelerate and augment wound healing angiogenesis in the rat

The object of this study was to determine the effect of PDWHF on wound healing angiogenesis. Sponges saturated with PDWHF were implanted in rats. Six hours to 14 days post-implantation, vascular corrosion casts were prepared and examined by SEM. Leukocyte margination and angiogenesis was accelerated by 24-48 hours. Vessel number was also greater than in the controls. Another series of PDWHF treated sponges were implanted. Fourteen days later the vasculature was perfused with Evans blue. Sponges were homogenized, and absorbance of the supernatants was determined. Absorbances of PDWHF supernatants was 2X greater than controls. PDWHF enhanced wound healing angiogenesis in the rat.

Disseminated aspergillosis in a patient with cystic fibrosis and allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is a well-known complication of cystic fibrosis (CF), with an estimated incidence of up to 11%. In patients with CF, the diagnosis of ABPA must be based on significant elevation of Aspergillus fumigatus (Af) antibody and total serum IgE, since it is common to already have other clinical and laboratory features of ABPA (Laufer et al., J Allergy Clin Immunol. 1984; 73:44-48). Once ABPA is identified in a patient, institution of corticosteroids is standard therapy. Invasive aspergillosis is a rare occurrence in patients with CF with or without ABPA, and has been reported in only one young adult who did not have ABPA (Giudotti et al., Am J Med Sci. 1982; 283:157-160). We present a case of a 15-year-old male with CF and ABPA who developed disseminated aspergillosis.

Organ entrapment and renal morcellation: permeability studies

We collected 24 intact LapSacs* during a laparoscopy course at our institution. Following laparoscopic nephrectomy or nephroureterectomy in a pig using high speed electrical tissue morcellation, the sacks were examined for perforation. When filled with water, 4 of the 24 LapSacs (16%) were found to have small perforations. The 20 remaining sacks were randomly divided into 3 groups of 6 and 2 sacks, although intact, were kept as substitutes to use if a trial with the study sacks could not be completed. Each group of 6 sacks was tested for permeability using 10 mg./ml. bovine serum albumin, 8 mg./ml. indigo carmine or 1 x 10(5)/ml. mouse bladder tumor cells. The results in the 18 tested sacks showed no dialysis of bovine serum albumin in the dialysate at 1, 3 and 18 hours, and no dialysis of indigo carmine at 0, 1, 2 and 3 hours. In 1 of 6 sacks tested with a mouse bladder tumor cell line a single cell was noted on the hemocytometer at 1 and 3 hours. The lack of an increasing concentration of cells at the 3-hour interval likely indicates that this represented contamination of the dialysate rather than ongoing leakage from a perforated sack in this case. We conclude that the LapSac, when properly used, remains impermeable throughout the morcellation process.

Effect of stent duration on ureteral healing following endoureterotomy in an animal model

Ureteral strictures were created in 18 minipigs. Six weeks after stricture inducement, endourologic incision with a balloon cutting device was performed and a 7 F internal polyurethane stent was placed. After this step, 14 pigs remained in the study and were randomized into three different groups depending upon the time when the stent was removed: 1, 3 or 6 weeks. Twelve weeks after stricture incision, the pigs were killed, the status of the incised ureteral segment was evaluated histologically, and a healing score was determined. There were no statistically significant overall differences among the mean values of the overall healing score throughout the three different groups. However, when the one-week and the six-week groups (p < .05) were compared with respect to strictures requiring more than one incision due to stricture length greater than 2 centimeters, a more favorable outcome occurred in the 1 week group. Based on these findings it may be reasonable to remove ureteral stents as early as 1 week after endoureterotomy and endopyelotomy.

Retroperitoneal endoscopic adrenalectomy: an experimental study

Laparoscopic approaches to adrenalectomy have been limited by the retroperitoneal (RP) location of the adrenal glands and their relative inaccessibility transabdominally. We developed a technique for endoscopic adrenalectomy in a domestic swine model using insufflation of the RP space with CO2 and retroperitoneoscopy. The technique for retroperitoneal endoscopic adrenalectomy was first developed in an acute study of three animals. A chronic survival study was then undertaken in six pigs. Unilateral right (n = 3) or left (n = 3) adrenalectomy was performed. Mean RP insufflation time was 14.5 min (range, 7-30 min), and mean dissection time after insufflation was 100 min (range, 80-120 min). Two additional animals died under anesthesia after RP insufflation and placement of the trocars for retroperitoneoscopy but before dissection of the adrenal gland. One death was unexplained at autopsy. The other death was associated with a right-sided pneumothorax attributable to penetration of the diaphragm by a trocar. The remaining six pigs recovered uneventfully from the procedure. Autopsies performed 37 to 51 days postoperatively showed minimal scarring of the adrenalectomy bed. The results suggest that posterior adrenalectomy using RP CO2 insufflation and direct retroperitoneoscopy is potentially applicable to the treatment of small adrenal lesions in humans.

Laparoscopic stapled bladder closure: laboratory and clinical experience

We report our experience with closure of the bladder during laparoscopic nephroureterectomy by using a gastrointestinal anastomosis type stapling device designed to deliver 6, 3 cm. rows of 3.5 mm. titanium staples via a 12 mm. trocar. We initially used this stapling device to secure a cuff of bladder in 8 female pigs undergoing laparoscopic nephroureterectomy. Followup in these animals was completed 2 to 6 months postoperatively. Then, 3 patients underwent laparoscopic ureterectomy using the laparoscopic stapler to transect and secure the ureter along with a cuff of bladder. In neither the laboratory nor the clinical situation were any complications encountered due to the transvesical staples (for example extravasation, stone formation, urinary tract infection or abscess formation). Our preliminary results indicate that titanium staples may be an effective method to provide rapid and secure closure of the bladder in patients undergoing either laparoscopic nephroureterectomy or laparoscopic ureterectomy.

Laparoscopic partial nephrectomy in the pig model

In an effort to further evaluate the potential application of laparoscopy to urologic surgery, we explored the feasibility of using this minimally invasive approach for performing a partial nephrectomy. Nine female pigs underwent laparoscopic partial nephrectomy (LPN) utilizing a plastic cable tie (15 mm. x 4 mm. x 1 mm.) to achieve renal ischemia and an Argon Beam Coagulator probe (ABC) (Birtcher Medical Systems) to fulgurate the transected surface. Six weeks after LPN, 6 pigs underwent creatinine clearance, renin level, arteriography, BP samples and were then killed. The renal remnants were weighed and sectioned for histological studies. These studies revealed excellent function of the renal remnant, no AV fistula, and no evidence of renovascular hypertension. LPN is a feasible, repeatable procedure in the pig. Control of the renal hilum, transient parenchymal compression with a plastic cable, and use of the argon beam coagulator are key elements in performing this procedure.

Laparoscopic ureterectomy: initial clinical experience

With a combination of cystoscopic and laparoscopic techniques, 3 patients underwent total ureterectomy for urothelial cancer without complication. Of the patients 2 underwent concomitant laparoscopic nephrectomy. Mean operating time was 8.2 hours for the laparoscopic surgery and mean hospital stay was 6 days. In 2 patients the ureter was removed intact, while in 1 it was morcellated along with the kidney before removal. In each case the bladder was closed with a 12 mm. GIA laparoscopic stapling device. After 3 to 9 months of followup no patient had recurrent disease or bladder stones on the staple line.

Transforming growth factor beta (TGF-B) stimulation of angiogenesis: an electron microscopic study

The object of this study was to examine the initiation and pattern of corneal angiogenesis stimulated by transforming growth factor beta (TGF-B) using scanning electron microscopy (SEM) of vascular corrosion casts and transmission electron microscopy (TEM). Fifty nanograms of TGF-B was combined with the slow release polymer Hydron and implanted in the rabbit cornea as an assay for angiogenic activity. Two and 7 days after implantation, the corneas were removed for TEM. At the same time intervals the limbal vasculature was filled with Mercox, an acrylic monomer. After the Mercox hardened, the tissue was digested with alternating immersions in 40% KOH and distilled water. The resulting casts were air-dried, sputter coated with gold and viewed with the scanning electron microscope. TEM revealed that 2 days after implantation, TGF-B elicited an influx of a vast number of inflammatory cells, which at two days were predominantly neutrophils. By 7 days the inflammation had subsided and typical capillaries were seen between the collagenous laminae of the normally avascular corneal stroma. SEM of vascular corrosion casts showed evidence of margination/diapedesis of leukocytes from the limbal venules 2 days post-implantation. In addition, the casts from the 7 day time point showed that new vessels arose solely from limbal venules.

Endopyelotomy and endoureterotomy with the acucise ureteral cutting balloon device: preliminary experience

Endoureterotomy and endopyelotomy usually involve an endoscopic antegrade approach. In an effort to simplify this technique, we designed an 8-mm balloon catheter with a 100-microns electrocautery cutting wire (Acucise) for retrograde incision of the ureter under fluoroscopic control. Twenty-eight patients with ureteral or ureteropelvic junction obstruction of 3.5 cm or less underwent Acucise endoureterotomy or endopyelotomy. The average operating time was 100 minutes, and the average hospital stay was 2.6 days. Follow-up was obtained with a subjective symptom score, intravenous urography, diuretic renal scan, a Whitaker test, or various combinations thereof. All patients had a minimum of 3 months of follow-up (mean 3.8 months; range 3-9 months). Overall, of the 21 patients who had symptoms of upper tract urinary obstruction, 14 (67%) had complete resolution, and another 4 (19%) had partial resolution, of their symptoms. Postoperative studies demonstrated normal upper tracts in 71% and improvement in another 14% of the patients. In our experience, the Acucise ureteral cutting balloon device provides an effective and efficient means for performing a retrograde endoureterotomy or endopyelotomy.

Retroperitoneal laparoscopic nephrectomy: laboratory and clinical experience

Laparoscopic nephrectomy using an entirely retroperitoneal approach was performed in six anesthetized female pigs. In each animal, the kidney was localized using fluoroscopy, following which the retroperitoneum was insufflated with CO2. Subsequently, a retroperitoneal laparoscopic nephrectomy was performed in a 48-year-old man with a chronically obstructed, nonfunctioning kidney. Although the retroperitoneal approach provides excellent exposure for the dissection of the renal hilum, anatomic factors in the human limit port placement and organ entrapment and increase the risk for development of a pneumothorax.

Ligation of the renal pedicle during laparoscopic nephrectomy: a comparison of staples, clips, and sutures

Evaluation of the role of staples, clips, and sutures for laparoscopic ligation of the renal artery revealed that occluding the renal artery with three, 9 mm titanium clips is as secure as occluding the renal artery with standard 2-0 and 0-silk ligatures. However, a triple staggered line of 2.5 mm staples placed across the renal artery was not as secure as either clips or silk sutures. The authors also studied eight female farm pigs who underwent laparoscopic nephroureterectomy with en masse stapled occlusion of the renal hilum. In one animal, an arteriovenous fistula was documented 6 months postoperatively. Currently, when laparoscopically occluding the renal hilum, the authors recommend a thorough dissection of the renal artery and renal vein; each should then be separately occluded so that three individually placed titanium clips remain on the stump of the renal artery and on the renal vein.

The role of shame in post-traumatic stress disorder

Shame is an important part of human experience but, by its very nature, is often neglected as an issue in treatment. Various recent conceptions of shame and its place in personality development, interpersonal relationships, and psychotherapy are presented. The contributions of affect theory are explored in their applications to the understanding of post-traumatic stress disorder, and implications for treatment are discussed.

The influence of exogenous eicosanoids on the radiation response of cultured bovine aortic endothelial cells

The radioprotection by several eicosanoids was investigated in cultures of bovine aortic endothelial cells. One hour before irradiation (0-500 cGy, 137Cs gamma rays) 10 micrograms/ml of PGD2, PGE1, PGI2, misoprostol (PGE1-analog), 16,16-dimethyl PGE2, PGA2, or 1 microgram/ml LTC4 was added. Radiation decreased incorporation of [3H]thymidine at 4 h, cell number/culture at 24 h, and cell survival as measured by colony formation. Under these conditions the eicosanoids were not radioprotective. Two eicosanoids, PGD2 and PGA2, appeared to be toxic. Because receptors might mediate eicosanoid-induced radioprotection, radioligand binding of PGE2 and LTC4 and levels of adenosine 3',5'-cyclic monophosphate (cAMP) were measured. Evidence for a receptor was equivocal; there was nonspecific binding and metabolism of LTC4. The level of cAMP was elevated by 16-16-dimethyl-PGE2 in the presence of isobutyl methylxanthine; however, this combination of the prostaglandin and the methylxanthine was not radioprotective. These investigations suggest that an elevated cAMP level alone does not lead to eicosanoid-induced radioprotection of bovine aortic endothelial cell monolayers in vitro.

Successful weaning from mechanical ventilation. Strategies to avoid failure

The majority of patients who require mechanical ventilation can be weaned quickly from the ventilator. Patients with severe lung disease and multisystem disease often require a more prolonged, gradual reduction of ventilatory support. Identification of patients who are ready to be weaned, correction of common problems that occur in weaning, and use of a standard approach during weaning trials can improve the likelihood of successful discontinuation of mechanical ventilation.

Effect of steroids on the cardiac output and renal changes of bacteremia

The effects of methyl prednisolone pretreatment in dogs prior to a bacterial infusion were measured in relation to cardiac output, blood pressure, intrarenal blood flow, and glomerular filtration rate. In dogs not pretreated with steroid, cardiac output fell 61.1 per cent 30 min postbacterial infusion and remained depressed for the balance of the experiment. Pretreated animals showed a similar 61 per cent depression in cardiac output immediately following bacterial infusion, but then experienced recovery of cardiac output and blood pressure to levels not significantly different from controls at the conclusion of the experiment. Changes in outer cortical bloodflow and glomerular filtration rate were not affected by steroid pretreatment. Based on the above data, the author concludes that the salutary effect of steroid pretreatment on cardiovascular dynamics occurs independently of changes in renal function.

Indomethacin and the gastric mucosal blood flow changes of sepsis

Recent evidence suggests that sepsis results in increased gastric mucosal blood flow (GMBF). To investigate the possible role of prostaglandins in mediating this response, the GMBF was measured in the fundus, corpus, and antrum of pig stomachs with and without pretreatment with indomethacin, an inhibitor of prostaglandin synthesis, before and after the induction of bacteremia. The studies were done in 22 piglets (seven sepsis controls, seven indomethacin controls and eight experimental [indomethacin pretreated sepsis] ). Sepsis was produced in piglets by bolus intravenous injection of 10(9) live Escherichia coli followed by an infusion of 10(9) E. coli/hr. Cardiac output (C.O.) was measured by thermodilution. GMBF was measured by microsphere trapping. Following sacrifice, hyperemia was noted in the sepsis group but not in the other groups. GMBF was determined by standard techniques (expressed as ml/min/100 gm tissue). There were significant (p less than 0.05) increases in gastric mucosal blood flow to the fundus (+47%), corpus (+50%), and antrum (+101%) at 15 minutes following the onset of E. coli infusion. At 135 minutes, the increase was only significant in the antrum. GMBF, however, did not change in the indomethacin control or indomethacin pretreated sepsis groups. These data demonstrate GMBF in the stomach following sepsis. The changes were not present in the indomethacin control or in the indomethacin pretreated sepsis groups. Since indomethacin is an inhibitor of prostaglandin synthesis, the results suggest that the GMBF may be a prostaglandin mediated response.

Pancreatic nesidioblastosis in adults. Report of a patient with hyperinsulinemic hypoglycemia

Hyperinsulinemic hypoglycemia in neonates occurs most commonly secondary to nesidioblastosis, a persistence of fetal development of the endocrine cells of the pancreas. In adults, hyperinsulinemic hypoglycemia is usually due to insulinoma or beta-cell hyperplasia. Nesidioblastosis arising in adults has only recently been reported. An adult patient with nesidioblastosis has been described. The light and electron microscopic films of this entity are shown in detail, and the embryology and treatment are discussed. Further understanding of this newly described disease entity will require research on factors that regulate the differentiation of beta cells of the pancreas.

Gastric mucosal blood flow and Escherichia coli bacteremia

The specific changes in gastric blood flow during sepsis are controversial. Previous investigations of intragastric blood flow using endotoxin models revealed decreased total gastric blood flow and decreased gastric mucosal blood flow. Endotoxin models are now thought to be inadequate due to the accompanying depression of the systemic circulation. More recently, increased gastric blood flow has been demonstrated in a septic hindlimb model. To further elucidate the changes in intragastric blood flow in sepsis, the gastric mucosal and nonmucosal blood flow were measured in the antrum and corpus of pig stomachs before and after the onset of sepsis. Increased gastric mucosal blood flow was demonstrated in both the antrum and corpus 15 minutes after the onset of E. coli bacteremia. By 75 minutes postonset, the changes were not significant, which implied partial recovery. Clinically, gastric mucosal ulcers may accompany the multiple organ system failure of sepsis. These data suggest that mucosal ischemia is not an etiologic factor as previously postulated from experiments with endotoxin.

The effects of Escherichia coli bacteremia on in vitro perfused kidneys

The renal response to sepsis results in increased renal blood flow, decreased renal vascular resistance, polyuric renal failure and a change in intracortical renal blood distribution. Prior reports used whole animal preparations, where the effects of sepsis on other organs may have led to systemic vasoactive changes altering the experimental model. To elucidate the direct effect of gram negative bacteremia on the kidney, intracortical hemodynamics and urinary flow were investigated using isolated canine kidneys perfused with a nonpulsatile pump oxygenator primed with modified dog plasma. Bacteremia was produced by 2.5 x 10(11) live Escherichia coli organisms infused directly into the perfusate. Intracortical blood flow distribution was measured by radioactive microsphere trapping using 15 microns diameter plastic radioactive microspheres. Urine flow increased 157% (p less than 0.05) following E. coli bacteremia while intracortical blood distribution was unchanged. The polyuric renal failure of sepsis is therefore, a direct result of bacteremia and not secondary to a change in intracortical flow as previously reported. The changes in intracortical blood distribution reported previously in sepsis using intact animal models probably reflect the renal response to release of vasoactive compounds originating in other organs rather than an intrinsic renal reaction to bacteremia.

Mesenteric hernia

Acute intestinal obstruction secondary to an idiopathic mesenteric hernia has been reviewed by collecting 139 reports from the literature and studying them from the standpoint of incidence, etiology, pathogenesis, clinical manifestations, diagnosis, treatment and mortality. An acute intestinal obstruction with strangulation in the absence of an external hernia and with no history of previous surgical procedures must suggest the possibility of an internal hernia, especially if the patient has a history of chronic intermittent abdominal distress and a palpable abdominal mass if found on examination.

Renal vascular effects of stroma and stroma-free hemoglobin

To assess the renal effects of hemoglobulin infusion, intrarenal hemodynamics were studied in 14 dogs using radioactive microspheres following the infusion of hemoglobin and stroma. Fractional renal microsphere distribution in the outer cortex remained at control levels following the infusion of hemoglobin. When the infusion of stroma followed, there was a 4.3 per cent, p less than 0.01, increase in the outer cortex microsphere distribution at the expense of the inner cortex, p less than 0.05. When the order was reversed, the stroma suspension being infused first, again there was a significant increase in the outer cortex distribution--6.1 per cent; p less than 0.01. When the infusion of hemoglobin followed, the outer cortex microsphere trapping reverted to control levels. These data revealed no effect upon intrarenal blood flow following the infusion of hemoglobin. The previously reported renal toxicity of hemoglobin infusion is, therefore, probably secondary to contamination with stroma. Hemoglobin should be further investigated for use as an ideal resuscitation fluid.

Changes in intrarenal blood flow during sepsis

The intrarenal hemodynamics of nine dogs were studied using 15 micron diameter plastic radioactive microspheres labeled with either 85Sr or 141Ce injected before and with the alternative isotope injected 30 minutes after the induction of sepsis. Total renal microsphere trapping increased by 30.6 per cent, p less than 0.01, after the induction of sepsis. The glomerular filtration rate was unchanged. Microsphere trapping in the outer and inner cortex increased by 36.9 per cent, p less than 0.005, and by 20.3 per cent, p less than 0.05, respectively, reflecting increased renal blood flow. Fractional renal microsphere distribution in the outer cortex increased from 70.0 to 73.4 per cent, p less than 0.01, following the induction of sepsis. These data confirm that sepsis results in renal vasodilatation. In addition, a shift in intrarenal blood flow to the outer cortex was demonstrated. Since the outer cortex is perfused with blood which first passes through the inner cortex, it can be hypothesized that renal blood flow in septic states may be passing through dilated glomerular vessels unable to trap microspheres in the inner cortex or passing through precapillary open arteriovenous shunts, or both, thereby bypassing inner cortical functioning glomeruli. This may partly explain the decreased renal function associated with increased renal blood flow in septic states.

Studies of the surgical scrub

A study comparing the relative efficacy of a five versus a ten minute surgical scrub was carried out using random sampling of personnel scrubbing for routine scheduled hospital surgical procedures. Scrubbing for five minutes was found to be equally as effective as scrubbing for ten minutes. Betadine was compared to pHisoHex as a scrubbing agent and found to be statistically more effective in degerming the skin following a five minute scrub. As a result of this study, a routine preoperative surgical scrub of five minutes' duration, using Betadine as the scrubbing agent, is recommended.

Adolescent breast masses

A retrospective experience with breast masses in 143 female and 22 male adolescents is reviewed: 104 females (71.7 per cent) had fibroadenomas and 1 (0.7 per cent) adenocarcinoma; all 22 males had gynecomastia. The significance of these findings is related to surgical therapy.